AAGL 2021 Endometriosis Classification: An Anatomy-based Surgical Complexity Score

Study ObjectiveTo develop a new endometriosis classification system for scoring intraoperative surgical complexity and to examine its correlation with patient-reported pain and infertility.DesignMulticenter study of patients treated at 3 recognized endometriosis centers.SettingThree specialized endometriosis surgical centers in São Paulo, Brazil and Barcelona, Spain.PatientsPatients aged 15 to 45 years with histologically proven endometriosis and no history of pelvic malignancy underwent laparoscopic treatment of endometriosis.InterventionsDemographic data and clinical history, including dysmenorrhea, noncyclic pelvic pain, dyspareunia, dysuria and dyschezia, were prospectively recorded. All patients were staged surgically according to the new 2021 American Association of Gynecologic Laparoscopists (AAGL) and revised American Society of Reproductive Medicine (ASRM) classification systems. The staging for each system was compared against a 4-level surgical complexity scale defined by the most complex procedure performed.Measurements and Main ResultsA total of 1224 patients undergoing surgery met inclusion criteria. The AAGL score discriminated between 4 stages of surgical complexity with high reproducibility (κ = 0.621), whereas the ASRM score discriminated between the complexity stages with poor reproducibility (κ = 0.317). The AAGL staging system correlated with dysmenorrhea, dyspareunia, dyschezia, total pain score, and infertility comparably with the ASRM staging system.ConclusionThe AAGL 2021 Endometriosis Classification allows for identifying objective intraoperative findings that reliably discriminate surgical complexity levels better than the ASRM staging system. The AAGL severity stage correlates comparably with pain and infertility symptoms with the ASRM stage.     

Reliability of Visual Diagnosis of Endometriosis

ObjectiveTo determine whether accuracy of visual diagnosis of endometriosis at laparoscopy is determined by stage of disease.DesignProspective longitudinal cohort study (Canadian Task Force classification II-2).SettingTertiary referral centers in three Australian states.PatientsOf 1439 biopsy specimens, endometriosis was proved in at least one specimen in 431 patients.InterventionsLaparoscopy with visual diagnosis and staging of endometriosis followed by histopathologic analysis and confirmation. Operations were performed by five experienced laparoscopic gynecologists.Measurements and Main ResultsHistopathologic confirmation of visual diagnosis of endometriosis adjusted for significant covariates. Endometriosis was accurately diagnosed in 49.7% of American Society for Reproductive Medicine (ASRM) stage I, which was significantly less accurate than for other stages of endometriosis. Deep endometriosis was more likely to be diagnosed accurately than superficial endometriosis (adjusted odds ratio, 2.51; 95% confidence interval, 1.50–4.18; p < .01). Lesion volume was also predictive, with larger lesions diagnosed more accurately than smaller lesions. In general, lesion site did not greatly influence accuracy except for superficial ovarian lesions, which were more likely to be incorrectly diagnosed visually as endometriosis (adjusted odds ratio, 0.16; 95% confidence interval, 0.06–0.41; p < .01). There was no statistically significant difference in accuracy between the gynecologic surgeons.ConclusionThe accuracy of visual diagnosis of endometriosis was substantially influenced by American Society of Reproductive Medicine stage, the depth and volume of the lesion, and to a lesser extent the location of the lesion.     

Clinical characteristics and pregnancy outcomes of infertile patients with endometriosis and endometrial polyps: A retrospective cohort study

