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EPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY

epeat transvaginal ultrasound-guided aspiration of ovarianndometrioma in infertile women with endometriosisenjie Zhu, MD; Zhen Tan, MM; Zhihong Fu, MD; Xuemei Li; Xiumin Chen; Yonghong Zhou

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BJECTIVE: We sought to investigate the effectiveness of repeatedransvaginal ultrasound-guided aspiration of endometriomas in infertileomen with endometriosis.

TUDY DESIGN: A retrospective study was performed in our depart-ent of reproductive health on 129 infertile women who underwentonthly repeated transvaginal aspiration of endometriomas. The recur-

ence and pregnancy were monitored during a follow-up period of 24onths.

ESULTS: Recurrences of cysts were found in 118 (91.5%) patients in

m J Obstet Gynecol 2011;204:61.e1-6.

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Table of Contents

n the third, 28 (21.7%) in the fourth, 12 (9.3%) in the fifth, 7 (5.4%) inhe sixth, and 36 (27.9%) in the 24th postaspiration month. Mean 3.1

2.8 times of aspirations per patient were performed without any ad-erse effect. There was a linear regression relationship between thehange of times of aspirations and the chance of recurrence of cysts.verall pregnancy rate of 43.4% (56/129) was obtained.

ONCLUSION: The repetitive aspiration of endometriomas is an effec-ive therapeutic option in patients with endometriosis.

ey words: aspiration, endometrioma, pregnancy, recurrence,
he first postaspirate month and 86 (66.7%) in the second, 60 (46.5%) repeated
ite this article as: Zhu W, Tan Z, Fu Z, et al. Repeat transvaginal ultrasound-guided aspiration of ovarian endometrioma in infertile women with endometriosis.

MT1tteofalaipyvwtAit5Lrmmrt4dr(

lthough endometriosis is a commondisease among women of reproduc-

ive age, the optimal management ap-roach toward it is still controversial. Sur-ical and hormonal treatments are 2raditional methods. However, none ofhese has absolute advantage or disadvan-age over the other in terms of reproduc-ive success. In general, surgery is advo-ated when a patient is diagnosed withersistent ovarian endometriomas despiteormonal treatment. Laparoscopic cystec-omy to remove ovarian endometriomas is

rom the Department of Reproductiveealth and Department of Gynecology,

hen-Zhen City Maternity and Childealthcare Hospital, Shen-Zhen, Guang-ong Province, Peoples Republic of China.

eceived Feb. 10, 2010; revised July 6, 2010;ccepted Aug. 24, 2010.

eprints: Wenjie Zhu, MD, No. 3012, Fu-Qiangoad, Shen-Zhen City, 518048, Guang-Dongrovince, [email protected].

002-9378/$36.002011 Mosby, Inc. All rights reserved.

oi: 10.1016/j.ajog.2010.08.040

VIDEOClick Supplementary Content underthe article title in the online

n effective procedure, but presence of pel-ic adhesions can make it difficult to visu-lize anatomic structures, leading to sub-ptimal resection, cyst recurrence, andurgical complications, such as hemoperi-oneum, rectovaginal fistula, anastomoticeakage/fistula, ureteral fistula/uroperito-eum, bowel perforation, pelvic abscess,eed for temporary loop ileostomy, post-perative bowel or ureteral anastomotictenosis, neurogenic bladder dysfunction,onstipation, and peripheral sensory dis-urbance, which may further jeopardizehe reproductive status of the women.1

Therefore, ultrasound-guided endo-etrioma aspiration has been proposed as

n alternative therapeutic modality in se-ected patients for the relief of symptoms2

r patients undergoing infertility treat-ent to improve reproductive outcome.3

tudies have reported varying rates ofecurrence after simple aspiration. Trans-aginal, ultrasound-guided ovarian endo-etrioma aspiration as an effective treat-ent is still controversial with studies

eing reported both in favor4 as well asgainst5 aspiration. In the present study,ur aim is to investigate the therapeuticfficacy and reproductive outcome fol-owing repeated transvaginal ultrasound-uided endometrioma aspiration in infer-

etriosis. m

JANUARY 2011 Ameri

ATERIALS AND METHODS

his is a retrospective study involving29 of 140 patients with pelvic endome-riosis undergoing single or repeatedransvaginal ultrasound-guided ovarianndometrioma aspiration treatment atur department of reproductive healthrom January 2000 through July 2007. Inll, 7.9% (11/140) of the patients wereost to follow-up (3 during the first yearnd 8 during the second), and were notncluded in this study. All these womenresented with infertility for at least 2ears and had been seeking pregnancy inarying duration. The mean (�SD) ageas 32.6 � 4.3 years and the mean dura-

