Study question To assess the effect of pentoxifylline, a methyl-xanthine with anti-inflammatory effects, for the management of premenopausal women with endometriosis. Summary answer There is not enough evidence to support the use of pentoxifylline in the management of premenopausal women with endometriosis to improve fertility and pain outcomes. What is known already Endometriosis is a chronic, inflammatory condition that occurs mainly during the reproductive years. It is characterized by endometrium-like tissue developing outside the uterine cavity. This endometriotic tissue development is dependent on estrogen produced primarily by the ovaries and partially by the endometriotic tissue itself and, therefore, hormonal management is traditionally used. In light of the body of evidence suggesting an immunological component to the pathophysiology of endometriosis, the anti-inflammatory agent pentoxifylline has been proposed as an alternative therapeutic agent. Study design, size, duration A Cochrane systematic review and meta analysis was performed. Electronic searches of the Cochrane Gynaecology and Fertility Specialised Register of Controlled Searches, CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL and AMED OVID were conducted to December 2020 to identify relevant randomised controlled trials (RCTs). In addition, electronic searches were conducted on the Epistemonikos database, Human Reproduction, Web of Knowedlge, OpenGrey, LILACS, Pubmed and Google. Participants/materials, setting, methods Participants: premenopausal women with endometriosis via laparoscopy/laparotomy. For extent of endometriosis, grades according to the AFS/rASRM scoring system were used. Intervention: pentoxifylline treatment for any period of time Comparisons: placebo, no treatment, medical treatment, surgical treatment. Two independent authors screened studies and extracted data. Risk ratios were calculated for dichotomous data (Peto odds ratio for low event rates) and mean differences (MD) for continuous data, with 95% confidence intervals (CI). Main results and the role of chance Five RCTs were included, involving 415 participants. Pentoxifylline vs placebo No trials reported on live birth or reduction of pain. We are uncertain whether pentoxifylline affects the clinical pregnancy rate (Peto OR 1.53, 95% CI 0.89 to 2.63; 3 RCTs, n = 285; I2 = 0%; very low-quality evidence), recurrence rate (Peto OR 0.83, 95% CI 0.26 to 2.60; 1 RCT, n = 121; very low-quality evidence), or miscarriage rate (Peto OR 1.99, 95% CI 0.20 to 19.37; 2 RCTs, n = 164; I2= 0%; very low-quality evidence). Pentoxifylline vs no treatment We are uncertain whether pentoxifylline impacts on pain reduction when compared to no treatment at one month (MD -0.36, 95% CI -2.08 to 1.36; 1 RCT; n = 34; very low-quality evidence), two months (MD -1.25, 95% CI -2.67 to 0.17; 1 RCT; n = 34; very low-quality evidence) or three months (MD -1.60; 95% CI -3.32 to 0.12; n = 34; very low-quality evidence). No studies reported on live birth. Pentoxifylline vs medical treatment One study compared pentoxifylline with the combined contraceptive pill, but could not be included in the meta-analysis, as it was unclear if the data were presented as +/- standard deviation. Pentoxifylline vs surgical treatment No study reported on this comparison Limitations, reasons for caution Based on the GRADE criteria, the quality of evidence was classified as very low with issues arising due to risk of bias and imprecision. Four studies did not apply the intention-to-treat principle. None of the studies reported on live birth rate, one of the primary outcomes of the review. Wider implications of the findings Future research should prioritise live birth and overall pain as the primary outcome and include patients with all endometriosis severity types. All included studies compared pentoxifylline with placebo or no treatment after surgery, which highlights the need for more types of comparisons, such as to hormonal contraception. Trial registration number Not applicable
Purpose of reviewAdenomyosis is a condition where endometrium-like tissue spreads within the myometrium. Although its prevalence in the general population is not exactly known, its clinical manifestations are well established and include pelvic pain, dysmenorrhea (painful periods), heavy menstrual bleeding and subfertility [1]. Adenomyosis often coexists with other gynaecological conditions, such as endometriosis or fibroids, and may cloud the clinical presentation [2]. The aim of this article is to review current noninterventional, nonsurgical management modalities and wherever possible offer information that allows women to make safe and informed choices regarding their treatment options. Recent findingsRecent studies support that medical strategies, including the Mirena coil, Dienogest and GnRH antagonists, are efficient in improving adenomyosis-associated symptoms. High-quality evidence is scarce and is needed to properly counsel women with this condition. Future research should prioritize overall pain, menstrual bleeding, quality of life and live birth as primary outcomes and assess women with different grades of adenomyosis.
Purpose of reviewTo review the recent evidence around the treatment of infertility in patients with endometriosis.Recent findingsThe management of endometriosis associated infertility remains challenging. There have been an increasing number of prospective observational studies highlighting the role of surgery to enhance assisted conception amongst those with deep rectovaginal endometriosis. Further validation studies confirm the role of the endometriosis fertility index in prediction of reproductive outcomes after surgery, and confirm that it can be employed in counselling patients prior to surgery on their likelihood of spontaneous conception. Further randomized trials are required to establish the role of surgically treating superficial and deep endometriosis and both spontaneous and assisted conception outcomes.SummaryEndometriosis continues to present challenges in counselling patients with regards to their fertility prospects. This article reviews the recent research findings that may assist in the management of patients with endometriosis associated infertility.
A 23-year-old low-risk primiparous patient, who was 35 weeks pregnant, presented in the emergency department after collapsing at home. Her observations showed severe hypertension with proteinuria. On examination, she had left hemiparesis and was aphasic. Fetal monitoring was reassuring. Initial CT did not reveal any evidence of intracranial pathology. She was stabilised and delivered via emergency caesarean section. Subsequent MRI and CT showed an acute right-sided infarct involving the right middle cerebral artery territory, frontal and parietal regions, and increased mass effect. She was transferred to the nearest neurosurgical centre where she was conservatively managed and discharged home 3 weeks later for continuing rehabilitation. She achieved a good recovery.
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