ObjectiveThe aim of this study was to discuss the clinical characteristics and the prognosis of surgically diagnosed endometriosis complicated by endometrial polyps and investigate the association between pregnancy outcomes during subsequent pregnancies.Materials and methodsFrom January 2013 to December 2016, 1263 infertile patients were enrolled in the study. We identified 451 patients with endometriosis, and divided them into a polyp group (n = 204) and a non-polyp group (n = 247) based on whether or not they were associated with endometrial polyps. Postoperative clinical pregnant women (n = 82) among the polyp group were then classified into a study group and a control group composed of those undergoing a singleton pregnancy (n = 164) who delivered during the same time period. Clinical statuses and complications during pregnancy and delivery were collected from hospitals and by telephone interviews and surveys through the mail.ResultsThe prevalence rate of endometriosis infertile group was obviously higher than the non-endometriosis infertile group ([45.23%; 204/451] versus [17.12%; 139/812]). Women suffering from stage 1 to 4 endometriosis had a 42.44% (73/172), 40.69% (59/145), 55.89% (38/68) and 51.52% (34/66) occurrence rate of endometrial polyps, respectively. The frequency of endometrial polyps for stage 3 and 4 patients was obviously higher than that of stage 1 and 2 patients ([53.73%; 72/134] versus [41.64%; 132/317]). Moreover, the occurrence rate of deep infiltrating endometriosis (DIE) was 57.81% (37/64), which was obviously higher than that of ovarian endometriosis (42.42%; 98/231) and peritoneal endometriosis (44.23%; 69/156). Of the 204 women diagnosed with posterior endometrial polyps, 89 became pregnant, 7 pregnancies ended in a spontaneous abortion, and 82 successfully delivered a baby. The clinical pregnancy rate of patients in stages 1 and 2 was wholly higher than that of patients in stages 3 and 4 ([48.70%; 56/115] versus [37.71%; 26/82]). The postsurgical pregnancy status of patients suffering from peritoneal endometriosis was slightly better than those with ovarian or DIE, but differences were not statistically significant (P = 0.626). We also found that the pregnancy rate was statistically elevated in patients whose EFI scores range from 7 to 10. When compared to the control group, women with endometriosis and endometrial polyps had a higher risk of their pregnancy being complicated by placenta previa (13.41%) and cesarean delivery (59.76%).ConclusionPatients with endometriosis have a higher frequency of endometrial polyps. We found that a combined hysteroscopy and laparoscopy surgical procedure is an effective way to increase pregnancy rates. Different endometriosis stages and types in patients were associated with clinical pregnancy and spontaneous abortion rates. Women affected by both endometriosis and endometrial polyps have an independently elevated risk of placenta previa and cesarean delivery during pregnancy.     

A Multicenter International Temporal and External Validation Study of the Ultrasound-based Endometriosis Staging System

Study ObjectiveThe aim of this study was to validate temporally and externally the ultrasound-based endometriosis staging system (UBESS) to predict the level of complexity of laparoscopic surgery for endometriosis.DesignA multicenter, international, retrospective, diagnostic accuracy study was carried out between January 2016 and April 2018 on women with suspected pelvic endometriosis.SettingFour different centers with advanced ultrasound and laparoscopic services were recruited (1 for temporal validation and 3 for external validation).PatientsWomen with pelvic pain and suspected endometriosis.InterventionsAll women underwent a systematic transvaginal ultrasound and were staged according to the UBESS system, followed by classification of laparoscopic level of complexity according to the Royal College of Obstetricians and Gynaecologists (RCOG) levels 1 to 3.Measurements and Main ResultsUBESS I, II, and III were then correlated with RCOG levels 1, 2, and 3, respectively. A comparison between temporal and external sites (skipping “A”) and between each site was performed in terms of the diagnostic accuracy of UBESS to predict RCOG laparoscopic skill level.A total of 317 consecutive women who underwent laparoscopy with suspected endometriosis were included. Complete transvaginal ultrasound and laparoscopic surgical outcomes were available for 293/317 (92.4%). At the temporal site, the accuracy, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of UBESS I to predict RCOG level 1 were 80.0%,73.8%, 94.9%, 97.2%, 60.2%, 14.5%, and 0.3%, respectively; of UBESS II to predict RCOG level 2 were 81.0%, 70.6%, 82.0%, 26.7%, 96.8%, 3.9%, and 0.3%, respectively; of UBESS III to predict RCOG level 3 were 91.0%, 85.7%, 92.4%, 75.0%, 96.1%, 11.3%, and 0.2%, respectively. At the external sites, the results of UBESS I to predict RCOG level 1 were 90.3%, 92.0%, 88.4%, 90.2%, 90.5%, 7.9%, and 0.1% respectively; UBESS II to predict RCOG level 2 were 89.2%, 100.0%, 88.5%, 37.5%, 100.0%, 8.7%, and 0.0%, respectively; and UBESS III to predict RCOG level 3 were 86.0%, 67.6%, 98.2%, 96.2%, 82.1%, 37.8%, and 0.3%, respectively.When patients requiring ureterolysis (i.e., RCOG level 3) in the absence of bowel endometriosis were excluded (n = 54), the sensitivity of UBESS III to correctly classify RCOG level 3 increased from 85.7% to 96.7% at the temporal site (n = 42) and from 67.6% to 96.0% at the external sites (n = 12) (p <.005).ConclusionThe results from this external validation study suggest that UBESS in its current form is not generalizable unless there is either or both bowel deep endometriosis and cul-de-sac obliteration present. The major limitation appears to be the misclassification of women who require surgical ureterolysis in the absence of bowel endometriosis.     

