How should endometriosis be diagnosed and managed based on the best available evidence from published literature?The current guideline provides 109 recommendations on diagnosis, treatments for pain and infertility, management of disease recurrence, asymptomatic or extrapelvic disease, endometriosis in adolescents and postmenopausal women, prevention and the association with cancer.Endometriosis is a chronic condition with a plethora of presentations in terms of not only the occurrence of lesions, but also the presence of signs and symptoms. The most important symptoms include pain and infertility.The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 December 2020 and written in English were included in the literature review.Based on the collected evidence, recommendations were formulated and discussed within specialist subgroups and then presented to the core guideline development group (GDG) until consensus was reached. A stakeholder review was organized after finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee.This guideline aims to help clinicians to apply best care for women with endometriosis. Although studies mostly focus on women of reproductive age, the guideline also addresses endometriosis in adolescents and postmenopausal women. The guideline outlines the diagnostic process for endometriosis, which challenges laparoscopy and histology as gold standard diagnostic tests. The options for treatment of endometriosis-associated pain symptoms include analgesics, medical treatments and surgery. Non-pharmacological treatments are also discussed. For management of endometriosis-associated infertility, surgical treatment and/or medically assisted reproduction are feasible. While most of the more recent studies confirm previous ESHRE recommendations, there are five topics in which significant changes to recommendations were required and changes in clinical practice are to be expected.The guideline describes different management options but, based on existing evidence, no firm recommendations could be formulated on the most appropriate treatments. Also, for specific clinical issues, such as asymptomatic endometriosis or extrapelvic endometriosis, the evidence is too scarce to make evidence-based recommendations.The guideline provides clinicians with clear advice on best practice in endometriosis care, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in endometriosis.The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payments. C.M.B. reports grants from Bayer Healthcare and the European Commission; Participation on a Data Safety Monitoring Board or Advisory Board with ObsEva (Data Safety Monitoring Group) and Myovant (Scientific Advisory Group). A.B. reports grants from FEMaLE executive board member and European Commission Horizon 2020 grant; consulting fees from Ethicon Endo Surgery, Medtronic; honoraria for lectures from Ethicon; and support for meeting attendance from Gedeon Richter; A.H. reports grants from MRC, NIHR, CSO, Roche Diagnostics, Astra Zeneca, Ferring; Consulting fees from Roche Diagnostics, Nordic Pharma, Chugai and Benevolent Al Bio Limited all paid to the institution; a pending patent on Serum endometriosis biomarker; he is also Chair of TSC for STOP-OHSS and CERM trials. O.H. reports consulting fees and speaker's fees from Gedeon Richter and Bayer AG; support for attending meetings from Gedeon-Richter, and leadership roles at the Finnish Society for Obstetrics and Gynecology and the Nordic federation of the societies of obstetrics and gynecology. L.K. reports consulting fees from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; honoraria for lectures from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; support for attending meetings from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; he also has a leadership role in the German Society of Gynecological Endocrinology (DGGEF). M.K. reports grants from French Foundation for Medical Research (FRM), Australian Ministry of Health, Medical Research Future Fund and French National Cancer Institute; support for meeting attendance from European Society for Gynaecological Endoscopy (ESGE), European Congress on Endometriosis (EEC) and ESHRE; She is an advisory Board Member, FEMaLe Project (Finding Endometriosis Using Machine Learning), Scientific Committee Chair for the French Foundation for Research on Endometriosis and Scientific Committee Chair for the ComPaRe-Endometriosis cohort. A.N. reports grants from Merck SA and Ferring; speaker fees from Merck SA and Ferring; support for meeting attendance from Merck SA; Participation on a Data Safety Monitoring Board or Advisory Board with Nordic Pharma and Merck SA; she also is a board member of medical advisory board, Endometriosis Society, the Netherlands (patients advocacy group) and an executive board member of the World Endometriosis Society. E.S. reports grants from National Institute for Health Research UK, Rosetrees Trust, Barts and the London Charity; Royalties from De Gruyter (book editor); consulting fees from Hologic; speakers fees from Hologic, Johnson & Johnson, Medtronic, Intuitive, Olympus and Karl Storz; Participation in the Medicines for Women's Health Expert Advisory Group with Medicines and Healthcare Products Regulatory Agency (MHRA); he is also Ambassador for the World Endometriosis Society. C.T. reports grants from Merck SA; Consulting fees from Gedeon Richter, Nordic Pharma and Merck SA; speaker fees from Merck SA, all paid to the institution; and support for meeting attendance from Ferring, Gedeon Richter and Merck SA. The other authors have no conflicts of interest to declare.This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (Full disclaimer available at www.eshre.eu/guidelines.).
