Dados do Trabalho

Title

Uterine ischemia following surgical treatment of deep endometriosis as a potential cause of endomyometrial compromise and failure in Assisted Reproduction: a case report.

Objective

To demonstrate that surgical intervention in deep endometriosis can determine structural, nervous, and especially vascular uterine risk, leading to impairment in in vitro fertilization outcomes

Methods

Case report of a 37-year-old woman who underwent surgery for deep endometriosis with an unfavorable outcome in in vitro fertilization due to probable uterine vascular impairment.

Results

A 37-year-old woman with pelvic pain and infertility due to deep endometriosis involving the rectum and bladder sought Assisted Reproduction service and underwent In Vitro Fertilization. She produced 12 good-quality blastocyst embryos and underwent three embryo transfers (ET), a total of 4 embryos transferred, but pregnancy was not achieved. Due to worsening clinical pain, videolaparoscopic surgery was recommended. During surgery, deep implants, the left annex, part of the bladder, and rectum were removed. Hysteroscopy was also performed, which was normal. After the procedure, she experienced amenorrhea with normal FSH levels. She underwent hysteroscopy again, which revealed a small uterine cavity, atrophic endometrium, and adhesions, which were cleared. She remained amenorrheic, and the endometrium did not respond to hormonal therapy and complementary measures. After a few months, she started to experience hypomenorrhea (scanty periods). A repeat hysteroscopy showed the same findings, and another adhesion lysis was performed. After 6 months, she restarted the ET process, and once again, the endometrium was underdeveloped, even with high doses of estrogen. On two occasions, she transferred 2 embryos. In total, she had transferred 8 blastocysts without success. Due to the critical reduction in uterine volume and the formation of adhesions, the hypothesis of uterine ischemia was raised, and an angiore sonance was indicated. The exam showed the absence of the left uterine artery and uncertainty about the origin of the right, as well as a clear reduction in vascular caliber, confirming the hypothesis of ischemia with repercussions on sub-endometrial vessels. Consequently, the transfer of the remaining embryos was suspended, and uterine replacement was recommended.

Conclusion

The possibility of uterine vascular damage following extensive surgeries for deep endometriosis should be considered in the management of infertile patients.

Keywords

Deep endometriosis. Endometrium. Uterine Cavity. Replacement uterus. Gestational Surrogacy.