Prediction of endometriosis by transvaginal ultrasound in reproductive-age women with normal ovarian size

ObjectiveTo predict endometriosis by transvaginal ultrasound (TVS) in reproductive-age women with normal ovarian size.DesignProspective study.SettingEl-Shatby Maternity Hospital, Alexandria University.Patients125 Women with symptoms suggestive of endometriosis and with normal ovarian size during TVS.InterventionsPatients were subjected to high frequency ultrasound and evaluated for the presence of ultrasound signs of endometriosis (TVS-based soft markers). All patients had laparoscopy (gold standard) immediately after TVS for documentation of the presence of endometriosis.Main outcome measuresSensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of TVS and of the TVS-based soft markers in diagnosing endometriosis.ResultsEndometriosis was confirmed laparoscopicaly in 68/125 patients (54.4%). The sensitivity, specificity, PPV, NPV and diagnostic accuracy of TVS in diagnosing endometriosis were 85.3%, 80.7%, 84.1%, 82.1% and 83.2%, respectively. Six TVS-based soft markers showed significant association (P < 0.05) with endometriosis (ovaries not at the same level, high left ovary, ovarian fixation to uterus, tender ultrasound, ovarian fixation to iliac vessels and non visualization of left ovary) with sensitivities of 85.3%, 80.9%, 80.9%, 66.2%, 55.9% and 55.9%, respectively. These markers could be considered as positive soft markers to predict endometriosis. The addition of these soft markers could improve the sensitivity, specificity, PPV, NPV and diagnostic accuracy to 97.3%, 98.5%, 95.7%, 89.9% and 91.2%, respectively.ConclusionTVS appears to be a useful imaging method for the prediction of endometriosis. The inclusion of TVS-based positive soft markers either alone or in combination improves our ability to predict endometriosis.     

Ultrasound Prediction of Segmental Bowel Resection in Women with Rectovaginal Endometriosis: A Single-Center Experience

Study ObjectiveTo retrospectively evaluate the ability of routinely collected preoperative ultrasound data to predict bowel resection during surgery for rectovaginal endometriosis.Design and SettingPatients at the University College London Hospital who underwent surgery for rectovaginal endometriosis during a 6-year period were identified from the prospectively generated hospital (British Society for Gynaecological Endoscopy) database. Imaging data were collected and analyzed to determine associations with the requirement for bowel resection.PatientsWe evaluated 228 consecutive women undergoing bowel surgery (shave, disc resection, or segmental resection) for rectovaginal endometriosis.InterventionsThe patients in our study underwent surgical resection of rectovaginal endometriosis and interventions included shave, disc resection, and segmental resection of the bowel. All patients underwent a preoperative transvaginal ultrasound to assess the extent of endometriosis.Measurements and Main ResultsThere were 206 rectal shaves (90.4%), 2 disc resections (0.9%), and 20 segmental bowel resections (8.8%). A multivariable analysis demonstrated an association between bowel resection and ≥2 nodules located in the rectovaginal space (odds ratio [OR] 6.85; 95% confidence interval [CI], 1.37–34.2), nodules in the vesicouterine pouch (OR 5.87; 95% CI, 1.03–33.3), and increasing nodule size (OR 2.39 per 1 cm increase per 1 cm diameter increase; 95% CI, 1.56–3.64).ConclusionUltrasound findings of endometriotic nodule location, number of nodules, and increasing size are independent predictors of segmental bowel resection at the time of surgery for rectovaginal endometriosis. This highlights the importance of accurate diagnostic evaluation to aid counseling and surgical planning in the preoperative setting for women with rectovaginal endometriosis.     

Optimal Timing of Prenatal Ultrasound in Predicting Birth Weight in Diabetic Pregnancies

ObjectiveThis study sought to determine the optimal timing of ultrasound in the third trimester to predict birth weight accurately in diabetic women with a singleton pregnancy.MethodsA retrospective cohort study of all diabetic women with a singleton pregnancy treated in Halifax, Nova Scotia, was performed. Estimated fetal weight was derived from ultrasound measures using the Hadlock2 equation. The Mongelli equation was used to predict birth weight. The association between gestational age at ultrasound and accuracy of predicted birth weight was assessed, with accuracy as a continuous variable representing the difference between predicted and actual birth weight and as a categorical variable (with four gestational age categories) representing whether predicted birth weight was within, over, or under 250 g of actual birth weightResultsThe cohort of 943 women comprised 121 (12.8%) with type 1 diabetes, 111 (11.7%) with type 2 diabetes, and 711 (75.4%) with gestational diabetes. Ultrasound scans performed at term were the most accurate in predicting birth weight. At this gestational age, the mean difference between predicted and actual birth weight was −30 g (95% confidence interval −109 to −48). After adjusting for maternal body mass index, age, smoking, type of diabetes, and interval between ultrasound examination and delivery, accuracy improved as gestational age at ultrasound increased (P = 0.005). The odds of underpredicting or overpredicting birth weight were not significantly affected by the timing of the ultrasound examination.ConclusionBecause the predictive accuracy of ultrasound prediction of birth weight improves with gestational age, fetal growth assessment at term is recommended to aid with delivery planning in women with diabetes.     

