Ethanol sclerotherapy in Infertile

women with endometrioma

Marendra Mahathir

Supervisor:
dr. Gunawa D.P., OBGYN (C)

Departemen Obstetrik dan Ginekologi

FKUI - RSPAD
 Learning Objective
• to understand the value ethanol sclerotherapy in
patients with a endometrioma
 Background
• Endometriosis is a common hormone-dependent
and refractory gynaecologic disease.
• The main clinical symptoms are a progressive
increase in dysmenorrhoea (40%–60%), menstrual
abnormalities and infertility (40%).

Himpunan Endokrinologi Reproduksi dan Fertilitas Indonesia (HIFERI)

 Background

• Ovarian endometrioma  cysts that are lined with

endometrial tissue and contain fluid that arises from
accumulation of menstrual debris. (17-44% of
women with endometriosis)
• Several medical methods are available were
invasive or non invasive treatment
• Ovarian cystectomy can lead to decreased
ovarian reserve surgical treatment less benefit for
infertile women
 Background
• To preserve the ovarian reserve, nonsurgical
management of ovarian endometrioma, including
expectant management, aspiration, or
sclerotherapy, has been advocated

• this is one of the reasons why sclerotherapy is

another option beside laparotomy or laparoscopy.

Professor Giuseppe Benagiano is Professor Emeritus at ‘la Sapienza’, University of Rome.

 Problem
• Is sclerotheraphy with etanol can be an effective
and safe alternative treatment in patient with
endometrioma?
 PICO
Description

Population Patient with endometrioma

Intervention Etanol Sclerotheraphy

Comparation -
Outcome Recurrent cysts, the ovarian
function
 Evident Search Methodology
PubMed (Advanced Search):
Endometrioma AND Etanol Sclerotheraphy
AND recurrent cysts AND the ovarian function

PubMed n=22

Papers for review of title and type

of article relevant n=3

• Relevant article n=3

• The electronic search generated 634 records; we
excluded 605
• by screening their titles and abstracts. 29 studies met the
inclusion criteria and were selected for full article
assessment
• An additional 11 studies were excluded for the following
reasons: study design (two case reports), four review
articles, one nonhuman study, one double
publication,and three that did not meet the outcome
measures.
• Finally, 18 studies were included in the present review
• 11 studies used the ethanol ‘‘washing’’ technique
(ethanol was instilled for 0–15 minutes and then
removed
• Methotrexate sclerotherapy was performed with
the use of 30 mg methotrexate diluted in 3 mL
normal saline solution
• tetracycline sclerotherapy was performed by
means of instillation of 20%–100% of the initial
aspirated cyst volume
Endometrioma Recurrence
and Symptoms Relief
 Endometrioma Recurrence
and Symptoms Relief

• Endometrioma recurrence after ethanol

sclerotherapy ranged from 0 to 62.5%. (FU > 6
months)
• The rates of endometrioma recurrence were 0–
13.3% when ethanol was left in situ and 0–62.5%
when it was used for ‘‘washing’’
• In one study, the recurrence rate was 62.5% when
ethanol instillation time was <10 minutes and 9.1%
when it was >10 minutes (P<.001)
 Endometrioma Recurrence
and Symptoms Relief

• The rates of endometrioma recurrence after

tetracycline range from 25% to 46%
• methotrexate sclerotherapy ranged from 25% to
46% and from 18% to 26% (two or more aspirations
were needed)
• Pain symptoms resolved or improved in 68%– 96%
after ethanol sclerotherapy and in 80% after
methotrexate sclerotherapy.
 Fertility and Pregnancy Outcome

• The overall pregnancy rate after sclerotherapy

ranged from 20% to 57%
• AFC was significantly higher after ethanol
sclerotherapy compared with laparoscopic
cystectomy
• In another study, there was no difference in AFC
between the two groups. However, a lower
concentration of AMH was observed in women who
underwent laparoscopic cystectomy
Fertility and Pregnancy Outcome
 Adverse Outcomes and Complications

• In women who were treated with the use of ethanol

sclerotherapy, abdominal pain was reported in five
studies (1.8%–15.3%), postoperative fever in one study
(5.5%), alcohol intoxication in one study (3.8%).
• Another studies, postoperative fever (19.3%) and
abdominal pain (12.9)%
• Complications after tetracycline sclerotherapy 
abdominal pain was the only reported complication

Endometrioma sclerotherapy was shown to be a safe

procedure with a relatively low rate of complications.
 Materials and methods:
• Prospective study, between January 2005 and
December 2013, Bangladesh
 Materials and methods:
• Cyst contents were sequentially aspirated and flushed
with normal saline until the aspirated fluid was clear
• Ethanol amounting 75% of aspirated fluid was instilled
and removed. Then 5-10 ml ethanol reinstilled and kept
in situ. .
• Patients were kept under GnRH or OCP for 8 to 12 weeks
• Ultrasound was performed at 6 weeks, 3 months, 6
months, 9 months and 12 months to assess the efficacy
of treatment
• Outcome measures were resolution of cyst and
pregnancy rates.
Result
• In this study found satisfactory result (79.25%
complete resolution) after aspiration and ethanol
sclerotharapy
• It indicates that ovarian reserve does not go down
after cyst aspiration and sclerotherapy in
comparison to cystectomy.
• No one developed serious postoperative
complications
 Ultrasound in Med. & Biol., Vol. 37, No. 10, pp. 1596–1602, 2011

• January 2006 and November 2008.

• the 198 patients, 97 patients underwent surgical therapy and 101 patients
underwent laparoscopic therapy

• Patients took gestrinone orally up to 3 months after receiving ultrasound-guided

interventional therapy.
Ultrasound in Med. & Biol., Vol. 37, No. 10, pp. 1596–1602, 2011
Ultrasound in Med. & Biol., Vol. 37, No. 10, pp. 1596–1602, 2011
Ultrasound in Med. & Biol., Vol. 37, No. 10, pp. 1596–1602, 2011
•  They concluded that ultrasound-guided
sclerotherapy with 95% ethanol retention is an
effective alternative therapy for recurrent ovarian
endometrioma
 Conclusion
• Cystectomy should be considered of therapy for
most cases of endometrioma.
• less invasive aspiration with ethanol sclerotherapy
(ethanol retention 95%) and is a good alternative,
which is safe and effective.