ion of infertility was 4.1 � 2.2 years.ll subjects were diagnosed with ovar-

an endometriomas by transvaginal ul-rasound scan (Aloka-1000, UST-985,-MHz transvaginal probe; Aloka Cotd, Tokyo, Japan), or by previous lapa-oscopic surgery or laparotomy treat-ent for pelvic endometriosis and endo-etriomas were being seen because of a

ecurrence. Prior to aspiration, 112 pa-ients had received hormonal treatment:7 danazol (600-800 mg/d in dividedoses for 4-7 months), 39 gonadotropin-eleasing hormone agonist (GnRH-a)triptorelin 3.75 mg/6 weeks for 3-6
onths), and 26 Diane-35 (1 tablet/d, 21
can Journal of Obstetrics & Gynecology 61.e1

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6

ablet/mo for 3-9 months; ScheringmbH & Co. Productions KG, Weimar,ermany). A total of 53 patients had un-ergone surgical treatments, of whom 24ad laparotomy done with ovarian cys-ectomy and adhesiolysis and had re-orted again with recurrence of ovarianndometriomas. In all, 29 women hadaparoscopic fulguration of endometri-tic implants and adhesiolysis to im-rove fertility, but had failed to conceiven a follow-up of �2 years with recur-ence of endometriotic cysts. Aspirationsr reaspirations were not done in thoseho presented genital infection or car-iovascular, respiratory, mental, he-atic, or renal disorders. In addition,atients who opted for in vitro fertiliza-ion-embryo transfer during follow-uperiod after they had received aspirationr reaspiration of cysts (3 of 8 patientsho were lost to follow-up during the

TABLE 1Characteristics of 129 patients with

Characteristics

Age, y...................................................................................................................

Duration of infertility, y...................................................................................................................

Infertility..........................................................................................................

Primary..........................................................................................................

Secondary...................................................................................................................

CA-125 level, U/mL...................................................................................................................

Preaspirate hormonal treatment..........................................................................................................

GnRH-a..........................................................................................................

Danazol..........................................................................................................

Diane-35...................................................................................................................

Previous surgery for ovarian endometriosis...................................................................................................................

Single cyst..........................................................................................................

Diameter of cysts, cm...................................................................................................................

Multiple cysts..........................................................................................................

Diameter of largest cyst, cm...................................................................................................................

Side of cyst..........................................................................................................

Right..........................................................................................................

Left..........................................................................................................

Bilateral...................................................................................................................

Diane-35; Schering GmbH & Co. Productions KG, Weimar, GeGnRH, gonadotropin-releasing hormone agonist.

Zhu. Repeated aspiration treatment for endometriomas. A

econd year) were not included in this a

1.e2 American Journal of Obstetrics & Gynecolog

tudy. All patients’ characteristics arehown in Table 1.

Cyst aspiration was done on anutpatient basis. An intramuscular in-

ection of 50-100 mg of pethidine hy-rochloride (Shenyang First Pharma-eutical NEPG, Shen-Yang, China) wasdministered to each woman just be-ore starting the procedure. The proce-ure proceeded in accordance withhat reported by Mittal et al.3 Aftermptying the bladder, the women werelaced in lithotomy position. Theyere then prepped using an asepticulva and vaginal douche. An ultra-ound examination was carried outust before the aspiration and the opti-

al site for puncture was selected. Theeedle guide was attached to the ultra-ound probe after cleaning and cover-ng it with a sterile condom. Underransvaginal ultrasonographic guid-

ndometriomas

No. of patients (%) or mean � SD

32.6 � 4.3..................................................................................................................

4.1 � 2.2..................................................................................................................

..................................................................................................................

88 (68.2)..................................................................................................................

41 (31.8)..................................................................................................................

46.4 � 19.5..................................................................................................................

..................................................................................................................

39 (30.2)..................................................................................................................

47 (36.4)..................................................................................................................

26 (20.2)..................................................................................................................

53 (41.08)..................................................................................................................

99 (76.7)..................................................................................................................

9.3 � 6.2..................................................................................................................

30 (23.3)..................................................................................................................

8.2.� 5.0..................................................................................................................

..................................................................................................................

56 (43.4)..................................................................................................................

46 (35.7)..................................................................................................................

27 (20.9)..................................................................................................................

y.