Sonographic Evaluation for Endometriosis in Routine Pelvic Ultrasound

Study ObjectiveTo show how the evaluation for endometriosis can be included in the routine pelvic ultrasound examination.DesignStepwise narrated video demonstration of the sonographic evaluation for endometriosis in routine pelvic ultrasound following the recommended sonographic approach published in the 2016 consensus paper by the International Deep Endometriosis Analysis (IDEA) group [1].SettingEndometriosis is a common and often debilitating gynecological disorder that affects 5–10% of women [2]. The prevalence is even higher among women with symptoms of endometriosis [2], which include chronic pelvic pain, acquired dysmenorrhea, dyspareunia, dyschezia, menorrhagia, abnormal bleeding, and infertility. Approximately 80% of women who have endometriosis have superficial lesions, whereas 20% have deep infiltrating endometriosis (DIE; [3]). Laparoscopy is the gold standard for diagnosing endometriosis, because it allows the diagnosis of all forms of endometriosis and often immediate removal of superficial endometriosis. The removal of DIE is considerably more complicated and usually cannot be completed unless it was diagnosed preoperatively. The technique to diagnose DIE with transvaginal ultrasound (TVUS) was first described in detail in 2009 [4]. Since then, the accuracy of TVUS for the prediction of DIE has been well established in the literature 5, 6, 7. TVUS is widely used as a first-line investigation for women with gynecological symptoms. The inclusion of an assessment for endometriosis in the routine pelvic ultrasound allows earlier diagnosis and better surgical outcomes for all women with DIE.InterventionsThe evaluation for endometriosis in routine pelvic ultrasound based on the IDEA consensus promotes a 4-step dynamic ultrasound approach [1]: (1) routine evaluation of uterus and adnexa with particular attention for sonographic signs of adenomyosis and the presence or absence of endometriomas; (2) evaluation of transvaginal sonographic ‘soft markers’ such as site-specific tenderness and ovarian mobility; (3) assessment of status of pouch of Douglas using the real-time ultrasound-based “sliding sign;” and (4) assessment of DIE nodules in the anterior and posterior compartments, which involves assessment of the bladder, vaginal vault, uterosacral ligaments, and bowel, including rectum, rectosigmoid junction, and sigmoid colon. Because 5–10% of women with DIE also have ureteric endometriosis, it is useful to assess the kidneys. Silent hydronephrosis is easily identified in 50–60% of patients with ureteric involvement. Although it is possible to identify DIE involving the ureters more directly, this requires more advanced skills, and further studies are still needed to better define the accuracy of ureteric DIE detection by TVUS 8, 9, 10.ConclusionTraditionally, only pathologies of the uterus and ovaries are assessed during a routine pelvic ultrasound. Here we demonstrate that the routine ultrasound examination can easily be extended beyond the uterus and ovaries into the posterior and anterior pelvic compartments to evaluate structural mobility and to look for deep infiltrating endometriotic nodules, wherewith women suffering from DIE can benefit from a preoperative diagnosis and subsequently, a single, well-planned procedure in the hands of a well-prepared team.     

Preoperative Imaging in Patients with Deep Infiltrating Endometriosis: An Important Aid in Predicting Depth of Infiltration in Rectosigmoid Disease

