Materials and Methods

This is a retrospective study involving 129 of 140 patients with pelvic endometriosis undergoing single or repeated transvaginal ultrasound-guided ovarian endometrioma aspiration treatment at our department of reproductive health from January 2000 through July 2007. In all, 7.9% (11/140) of the patients were lost to follow-up (3 during the first year and 8 during the second), and were not included in this study. All these women presented with infertility for at least 2 years and had been seeking pregnancy in varying duration. The mean (±SD) age was 32.6 ± 4.3 years and the mean duration of infertility was 4.1 ± 2.2 years. All subjects were diagnosed with ovarian endometriomas by transvaginal ultrasound scan (Aloka-1000, UST-985, 5-MHz transvaginal probe; Aloka Co Ltd, Tokyo, Japan), or by previous laparoscopic surgery or laparotomy treatment for pelvic endometriosis and endometriomas were being seen because of a recurrence. Prior to aspiration, 112 patients had received hormonal treatment: 47 danazol (600-800 mg/d in divided doses for 4-7 months), 39 gonadotropin-releasing hormone agonist (GnRH-a) (triptorelin 3.75 mg/6 weeks for 3-6 months), and 26 Diane-35 (1 tablet/d, 21 tablet/mo for 3-9 months; Schering GmbH & Co. Productions KG, Weimar, Germany). A total of 53 patients had undergone surgical treatments, of whom 24 had laparotomy done with ovarian cystectomy and adhesiolysis and had reported again with recurrence of ovarian endometriomas. In all, 29 women had laparoscopic fulguration of endometriotic implants and adhesiolysis to improve fertility, but had failed to conceive on a follow-up of >2 years with recurrence of endometriotic cysts. Aspirations or reaspirations were not done in those who presented genital infection or cardiovascular, respiratory, mental, hepatic, or renal disorders. In addition, patients who opted for in vitro fertilization-embryo transfer during follow-up period after they had received aspiration or reaspiration of cysts (3 of 8 patients who were lost to follow-up during the second year) were not included in this study. All patients’ characteristics are shown in Table 1 .

Cyst aspiration was done on an outpatient basis. An intramuscular injection of 50-100 mg of pethidine hydrochloride (Shenyang First Pharmaceutical NEPG, Shen-Yang, China) was administered to each woman just before starting the procedure. The procedure proceeded in accordance with that reported by Mittal et al. After emptying the bladder, the women were placed in lithotomy position. They were then prepped using an aseptic vulva and vaginal douche. An ultrasound examination was carried out just before the aspiration and the optimal site for puncture was selected. The needle guide was attached to the ultrasound probe after cleaning and covering it with a sterile condom. Under transvaginal ultrasonographic guidance, a 16-gauge, 350-mm long needle was used for transvaginal puncture and inserted into the endometriomas and the contents were aspirated. The progress of the needle was observed through the tissues on the ultrasound until the tip was visualized well within the cyst. The needle tip was monitored throughout aspiration. High negative pressure of 200-400 mm Hg during aspiration was controlled and regulated manually according to the thickness of contents ( Videos 1-18 ). To prevent the contents of cysts leaking from the cyst wall, postaspiration normal saline irrigation was avoided. A little normal saline may be used during aspiration only when the contents are too sticky to be aspirated. All contents aspirated from the cysts were subjected to cytopathological examination.

Postoperative recurrences of endometriomas were monitored by monthly transvaginal ultrasound scan. Single or multiple cysts of ≥30 mm diameter after first aspiration was the indication for reaspiration, which was performed 3-5 days after the menstrual period of the following cycle. Repeated aspirations were done monthly if the recurrent cysts reached the size needed to aspirate. All patients were directed to try to conceive and followed up for 2 years after aspiration.

All patients were informed that this was a simple and safe technique, and its clinic efficacy had not been confirmed yet, although some previous studies described this technique in the literature for the same purpose with a good outcome. Subjects all signed an informed consent form. Institutional review board approval was not required for this retrospective study.

Statistical analysis was performed using the Fisher’s exact test where appropriate. A linear test for trend (linear regression) was used to analyze a linear regression relationship between the changes of times of aspirations (independent variable) and the chances of recurrences of cysts (dependent variable). A P value < .05 was considered statistically significant. All statistics were performed using software (SPSS 13.0; SPSS Inc, Chicago, IL).