American Fertility Society Research Articles

Management of Mullerian Development Anomalies: 9 Years' Experience of a Tertiary Care Center.

Objectives:This study aimed to analyze the clinical and imaging findings as well as the outcomes of patients with Mullerian duct anomalies.Materials and Methods:A retrospective analysis of 41 patients with Mullerian development anomalies treated in a tertiary care center in the past 9 years was done. The presenting symptoms, radiological findings, management, and the outcomes were evaluated.Results:According to the American Fertility Society's classification, 11 patients presented in Class I, 6 in Class II, and 24 in Class III of the classification. It was found that some of the defects such as the unicornuate uterus, a unicornuate uterus with noncommunicating rudimentary horn, and longitudinal vaginal septum were usually asymptomatic whereas disorders such as Mayer-Rokitansky-Küster-Hauser (MRKH), cervicovaginal atresia, and transverse vaginal septum presented with the absence of menarche, cyclical abdominal pain, and abdominal mass, respectively. Defects such as the bicornuate uterus, didelphys uterus, and septate uterus present with poor reproductive performance. Unicornuate uterus with communicating horn presented with rupture of the horn in the antenatal period, which was managed vigorously. Vaginoplasty with a skin graft and amnion graft had excellent results in MRKH syndrome. Patients with cervicovaginal atresia had a poor prognosis and ultimately required a hysterectomy. Hysteroscopic septal resection improved the reproductive performance in the patients with septate uterus.Conclusion:This study concluded that the management of uterine malformations is individualized depending on the symptoms and fertility concerns. Cervicovaginal atresia was associated with restenosis after surgery ultimately required a hysterectomy. MRKH had excellent results with McIndoe vaginoplasty. Optimal and timely management may lead to better outcomes.

Decision Tree Analysis: A Retrospective Analysis of Postoperative Recurrence of Adhesions in Patients with Moderate-to-Severe Intrauterine.

Objective To establish and validate a decision tree model to predict the recurrence of intrauterine adhesions (IUAs) in patients after separation of moderate-to-severe IUAs. Design A retrospective study. Setting A tertiary hysteroscopic center at a teaching hospital. Population Patients were retrospectively selected who had undergone hysteroscopic adhesion separation surgery for treatment of moderate-to-severe IUAs. Interventions Hysteroscopic adhesion separation surgery and second-look hysteroscopy 3 months later. Measurements and Main Results Patients' demographics, clinical indicators, and hysteroscopy data were collected from the electronic database of the hospital. The patients were randomly apportioned to either a training or testing set (332 and 142 patients, respectively). A decision tree model of adhesion recurrence was established with a classification and regression tree algorithm and validated with reference to a multivariate logistic regression model. The decision tree model was constructed based on the training set. The classification node variables were the risk factors for recurrence of IUAs: American Fertility Society score (root node variable), isolation barrier, endometrial thickness, tubal opening, uterine volume, and menstrual volume. The accuracies of the decision tree model and multivariate logistic regression analysis model were 75.35% and 76.06%, respectively, and areas under the receiver operating characteristic curve were 0.763 (95% CI 0.681–0.846) and 0.785 (95% CI 0.702–0.868). Conclusions The decision tree model can readily predict the recurrence of IUAs and provides a new theoretical basis upon which clinicians can make appropriate clinical decisions.

Agenesis Serviks

Background : Cervical agenesis is an extremely rare congenital anomaly of female reproductive system with manifestation on the absence of uterine cervix with normal development of uterine and secondary sex signs. According to the American Fertility Society, cervical agenesis is classified as type IB Müllerian anomaly. Symptoms are include primary amenorrhea, cyclic abdominal lower pain and infertility.Objective : To report the treatment of cervical agenesis.Case Report : Reportedly, a woman, 28 years old, came with complaints of primary amenorrhea, cyclic abdominal lower pain and 3 years of primary infertility. From speculum and transvaginal ultrasonography examination, the uterine was slightly smaller than normal, without cervical uterine, found adhesion, both ovarian were normal. Laparoscopic utero-vaginal anastomosis was performed and catheter condom was maintained in the cervical canal for 3 months. Two weeks after catheter was removed, a hysteroscopy was performed, but the canal was found closed.Conclusion : In this case, after the laparoscopic utero-vaginal anastomosis was performed, the cervical canal which has been made, is found closed. So, a further evaluation is needed to get more effective results.Keywords: Type IB Müllerian anomaly, cervical agenesis, primary amenorrhea, infertility, laparoscopic utero-vaginal anastomosis