Obstet Gynecol 2011.

nce, a 16-gauge, 350-mm long needle I

y JANUARY 2011

as used for transvaginal puncture andnserted into the endometriomas andhe contents were aspirated. Therogress of the needle was observedhrough the tissues on the ultrasoundntil the tip was visualized well within

he cyst. The needle tip was monitoredhroughout aspiration. High negativeressure of 200-400 mm Hg during as-iration was controlled and regulatedanually according to the thickness of

ontents (Videos 1-18). To prevent theontents of cysts leaking from the cystall, postaspiration normal saline irri-ation was avoided. A little normal sa-ine may be used during aspirationnly when the contents are too stickyo be aspirated. All contents aspiratedrom the cysts were subjected to cyto-athological examination.Postoperative recurrences of endo-etriomas were monitored by monthly

ransvaginal ultrasound scan. Single orultiple cysts of �30 mm diameter after

rst aspiration was the indication foreaspiration, which was performed 3-5ays after the menstrual period of the fol-

owing cycle. Repeated aspirations wereone monthly if the recurrent cystseached the size needed to aspirate. All pa-ients were directed to try to conceive andollowed up for 2 years after aspiration.

All patients were informed that thisas a simple and safe technique, and its

linic efficacy had not been confirmedet, although some previous studies de-cribed this technique in the literatureor the same purpose with a good out-ome. Subjects all signed an informedonsent form. Institutional review boardpproval was not required for this retro-pective study.

Statistical analysis was performed us-ng the Fisher’s exact test where appro-riate. A linear test for trend (linear re-ression) was used to analyze a linearegression relationship between thehanges of times of aspirations (inde-endent variable) and the chances of re-urrences of cysts (dependent variable).

P value � .05 was considered statisti-ally significant. All statistics were per-ormed using software (SPSS 13.0; SPSS

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ESULTSytology of aspirates in all patients re-ealed multiple hemosiderin-laden mac-ophages, negative for neoplastic cellsnd compatible with the diagnosis of en-ometriosis. All 129 patients had ultra-ound reexamination following the aspi-ation every month for a minimum of 6onths. Afterward the interval of ultra-

ound examination was adjusted for 1-2onths up to 24 months. In all, 48

37.2%) patients volunteered to receiveostoperative medication: 13 receivednRH-a (triptorelin 3.75 mg/6 weeks formonths) and 35 received Diane-35 (1

ablet/d, 21 tablets/mo for 3 months;chering GmbH & Co. ProductionsG). Of the 129 women, 118 (91.5%)ad recurrences of cysts in the first post-spiration month and reaspirations wereerformed immediately for them. Afterhat, 86 (66.7%) had recurrence in theecond, 60 (46.5%) in the third, 2821.7%) in the fourth, 12 (9.3%) in thefth, and 7 (5.4%) in the sixth postaspi-ation month and reaspirations wereerformed right away for them at eachorresponding month. Mean 3.1 � 2.3imes of aspirations per patient were per-ormed. None of the patients had under-one �7 aspirations or reaspirations.he interval between 2 aspirations varied

rom 26-39 days (mean 33 � 6 days).ingle cyst aspirations were performedn 102 women and 27 patients under-ent bilateral cyst aspirations or re-

spirations. There were no aspiration-elated adverse events. The surgical pro-

TABLE 2Correlation of initial cyst size with

Cyst size, cm Aspiration, n (%)

3-5 24 (18.6)...................................................................................................................

5-9 53 (41.1)...................................................................................................................

9-12 43 (33.3)...................................................................................................................

�12 9 (7.0)...................................................................................................................

Totala 129 (100.0)...................................................................................................................

n � no. of patients aspirated.a There was linear regression relationship between times of as

153.714-22.714X, R2 � 0.971).


edure lasted for 7-41 minutes. The

ontents became thinner and thinner,nd the time for each reaspiration washorter and shorter when repeated aspi-ations were done. Volume aspiratedaried from 26-370 mL. The size of thearger cyst and volume aspirated was cor-elated. For different groups of 3-5, 5-9,-12, and �12 cm in terms of size ofysts, correlation of initial cyst size withostaspiration recurrence and reaspira-ion is displayed in Table 2. The recur-ent rates were decreased gradually fol-

FIGURERelationship between times of asp

32nd1st

100.00

80.00

60.00

40.00

20.00

0.00

Re

cu

rre

nt

rate

(%)

Ashu. Repeated aspiration treatment for endometriomas. Am

staspiration recurrence and reaspira

Recurrence and reaspiration, n (%)

First Second Third

21 (16.3) 17 (13.2) 11 (8.5).........................................................................................................................