Study ObjectiveTo determine the diagnostic accuracy of specialist-performed transvaginal ultrasound (TVUS) and pelvic magnetic resonance imaging (MRI) modalities in predicting depth of deep infiltrating endometriosis (DIE) of the rectosigmoid by comparison with histologic specimens obtained at surgery.DesignA retrospective analysis, which met the Standards for Reporting of Diagnostic Accuracy Studies (2015) guidelines for a diagnostic accuracy study.SettingTertiary teaching hospital.PatientsA total of 194 cases who underwent preoperative discussion at the gynecologic endosurgery unit multidisciplinary meeting between January 2012 and December 2019 were eligible for inclusion.InterventionsRetrospective assessment of the accuracy of TVUS and MRI in predicting histologic depth of rectosigmoid DIE after operative management.Measurements and Main ResultsAl total of 135 surgeries were performed for DIE; 20 underwent a rectal shave, 14 had a disc/wedge resection, 38 an anterior/segmental resection, and 63 had no rectosigmoid surgery. Of the 52 patients with full-thickness rectal wall excision, all patients had at least one imaging modality available for review; 42 (81%) had both. At least one imaging modality was in agreement with histologic depth in 48 cases (92%) (sensitivity, 94%; specificity, 50%; positive predictive value [PPV], 97.9%; negative predictive value [NPV], 25.0%; area under the receiver operating curve, 0.720; 95% confidence interval, 0.229–1.000). When TVUS was assessed in isolation, the test remained sensitive for any rectal wall involvement (sensitivity, 93.6%; specificity, 50.0%; PPV, 97.8%; NPV, 25.0%; area under the receiver operating curve, 0.718; 95% confidence interval, 0.227–1.000). When only MRI was assessed, the test demonstrated both high sensitivity and specificity for rectal wall disease (sensitivity, 86.4%; specificity, 100%; PPV, 100%; NPV, 14.2).ConclusionSpecialist-performed TVUS and MRI are accurate in predicting depth of disease in rectosigmoid endometriosis. These modalities were similar in their diagnostic performance at assessing depth of rectal wall involvement, and their use is justified in the preoperative planning of these gynecologic surgeries.     

Correlation of angiogenic cytokines-leptin and IL-8 in stage,type and presentation of endometriosis

Pelvic endometriosis is a chronic inflammatory disease with an immunological background. Yet there is paucity of contemporary research exploring both the angiogenic cytokines, leptin and IL-8 for a possible role in its pathophysiology. Objective: To compare levels of both leptin and IL-8 in peritoneal fluid (PF) in women with endometriosis vs. fertile controls and correlate with disease stage, type and symptoms. Materials and methods: PF from 58 women with endometriosis and 28 women undergoing tubal ligation was collected at laparoscopy and leptin and IL-8 levels were measured using ELISA. Results showed significantly higher levels of both cytokines in women with endometriosis. Significantly higher leptin and IL-8 levels were demonstrated in patients with early peritoneal (ASRM stage I and II) and advancing disease (ASRM stage III and IV), respectively. Levels of leptin/IL-8 were significantly lower in patients with endometrioma (4.8?ng/mL/32 pg/mL) vs. implants (13.0?ng/mL/68 pg/mL). There was no correlation of infertility or chronic pelvic pain with these levels. Conclusion: Both leptin and IL-8 levels are raised in PF of women with endometriosis reflecting inflammation and dysregulated immunomodulation. Higher levels of leptin were seen in early stages; IL-8 seems to stimulate the disease in a dose-dependent manner.     

Association Between Laparoscopic Appearance of Superficial Endometriosis,Positive Histology,and Systemic Hormone Use

Study ObjectiveTo assess the association between laparoscopic appearance of superficial endometriosis lesions, histopathology, and systemic hormone use.DesignRetrospective study.SettingTertiary care academic medical center.PatientsWe identified 266 women who underwent laparoscopic surgery at an endometriosis center with excision of lesions consistent with possible superficial endometriosis between September 2015 and November 2018.InterventionsAppearance of the peritoneal lesions was confirmed with review of surgical videos and correlated with each pathology specimen. Lesions were dichotomized on positive or negative pathology assessment. All pathology-positive lesions were further dichotomized by hormone use within 1 month of surgery.Measurements and Main ResultsA total of 841 lesions were biopsied from included subjects during the study period. Of those, 251 biopsies were negative, and 590 were positive for endometriosis on pathology assessment. Lesions had significantly higher odds of positive histology when they were red (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.17–2.48), white (OR, 1.99; 95% CI, 1.47–2.70), blue/black (OR, 2.98; 95% CI, 2.00–4.44), or puckering (OR, 9.78; 95% CI, 2.46–38.91) in appearance. The following combined characteristics had significantly higher odds of positive histology: white and blue (OR, 5.98; 95% CI, 2.97–12.02), red and white (OR, 2.22; 95% CI, 1.38–3.56), red and blue (OR, 4.11; 95% CI, 1.83–9.24), and clear and white (OR, 8.77; 95% CI, 1.17–66.02). Among positive biopsies, those with hormone exposure were more likely to have clear lesions than those without hormone use (OR, 3.36; 95% CI, 1.54–7.34) and were 2.89 times more likely to have clear and white lesions (95% CI, 1.07–7.85).ConclusionAlthough lesions suspicious for endometriosis may have differing rates of positive pathology based on appearance, no lesion characteristic was able to exclude the possibility of endometriosis. In addition, hormone use may influence lesion appearance at the time of surgery, with clear lesions more prevalent. These data have implications for appropriate identification of endometriosis at the time of laparoscopy to ensure accurate diagnosis and complete treatment of disease.     