Agenesis Serviks

Background : Cervical agenesis is an extremely rare congenital anomaly of female reproductive system with manifestation on the absence of uterine cervix with normal development of uterine and secondary sex signs. According to the American Fertility Society, cervical agenesis is classified as type IB Müllerian anomaly. Symptoms are include primary amenorrhea, cyclic abdominal lower pain and infertility. Objective : To report the treatment of cervical agenesis. Case Report : Reportedly, a woman, 28 years old, came with complaints of primary amenorrhea, cyclic abdominal lower pain and 3 years of primary infertility. From speculum and transvaginal ultrasonography examination, the uterine was slightly smaller than normal, without cervical uterine, found adhesion, both ovarian were normal. Laparoscopic utero-vaginal anastomosis was performed and catheter condom was maintained in the cervical canal for 3 months. Two weeks after catheter was removed, a hysteroscopy was performed, but the canal was found closed. Conclusion : In this case, after the laparoscopic utero-vaginal anastomosis was performed, the cervical canal which has been made, is found closed. So, a further evaluation is needed to get more effective results. Keywords: Type IB Müllerian anomaly, cervical agenesis, primary amenorrhea, infertility, laparoscopic utero-vaginal anastomosis

Bladder and Urinary Deep Pelvic Endometriosis: A Step-by-Step Standard Approach

To demonstrate how to treat bladder and ureteral deep pelvic endometriosis using a laparoscopic approach with partial cystectomy and resection and end-to-end anastomosis of the ureter. Step-by-step explanation of the surgery using a video approved by the local institutional review board. University Hospital of Strasbourg, France. A 27-year-old nulliparous woman with severe endometriosis stage IV (revised American Fertility Society classification score >40) of the bladder and left ureter. On pelvic magnetic resonance imaging, we found dilatation of the left ureter and left hydronephrosis induced by a 17-mm endometriosis nodule. A JJ probe was placed on the left ureter before the surgery because of dilatation of the ureter and decreased renal function. During the exploration, we found an abdominal cavity free of adhesion. There was an endometriosis implant in the bladder in front of the uterus and a large nodule of the left uterosacral ligament that was compressing the ureter. In the first step, we made a section of the round ligament to perform anterior ureterolysis and progressive dissection of the nodule surrounding the ureter. Once the nodule was resected, tight stenosis was observed approximately 1 cm from the bladder. The vesicouterine and vesicovaginal spaces were then dissected to pass under the nodule to the vagina. We opened the dome of the bladder using the thunderbeat (Olympus) and dissected the bladder to remove the transfixing nodule while staying away from the ureters. The closure of the bladder was performed by 2 lateral sutures and a running suture using a braided suture (V-Loc) 2-0, with good tightness as checked by a blue test. Ureteral resection was performed around the JJ probe in place to remove the stenotic zone; thereafter, we performed an end-to-end anastomosis of the ureter using 4 sutures of monofilament (Monocryl) 4-0 with a good anatomic result. Finally, an omentoplasty was fixed around the ureter using a 2-0 monofilament suture (Monocryl). The postoperative course was uneventful. A Foley catheter was left in place for 10 days, and the JJ probe was removed 6 weeks later. The operative time was 140 minutes. The step-by-step explanation technique was simple with minimal operative difficulty and a low rate of morbidity. This video shows how deep urinary endometriosis can be treated laparoscopically. Mastering suturing is essential to avoid complications.

Circulating Endometrial Cells: A New Source of Information on Endometriosis Dynamics.