Postmenopausal endometriosis is rare. The purpose of this presentation is to give a review of the topic based on existing literature.A Medline search concerning postmenopausal endometriosis was carried out. Hormone therapy and risk of malignancy in these patients are discussed.Some 32 case reports on postmenopausal endometriosis were found. The most common location is in the ovaries. Estrogens stimulate endometriosis. There is a risk of recurrence or de novo occurrence of endometriosis after the menopause in patients who take hormone therapy (HT); especially estrogen only therapy (ET). So far, treatment has primarily been surgery (hysterectomy (TAH) and bilateral oophorectomy (BSO)).There is little experience with medical treatment (aromatase inhibitors). The risk of malignant transformation of premenopausal endometriosis is around 1%. Furthermore, patients with endometriosis have an increased risk of ovarian cancer, and, apparently, other malignancies. The risk of malignant transformation appears to be further elevated in patients who take ET, although this subject is not fully elucidated.Although the condition is rare, it is important to be aware of endometriosis after the menopause. Postmenopausal endometriosis infers a risk of recurrence and malignant transformation. Although solid evidence is lacking, the risk of malignant transformation appears to be lower during combined HT compared to ET. Thus, hormone replacement therapy should generally be reserved for patients with severe climacteric complaints, and if indicated, combined therapy should be used.
Previous studies have indicated that culture media vary in efficiency and outcomes, such as live birth rate, birthweight and embryo quality. Does Vitrolife G5 series culture media result in higher live birth rates and birthweight compared to other common culture media? This study is a systematic review based on the PRISMA criteria. Relevant search terms, mesh terms (PubMed and Cochrane) and Emtree terms (Embase) were identified. We searched the literature using PubMed, Embase and Cochrane, on November 10, 2019. The inclusion criteria involved published articles in English comparing Vitrolife G5 to other common culture media. We included randomized controlled trials (RCTs) and cohort studies. The quality of the studies was assessed using the Cochrane Risk of Bias tool 2.0 and the Newcastle-Ottawa Scale. Primary outcomes were live birth rate and birthweight. Secondary outcomes were fertilization rate, implantation rate, biochemical pregnancy rate, clinical pregnancy rate, miscarriage rate, multiple pregnancies and congenital malformations. Of 187 articles screened, 11 studies fulfilled the inclusion criteria: Five RCTs and six retrospective cohort studies. Only one study reported live birth rate, showing a non-significantly higher live birth rate for Vitrolife G5 media. Birthweight had equivocal results with three of six studies, showing significantly lower (2)/higher (1) birthweights, whereas the others were non-significant. Overall, there were no significant differences concerning secondary outcomes. The results are equivocal, and we need more studies to evaluate culture media and their effect on short- and long-term health.
Background: The number of women with congenital heart disease (CHD) becoming pregnant are increasing. Although menstrual irregularities appear to occur more often in these patients, knowledge on their fertility is limited. In this nationwide cohort study, we evaluated the risk of impaired fertility in women with CHD compared with unaffected women using time to pregnancy (TTP).Methods: The Danish National Birth Cohort (DNBC) of pregnant women constituted the study population. Information on TTP and use of medically assisted reproduction (MAR) treatment was reported at a first trimester interview. Women with CHD were identified by linkage to the Danish National Patient Registry. Two outcome variables were defined; TTP > 6 months or use of MAR treatment to conceive (i.e. subfertile) and TTP > 12 months or use of MAR treatment to conceive (i.e. infertile). Risk ratios for subfertility and infertility with 95% confidence intervals were estimated using binomial logistic regression.Results: Among 93,832 pregnancies in 84,922 women, CHD was diagnosed in 333 women (0.4%), contributing with 360 pregnancies. The CHD was of simple complexity in 291 (87.4%) of the women. No association was found between a diagnosis of CHD and longer TTP. The same was observed when comparing women with simple CHD and unaffected women. The number of women with complex CHD were too low for evaluation.Conclusions: Women with CHD had no increased risk of impaired fertility, assessed by TTP, when compared with unaffected women. A separate analysis of women with complex CHD was hampered by the low number included.