Prediction of pelvic pathology in subfertile women with combined Chlamydia antibody and CA-125 tests

Objectives

Chlamydia antibody test (CAT) has been proposed to predict tubal disease. A correlation between CA-125 and the extent of endometriosis has been found by others. In this study we explored whether a combination of the two tests adds to the predictive value of the individual tests for predicting tubal disease or endometriosis. We also used the combination of tests as a new index test to screen for severe pelvic pathology.

Study design

This retrospective study compares the findings of 240 laparoscopies with the serological test results. Findings were classified according to the existing ASRM scoring systems for adnexal adhesions, distal tubal occlusion and endometriosis. Severe pelvic pathology was defined as the presence of ASRM classes III and IV tubal disease or ASRM classes III and IV endometriosis. The predictive value was calculated for both tests separately and for the combined test. The combined test was positive if at least one test result was abnormal (CAT positive and/or CA-125 ≥35 IU/ml).

Results

67/240 women had tubal disease, 81/240 had some degree of endometriosis. The odds ratios (ORs) of the CAT and the combined test to diagnose severe tubal disease were 6.6 (2.6–17.0) and 7.3 (2.9–19.3), respectively. The ORs of the CA-125 and the combined test to diagnose severe endometriosis were 15.6 (6.2–40.2) and 3.0 (1.2–8.0), respectively. Severe pelvic pathology was present in 65/240 women (27%). The ORs for severe pelvic pathology of the CAT, CA-125 and the combined test were 2.5 (1.4–5.3), 4.9 (1.9–9.6) and 6.6 (3.3–13.4), respectively. If the combined test was normal 15 out 131 women (11%) were shown to have severe pelvic pathology.

Conclusions

The combined test adds hardly anything to the predictive value of CAT alone to diagnose severe tubal disease. The combined test is better than the CAT to predict severe pelvic pathology, but is not significantly better than the CA-125. If both the CAT and CA-125 are normal one could consider not performing a laparoscopy.     

The utility of ultrasound and magnetic resonance imaging versus surgery for the characterization of müllerian anomalies in the pediatric and adolescent population

Study ObjectiveTo evaluate the utility of transabdominal ultrasound and magnetic resonance imaging in the evaluation of American Society for Reproductive Medicine ²(ASRM)-classified müllerian anomalies compared to surgical findings in the pediatric and adolescent population.DesignRetrospective chart review.SettingTertiary academic center.ParticipantsThirty-eight patients with müllerian anomalies seen in our pediatric and adolescent gynecology clinic were identified both on the basis of ICD-9 codes and having magnetic resonance imaging at Texas Children's Hospital between 2004 and 2009.InterventionsNone.Main Outcomes MeasureCorrelation among transabdominal ultrasound and magnetic resonance imaging findings with surgical findings.ResultsMean age was 12.2 (± 4.1) years. Twenty-eight patients underwent magnetic resonance imaging and required surgical intervention, and 88.5% demonstrated correlative consistency with surgical findings. Twenty-two patients underwent ultrasound, magnetic resonance imaging, and surgery, which revealed consistency among ultrasound and surgical findings (59.1%) and consistency among magnetic resonance imaging and surgical findings (90.9%). In ASRM diagnoses evaluated by magnetic resonance imaging, surgical findings correlated in 92% (Pearson 0.89). Overall, 55.2% of patients had a renal malformation.ConclusionsMagnetic resonance imaging is the gold standard imaging modality for müllerian anomalies and is an effective technique for noninvasive evaluation and accurate classification of the type of anomaly in the pediatric and adolescent population. Magnetic resonance imaging should be considered as an adjunct to transabdominal ultrasound to evaluate müllerian anomalies.     