The focus of the presented work was to isolate and characterize circulating endometrial cells (CECs) enriched from peripheral blood (PB) of patients with diagnosed endometriosis. The molecular characteristics of CECs could be supportive for an understanding of endometriosis pathogenesis and treatment decisions in the future. Material and Methods: Blood samples (n = 423) were tested for CECs presence. Subsequently, gene expression analysis (GEA) was carried out for CECs. In parallel, CECs presence and characteristics were tested during menstrual cycle (MC) phases in 11 patients. CECs were enriched by size-based separation. Results: CECs were present in 78.4% of the tested blood samples. In line with the revised American Fertility Society (rAFS) classification, CECs presence was confirmed in all the acknowledged endometriosis stages: minimal, mild, moderate, and severe. Surprisingly, CECs negativity rate was also reported for severe disease in 21.1% of cases. The CECs captured during MC phases displayed different cytomorphology, including epithelial, stromal, and stem cell-like characteristics. The highest CECs numbers were detected in the mid-secretory phase of MC, which corresponds to uterine lining decidualization. CECs captured during mid-secretory periods expressed genes KRT18, NANOG, and VIM in higher amounts when compared to the proliferative phase of MC, where genes KRT19 and ESR1 were mostly elevated. GEA of the super-positive CECs samples (1000 CECs/8 mL PB) revealed high expression of genes KRT18, VIM, NANOG, and FLT1. The expression of these genes was also elevated in the endometriosis tissue samples and endometrioma. Conclusion: The panel of the identified CEC genes could be tested in a prospective manner to confirm the role of CECs in endometriosis pathogenesis and diagnostics.

1678 Cold Scissor Ploughing Technique in Hysteroscopic Adhesiolysis-A Comparative Study

Study Objective To investigate the efficacy, feasibility, and safety of cold scissor ploughing technique in hysteroscopic adhesiolysis for intrauterine adhesions. Design Retrospective cohort study. Setting University-affiliated hospital. Patients or Participants A total of 179 intrauterine adhesion (IUA) patients who had undergone hysteroscopic adhesiolysis (HA) at the Third Xiangya Hospital of Central South University were enrolled in this study from January 2016 to October 2017. They were divided into three groups according to the surgical technique used. The groups were: cold scissors ploughing group (PG) (n=81); traditional group (TG:) (n=42); and, electrosurgical group (EG) (n=56). Interventions PG: use cold scissors to dissect the adhesion and cut the scar tissue using a ploughing technique; TG: use cold scissors to dissect the adhesion, but not deal with the scar tissue; and, EG: use resectoscope to dissect the adhesion with an energy L-hook electrode. Measurements and Main Results American Fertility Society (AFS) scores, along with adhesion types and areas; visible uterine horn and tubal ostia; menstrual recovery; pregnancy rates and live birth rates were evaluated to determine surgical efficacy. Feasibility was evaluated by technique replacement rates. Safety was evaluated by intra- and post- operative complication rates. Neither patient pre-operation history or adhesion rates were significant (P>0.05). There were significant differences between PG and TG, as well as PG and EG in: postoperative AFS scores; IUA reverse rates; reduced adhesion areas; pregnancy rates and live birth rates (P Conclusion Cold scissor ploughing is effective, feasible, and safe for HA, which is worth further study.

1421 Removal of a Noncommunicating Cavitary Horn using a 4 Quadrant Laparoscopic Technique

Video Objective Review noncommunicating uterine horns; incidence, diagnosis and surgical management. Demonstrate the steps needed to safely remove this type of horn using our 4 quadrant laparoscopic approach. Setting A 21 year old nulligravid female with severe dysmenorrhea and acute worsening pain, found to have a uterine malformation. MRI confirming a unicornuate uterus with American Fertility Society class II b malformation. Interventions A 4 quadrant laparoscopic approach, combining retroperitoneal dissection with myomectomy techniques, to safely remove the noncommunicating functional horn. Conclusion Even though rare, uterine abnormalities must be ruled out as a cause of continued female pelvic pain. Once a noncommunicating functional horn is diagnosed, principles used in laparoscopic hysterectomy and myomectomy can be combined to safely remove it. Our 4 quadrant laparoscopic technique allows both surgeon and assistant to actively participate in most minimally invasive gynecologic surgery in an ergonomic fashion.