48 (37.2) 33 (25.6) 20 (15.5).........................................................................................................................

40 (31) 28 (21.7) 21 (16.3).........................................................................................................................

9 (7.0) 8 (6.2) 8 (6.2).........................................................................................................................

118 (91.5) 86 (66.7) 60 (46.5).........................................................................................................................

ions and recurrences of cysts. Each increase with aspiration wou


JANUARY 2011 Ameri

owing monthly repeated aspirationsFigure).

A linear test for trend (linear regres-ion) shows that there was a linear re-ression relationship between thehanges of times of aspirations (inde-endent variable) and the chances of re-urrences of cysts (dependent variable).ach increase with aspiration would de-rease the recurrent chances of the mean2 patients in total (y � 153.714-2.714X, R2 � 0.971), 5 patients in 3-5

ions and recurrence of cysts

7th6th5th4th

iration (time)stet Gynecol 2011.

n

Fourth Fifth Sixth

2 (1.6)..................................................................................................................

10 (7.8) 3 (2.3) 1 (0.8)..................................................................................................................

9 (7.0) 5 (3.9) 3 (2.3)..................................................................................................................

7 (5.4) 4 (3.1) 3 (2.3)..................................................................................................................

28 (21.7) 12 (9.3) 7 (5.4)..................................................................................................................

crease recurrence chances of mean 22 patients in total (y �

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m group (y � 30.800-5.229X, R2 �.969), 7 patients in 5-9 cm group (y �2.429-6.607X, R2 � 0.964), 7 patients in-12 cm group (y � 51.143-7.464X, R2 �.965), and 1 patient in �12 cm group (y

11.000-1.036X, R2 � 0.862).Postoperative follow-up were com-

leted in all patients up to 24 months.he final recurrences of cysts were

ound in 27.9% (36/129) patients (16

TABLE 3Recurrences and pregnancies in va

Variable

Month

1-3

No. of recurrences...................................................................................................................

Cyst size, cma

..........................................................................................................

�9..........................................................................................................

�9...................................................................................................................

Preaspirate medical treatmenta..........................................................................................................

Yes..........................................................................................................

No...................................................................................................................

Postaspirate medical treatmenta..........................................................................................................

Yes..........................................................................................................

No...................................................................................................................

Side of cysta..........................................................................................................

Left..........................................................................................................

Right..........................................................................................................

Bilateral...................................................................................................................

No. of conceptions 2...................................................................................................................

Cyst size, cma

..........................................................................................................

�9 1..........................................................................................................

�9 1...................................................................................................................

Preaspirate medical treatmenta..........................................................................................................

Yes 2..........................................................................................................

No 0...................................................................................................................

Postaspirate medical treatmenta..........................................................................................................

Yes 0..........................................................................................................

No 2...................................................................................................................

Side of cysta..........................................................................................................

Left 1..........................................................................................................

Right 1..........................................................................................................

Bilateral 0...................................................................................................................

n � no. of patients.a No statistically significant differences were found when com


uring the first year and 20 during the o


econd). There were no significant dif-erences in the recurrence rates of cystsetween the patients with and withoutrevious surgery or postoperativeedication; with left cysts and right

ysts; or with larger cysts and smallerysts. The distribution of recurrencesn various patients and months is de-cribed in Table 3.

Conception was planned following

d patients and months of follow-up,

f follow-up

4-6 7-9 10-12 13-15 1

9 7 5.........................................................................................................................

.........................................................................................................................

4 4 1.........................................................................................................................

5 3 4.........................................................................................................................

.........................................................................................................................

7 6 5.........................................................................................................................

2 1 0.........................................................................................................................

.........................................................................................................................

4 2 1.........................................................................................................................

5 5 4.........................................................................................................................

.........................................................................................................................

4 2 2.........................................................................................................................

4 3 3.........................................................................................................................

1 2 0.........................................................................................................................

6 8 11 12 1.........................................................................................................................

.........................................................................................................................

2 4 4 6.........................................................................................................................

4 4 7 6.........................................................................................................................

.........................................................................................................................

5 7 9 10.........................................................................................................................

1 1 2 2.........................................................................................................................

.........................................................................................................................

2 3 4 5.........................................................................................................................

4 5 7 7.........................................................................................................................

.........................................................................................................................

2 3 4 4.........................................................................................................................

3 3 5 5.........................................................................................................................