What Are Patients Reading? Quality Assessment of Endometriosis Information on the Internet

ObjectiveEvaluate the quality of information reported online about endometriosis and period pain.MethodsAn online search identified the top 20 websites for 4 search engines (Google, Ask, Bing, Yahoo). Videos, duplicates, and websites not containing information related to endometriosis and period pain were excluded. Three independent authors screened websites and systematically extracted data on website characteristics and on diagnosis and treatment mentions. Website accuracy and completeness were rated for a score out of 15. The Flesch readability ease score (FRES) was used to assess readability.ResultsOf 34 websites included, most were news related (44.1%) and health care affiliated (26.5%). Websites with affiliations had significantly higher accuracy scores than those without. Those with references had significantly higher completeness than those without. Non–news-related websites had significantly higher accuracy and completeness than news-related websites. The most commonly reported symptoms were dysmenorrhea (97.1% of websites), infertility (88.2%), and dyspareunia (82.4%). Cancer was mentioned on 41.1% of websites. Diagnostic laparoscopy (91.0%) and ultrasound (88.3%) were the most commonly mentioned diagnostic tools. Commonly reported therapeutics included the oral contraceptive pill (79.4%), laparoscopy (70.6%), non-steroidal anti-inflammatory drugs (NSAIDs; 67.6%), and gonadotropin-releasing hormone (GnRH) agonists (64.7%). Hysterectomy (59.0%) was mentioned more than progestins (53.0%). Overall, 18 of 34 websites (53%) contained 1 or more inaccurate or misleading statements.ConclusionWhile most websites contained accurate statements, commonly reported misconceptions included an emphasized risk of cancer, lack of use/benefit of ultrasound for diagnosis, and a bias for surgical over medical management, where laparoscopy was mentioned more than first-line medications. This study highlights the importance of directing patients to evidence-based resources.     

Ultrasound-Based Endometriosis Staging System: Validation Study to Predict Complexity of Laparoscopic Surgery

Study Objective

To validate the preoperative ultrasound-based endometriosis staging system (UBESS) for predicting the correct Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and Australasian Gynaecological Endoscopy and Surgery (AGES) Society's level of laparoscopic skill required for endometriosis surgery.

Prevalence of Use and Perceived Effectiveness of Medical,Surgical, and Alternative Therapies for Endometriosis Pain in Canadians

ObjectivesTo describe the use and perceived effectiveness of medical, surgical, and alternative therapies (e.g., diet, exercise, heat, cannabis, etc.) in managing endometriosis-associated pain in Canadians.MethodsA cross-sectional online survey was distributed via The Endometriosis Network Canada (TENC) from February to March 2021. Canadians aged 18–50 years with diagnosed or suspected endometriosis were eligible to participate.ResultsA total of 434 survey responses were included, and 93.8% of respondents reported that they used at least 1 alternative therapy in the past 6 months for endometriosis-associated pain. Respondents used an array of medical (2.3/6 months), surgical (1.7/lifetime), and alternative therapies (6.9/6 months) to manage their pain, yet 61.9% of respondents did not feel it was adequately managed. The most common alternative therapies were heat, meditation/mindfulness/rest, and diet.ConclusionAlternative therapies were commonly used by Canadians living with endometriosis to manage pain. Cannabis and heat were perceived as the most effective alternative therapies. Here, we gain a better understanding of alternative therapies that can provide an additional therapeutic avenue that clinicians and people living with endometriosis may wish to discuss and explore.     

Adenomyosis has no adverse effects on IVF/ICSI outcomes in women with endometriosis treated with long-term pituitary down-regulation before IVF/ICSI

Objectives

To establish the effect of adenomyosis on IVF/ICSI outcomes in infertile patients with endometriosis who were pretreated with long-term (≥3 months) GnRH-agonist prior to IVF/ICSI.

Study design

Retrospective study in 74 infertile patients with surgically proven endometriosis who were treated with IVF/ICSI between January 2002 and March 2007. The diagnosis of adenomyosis was based on transvaginal ultrasound criteria. All patients were pretreated with long-term (≥3 months) GnRH-agonist prior to IVF/ICSI.

Results

90.4% of the patients were diagnosed with endometriosis rASRM stages III-IV. Adenomyosis was demonstrated in 27% of them and was predominantly located in the posterior wall of the uterus. The following IVF/ICSI outcomes were found: a mean duration of GnRH-agonist use prior to IVF/ICSI of 5.35 months (3-26); a mean dosage of FSH used of 208 IU (75-450); the mean number of oocytes retrieved was 8.73 (1-30); the mean number of embryos obtained was 3.86 (0-16); the mean number of embryos transferred was 1.6; a mean fertilization rate of 43.6%; a mean implantation rate of 26.3%; a mean miscarriage rate of 24.3%; and a clinical pregnancy rate (fetal heart activity on ultrasound beyond 12 weeks of gestation) of 31.7%. No significant differences were found for any of the IVF/ICSI outcomes between women with and without adenomyosis.