Despite the high number of frozen embryo transfer (FET) cycles being conducted (190 000 cycles/year) in Europe, the timing of blastocyst transfer and the use of luteal phase progesterone support in modified natural cycle FET (mNC-FET) in assisted reproductive technologies are controversial. In mNC-FET, the timing of blastocyst warming and transfer is determined according to the time of implantation in a natural cycle, aiming to reach blastocyst endometrial synchronicity. However, the optimal day of blastocyst transfer following ovulation trigger is not determined. In addition, the value of luteal phase support to maintain the endometrium remains uncertain. Thus, there is a need to identify the optimal timing of blastocyst warming and transfer and the effect of luteal phase support in a randomised controlled trial design. The aim of this randomised controlled trial is to investigate if progesterone supplementation from the early luteal phase until gestational age 8 weeks is superior to no progesterone supplementation and to assess if blastocyst warming and transfer 6 days after ovulation trigger is superior to 7 days after ovulation trigger in mNC-FET with live birth rates as the primary outcome.Multicentre, randomised, controlled, single-blinded trial including 604 normo-ovulatory women aged 18-41 years undergoing mNC-FET with a high-quality blastocyst originating from their first to third in vitro fertilisation/intracytoplasmic sperm injection cycle. Participants are randomised (1:1:1:1) to either luteal phase progesterone or no luteal phase progesterone and to blastocyst warming and transfer on day 6 or 7 after human chorionic gonadotropin trigger. Only single blastocyst transfers will be performed.The study is approved by the Danish Committee on Health Research Ethics (H-18025839), the Danish Medicines Agency (2018061319) and the Danish Data Protection Agency (VD-2018-381). The results of the study will be publicly disseminated.The study is registered in EudraCT (2018-002207-34) and on ClinicalTrials.gov (NCT03795220); Pre-results.
Phantom breast syndrome after mastectomy has already been reported by us and other authors. The temporal course, character, and extent of these phenomena, however, have not yet been elucidated. Objective To investigate in a prospective study the incidence, clinical picture, and temporal course of phantom breast syndrome during a 6-year period. Design One-hundred twenty women who embarked on consecutive postoperative control or treatment at our department during a 1-year period were interviewed by a standard questionnaire 3 weeks after the operation. Of these, 110 patients were interviewed 1 year later and 69 were interviewed again 6 years later. Patients The median age at the first interview was 54 years (Quartile (Q)1 =45 years; Q3 = 62 years) and at the third interview 6 years later, 60 years (Q1 = 51 years; Q3 = 68 years). Results The incidence of phantom pain and nonpainful phantom sensations was 13.3% and 15.0%, respectively, 3 weeks after mastectomy, 12.7% and 11.8%, respectively, after a year, and 17.4% and 11.8%, respectively, after 6 years. We found significant relationships between preoperative pain and phantom breast syndrome, but no significant relationship between age and the occurrence of this syndrome. Neither postoperative sequelae nor cancer treatment including radiotherapy seemed to affect the occurrence of phantom breast syndrome. Pain in the scar, which was clearly distinguishable from phantom pain, was present in 35.0% of the patients 3 weeks postoperatively, in 22.7% after 1 year, and persisted in 30.9% 6 years later. Conclusions The present incidence of phantom-related phenomena is close to the incidence reported by others. However, persistent phantom pain after mastectomy may be more common than usually expected. Also, the persistence of pain in the scar seems to be more common than generally expected.