1 2 2 3.........................................................................................................................

g rates of recurrence and pregnancy.


perations. A total of 56 women con- m

y JANUARY 2011

eived during the follow-up period.verall pregnancy rate of 43.4% (56/

29) was obtained. Twelve patientschieved pregnancy by intrauterine in-emination, 9 due to abnormalities of theusband’s semen and 3 due to cervical

actors. The remaining 44 conceived nat-rally. In all, 73.2% (41/56) of the preg-ancies were obtained in the durationetween the 7th and 18th postoperative

%)

8 19-21 22-24 Total

4 3 36 (27.9)..................................................................................................................

..................................................................................................................

2 1 17 (32.7)..................................................................................................................

2 2 19 (24.4)..................................................................................................................

..................................................................................................................

4 3 31 (27.7)..................................................................................................................

0 0 5 (29.4)..................................................................................................................

..................................................................................................................

1 1 12 (25.0)..................................................................................................................

3 2 24 (29.6)..................................................................................................................

..................................................................................................................

1 1 12 (26.1)..................................................................................................................

2 2 18 (32.1)..................................................................................................................

1 0 6 (22.2)..................................................................................................................

5 2 56 (43.4)..................................................................................................................

..................................................................................................................

2 1 24 (46.2)..................................................................................................................

3 1 32 (41.6)..................................................................................................................

..................................................................................................................

4 2 48 (42.9)..................................................................................................................

1 0 8 (47.1)..................................................................................................................

..................................................................................................................

2 1 21 (43.8)..................................................................................................................

3 1 35 (43.2)..................................................................................................................

..................................................................................................................

1 1 19 (41.3)..................................................................................................................

3 1 25 (44.6)..................................................................................................................

1 0 12 (44.4)..................................................................................................................

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www.AJOG.org Reproductive Endocrinology and Infertility Research

ound when the pregnancy rates amongbove-mentioned various patients wereompared (Table 3). To date, 45 healthyabies have been delivered and 7 womenre in ongoing pregnancies. Abortionccurred in 3 and 1 patient had ectopicregnancy.

OMMENTn the present study, we analyzed the re-roductive outcomes of 129 infertile pa-ients who underwent repeated trans-aginal ultrasound-guided aspiration ofndometrioma. With accumulated preg-ancy rate of 43.4% for 2 years of follow-p, the procedure was considered an ef-

ective therapeutic option in patientsith endometriomas. Transvaginal aspi-

ations of endometriomas were tried asn alternative therapeutic modality inatients with endometriomas.3,6,7 Theeproductive outcome was comparableith conservative surgical management

ncluding laparoscopy. However, oneroblem present in these studies was theigher recurrence rate, which made itifficult for the patients to achieve preg-ancy. This was an important factor why

his simple and safe therapeutic modalityas not extensively spread and applied.

n our series of 129 patients, we foundhat the recurrence rates were reduced byepeated aspirations of cysts. It was1.5% in the first postaspirate month,nd 66.7% in the second. However, itas decreased to 5.4% after 6 consecu-

ive aspirations. If the repeated aspira-ions were continued, we believed thathe recurrence rate would be controlledt a very low level and an optimal thera-eutic effect could be achieved. Theauses of infertility for patients with en-ometriosis may be in varied aspects in-luding immunologic, mechanical, andndocrine; however, all of these factorsre associated with the ectopic endome-rial tissue. If only 1 time of aspirationould remove completely the ectopic en-ometrial tissue, the recurrence woulde avoided.The recurrence rate reduced by repet-

tive aspirations can be explained byathophysiology of endometriosis. Theyclic bleeding can occur in ectopic en-
ometrial tissue as does in entopic endo- i
etrium. Finally, the endometriomaorms gradually, and becomes larger andarger. The content becomes stickier dueo the absorption of the water part of theontent. Importantly, the inflammationhat occurred in normal tissues adjacento cyst made it difficult to define the wallf cyst from the normal tissue. In a re-ort about laparoscopic cystectomy theormal ovarian tissue adjacent to theyst wall was detected in 71% of patientsith endometriosis, whereas normalvarian tissue was removed from only.4% of patients with other benignysts.8 The residuals of cyst wall and con-ent have a bearing on the recurrence ofhe cyst. Disappeared after aspiration,he cyst is refilled with much more fluidt subsequent aspirations. This may bexplained with the exfoliation/menstru-tion of residual endometriotic tissues orissue reaction from mechanical stimu-ation of aspiration. Additionally, theticky content and thick cyst wall indi-ate a long disorder process, which re-ults in a suboptimal aspiration with