Conclusions

Adenomyosis had no adverse effects on IVF/ICSI outcomes in infertile women with proven endometriosis who were pretreated with long-term GnRH-agonist.     

Endometriosis in Young Women: The Experience of GISE

Study ObjectiveTo analyze the clinical manifestations of endometriosis in adolescents.Designprospective clinical study.SettingUniversity and General hospitals.ParticipantsA total of 38 females aged ≤21 years who had a first surgically confirmed diagnosis of endometriosis during the period including years 2005–2006 at 12 participating centers were identified. Endometriotic lesions were staged according to the 1985 revised American Fertility Society [renamed American Society for Reproductive Medicine (ASRM)] classification.ResultsThe mean age at diagnosis was 18.6 years, except in 3 cases (7.9%) in which it was made at ≤15 years of age. None of the patients had a prior diagnosis of genital malformations, nor were any cases of diagnosed familiarity for endometriosis. Pelvic pain was present in all cases, although in 3 cases the presence of a pelvic mass was the indication for surgery.ConclusionsThe main clinical finding emerging from this analysis suggests that pelvic pain is the main symptom. In our series pain was present in all cases and an ovarian endometrioma was present in three cases. With regard to the stage and site of the disease, the frequency of minimal-mild endometriosis was lower than in adult cases observed in the experience of GISE.     

Expression of inflammatory cytokines in serum and peritoneal fluid from patients with different stages of endometriosis

Objective: To investigate the level of inflammatory cytokines in endometriosis patients, and explore the relationship between IL-37 concentration and endometriosis stages.

Methods: Inflammatory cytokine concentrations from 27 patients with different stages of endometriosis and 52 controls without endometriosis were examined by ELISA. Then, the specificity and sensitivity of cytokines for distinguishing from controls and the different stages of endometriosis were analyzed using the ROC curve.

Results: The difference in serum concentrations of IL-37, IL-17A, IL-10, and IL-2 between the endometriosis and control groups was statistically significant (p?p?p?=?.0034), IL-10 concentrations in PF were significantly lower in the early-stages of endometriosis than in the more advanced groups (p?=?.0439), and IL-4 concentration in PF was significantly higher in more advanced endometriosis (p?=?.0228). The sensitivity and specificity of serum IL-37 for distinguishing endometriosis were 81.48% and 83.33%, respectively, and the cutoff concentration was 69.84?pg/ml. For IL-17A, the sensitivity and specificity were 96.30% and 100%, respectively, and the cutoff concentration was 57.54?pg/ml. For IL-10, the sensitivity and specificity was 92.59% and 100%, respectively, and the cutoff concentration was 3.301?pg/ml. For IL-2, the sensitivity and specificity were 74.07% and 93.75%, respectively, and the cutoff concentration was 1.813?pg/ml. For PF IL-2, the sensitivity and specificity were 29.73% and 100%, respectively, and the cutoff concentration was 1.06?pg/ml.

Conclusions: IL-37, IL-17A, IL-10, and IL-2 may play a significant role in immune response in endometriosis. IL-37 levels may be used as a diagnostic marker for endometriosis.     

Stages of endometriosis: Does it affect in vitro fertilization outcome

ObjectiveWomen with endometriosis often need in vitro fertilization (IVF) to conceive. There are conflicting data on the results of IVF in patients with endometriosis. The present study was undertaken to investigate whether or not the stage of endometriosis affects the IVF outcome in order to give the best patient counselingMaterials and methodsWe compared IVF outcome measures between 40 patients with surgically confirmed minimal and mild endometriosis (American Society for Reproductive Medicine Stage I/II) and 38 patients with moderate and severe endometriosis (Stage III/IV). Each group was also compared with a control group of 157 patients with tubal factor infertility. Outcome measures included number of follicles, number of oocytes, mean number of ampoules of gonadotropins, cumulative pregnancy, and live birth ratesResultsHigher cancelation rates, higher total gonadotropin requirements, and lower oocyte yield were found in women with endometriosis Stage III and IV compared with both the Stage I/II and control groups. The fertilization rate was higher in Stage III/IV endometriosis compared to Stage I/II. Clinical pregnancy and live birth rates were comparable between patients with endometriosis Stage I/II and control group, whereas they were significantly lower in patients with endometriosis Stage III/IV compared to other two groups.ConclusionThe American Society for Reproductive Medicine classification of endometriosis is useful in predicting IVF outcome. Advanced endometriosis means a worse prognosis for IVF treatment compared to milder stages or tubal factor infertility. The decreased fertilization rate in Stage I/II endometriosis might be a cause of subfertility in these women, as a result of a hostile environment caused by the disease.