uch more residual of contents andall. It does not seem likely that aspira-

ion of the cyst contents would aspiratehe endometriotic plaque on the wall.he recurrence risk of 28% at 2 yearsay be indicative of the slow sloughing

f endometrial tissues from the cyst wallith rising recurrence rates if followed

onger still. However, we believe each as-iration will remove more or less the en-ometriotic tissues shedding from theall following the change of menstrual

ycle or the effect of previous aspiration.ollowing repeated aspirations, the en-ometrial tissues appear to line only amall portion of the cyst wall and resultn a low rate of recurrence and slowrowing. Without residual postaspiratendometriotic tissues, cyst walls collapseue to scarring making reaccumulation

mpossible. We consider that the moreesidual the ectopic endometrial tissues, the more severe the detriment to re-roductive function. Furthermore, reliefr loss of mechanical pressure from thendometriomas is beneficial to ovarianlood supply, ovarian reserve, folliclerowth, and achievement of pregnancy.Infertility is still an important problem

n many patients with endometriosis. f

JANUARY 2011 Ameri

he estimate has been recently con-rmed by long-term follow-up data in-icating an overall probability of reop-ration of 54-58% after 5-7 years withaparoscopic operation.9,10 This figureas as high as 72% in the 19- to 29-year-ld age group. Normal ovarian tissue ad-

acent to the cyst wall was detected in8.7% of patients who underwent a lapa-oscopic cystectomy, leading to loss ofrimordial, primary, and secondary

ollicles.8 A short communication11 de-cribed the delayed onset of prematurevarian failure in some young patientsetween 5-24 months after operative

aparoscopy for ovarian endometriosis,hich is of particular concern to youngatients who are referred for video lapa-oscopy as a treatment for ovarian en-ometriosis.12 The 43% pregnancy rateakes this approach viable since the

aparoscopic therapies are not withoutegative consequences. A recent studyhowed that 12- and 24-month cumula-ive pregnancy rates were 13% and 22%fter repetitive surgery for recurrent en-ometriosis in infertile women com-ared with 25% and 30% in first-linerocedure.13 Compared with traditionalperative approaches, laparoscopy or

aparotomy, transvaginal repeated endo-etriomas aspiration is a simple, safe,

nexpensive, and easily repeatable thera-eutic modality with comparable repro-uctive success.In our patients, normal saline was not

sed to irrigate the cyst following thespiration. Although the wall or mem-rane adhered to the normal tissueightly, it was thin and weak. In the pre-ious laparotomy of endometriomas, weound it very difficult to separate endo-

etrioma from normal tissues, but theyst was easy to break even if the surgeonid it carefully. It was possible that the

rrigation with normal saline could causeeakage of the content from the hole as-irated or rupture caused by irrigation

tself, which may lead to spread and im-lantation of ectopic endometrial tis-ues. We did not use antibiotic prophy-axis. Interestingly, none of our patientsad infection due to the aspiration pro-edure, just as no infection occurredfter oocyte retrieval during in vitro
ertilization-embryo transfer program

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ithout any antibiotic therapy in ourenter.

Some other studies reported that scle-otherapy with 95% ethanol2 or metho-rexate14 following the aspiration of cystselieved the recurrence of endometrio-as. The mechanism of treatments was

o try to destroy the residual wall of cyst.owever, recurrence still was not avoid-

d.2 It is dangerous in the case of inad-ertent injection of alcohol into the peri-oneal cavity.

In the present study, we found thatreaspirate or postaspirate medicalreatment did not offer any advantageso our patients with regard to facilitatingperation or postaspirate recurrence.uzii et al15 also showed that preopera-

ive medical GnRH-a treatment forvarian endometriosis did not supportny benefit for endometriosis-associatednfertility. Some studies demonstratedhat previous preoperative medical treat-

ent was a risk factor for recurrencefter cystectomy of ovarian endometrio-as.16,17 A recent study argues that pre-

perative medical treatment may actu-lly be detrimental for patients withvarian endometriosis.14 Although theperative pattern of laparoscopic cystec-omy or laparotomy differs from that ofspiration of cyst, the present studyhowed that the rates of recurrence andregnancy following repetitive aspirationf cysts were not improved by preaspirate
r postaspirate medical treatment. How- V

ver, a randomized controlled study onreaspirate or postaspirate medical treat-ent is essential to determine the best

herapeutic option in terms of both recur-ence rate and pregnancy rate.

In summary, the repetitive aspiration ofndometriomas is an effective therapeuticption for patients with endometriosis. f

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