Analysis of the Predictive Factors for the Recurrence of Deep Infiltrating Endometriosis: A 2-Year Prospective Study

Objective: To investigate factors that may be associated with the recurrence of deep infiltrating endometriosis (DIE) and DIE-related symptoms. Methods: Starting in September 2014, women with a confirmed diagnosis of DIE based on surgical and histological findings were included in the prospective study with a 2-year follow-up in our hospital. A total of 84 consecutive patients were included, all of whom underwent laparoscopic surgery. The data were obtained from the medical records of the patients. Follow-up data, including presence of pain as assessed using the visual analog scale (VAS) score and ultrasonography/magnetic resonance imaging findings, were obtained at 3, 6, 9, 12, and 24 months postoperatively. Variables, such as age, body mass index, severity and duration of symptoms, size and location of the lesion, and pre- and postoperative medical treatment, were evaluated using univariate and multivariate analyses to identify factors correlated to recurrence. Results: A total of 11 (13.1%) patients presented with recurrence, with a mean time to recurrence of 14.2 months. The univariate analysis showed that the longer duration of menstruation (7.4 vs. 6.0, P = 0.010), the more advanced revised American Fertility Society (rAFS) stage (Stages I and II vs. III and IV, χ2 = 9.964, P = 0.001), the higher VAS score for dysmenorrhea (9.4 vs. 5.2, P = 0.001), and the more severe pain during defecation (7.8 vs. 4.8, P = 0.016) were positively correlated to DIE recurrence. However, the multivariate analysis also revealed that a more severe dysmenorrhea and advanced rAFS stage were the independent factors associated with the recurrence of DIE, with an odds ratio of 1.895 (confidence interval [CI]: 1.061–3.385, P = 0.031) and 4.310 (CI: 1.091–17.028, P = 0.037), respectively. Conclusions: More than 10% of patients presented with recurrence of DIE 2 years after surgery. Recurrence of DIE was more common in patients who complained of more severe dysmenorrhea and had an advanced rAFS stage.

Predicting the likelihood of a live birth for women with endometriosis-related infertility

ObjectiveEndometriosis affects 10% of women in reproductive age and alters fertility. Its management is still debated notably the timing of surgery and ART in infertility. Several tools have been created to guide the practitioner and the couple yet many limitations persist. The objective is to create a nomogram to predict the likelihood of a live birth after surgery followed by assisted reproductive technology (ART) for patients with endometriosis-related infertility. Study designAll women in a public university hospital who attempted to conceive by ART after surgery for endometriosis-related infertility from 2004 to 2016 were included. We created a model using multivariable linear regression based on a retrospective database. ResultOf the 297 women included, 171 (57.6%) obtained a live birth. Age, duration of infertility, number of ICSI-IVF cycles, ovarian reserve and the revised American Fertility Society (rAFS) score were included in the nomogram. The predictive model had an area under the curve (AUC) of 0.77 (95% CI, 0.75–0.79) and was well calibrated. The external validation of the model was achieved with an AUC of 0.71 (95% CI, 0.69–0.73) and calibration was good. The staging accuracy according to AUC criteria for the nomogram compared to the currently used Endometriosis Infertility Index to predict live births were 0.77 (95% CI, 0.75–0.79) and 0.60 (95% CI: 0.57–0.63), respectively. ConclusionThis simple tool appears to accurately predict the likelihood of a live birth for a patient undergoing ART after surgery for endometriosis-related infertility. It could be used to counsel patients in their choice between spontaneous versus ART conception, or oocyte donation.

Ureteral endometriosis in patients with deep infiltrating endometriosis: characteristics and management from a single-center retrospective study.

As a serious type of deep infiltrating endometriosis (DIE), ureteral endometriosis (UE) can result in decreased kidney function. The aims of this study are to investigate risk factors and surgical treatments for UE. The study enrolled 329 patients with deep infiltrating endometriosis, who were treated with laparoscopic surgery between January 2014 to September 2018. All patients were divided into one of two groups: UE or non-UE. Clinical information and other surgery variables of the two groups were examined. Out of 329 patients with DIE, 68 (20.67%) cases of UE were diagnosed. Among them, 37 patients also had hydroureteronephrosis. In a multivariate analysis, the variables revised American Fertility Society (rAFS) stage IV, uterosacral ligament (USL) DIE lesion ≥ 3cm in diameter and previous surgery for endometriosis significantly increased the risk of UE. A total of 27.03% (10/37) of patients with UE and hydroureteronephrosis showed decreased kidney function. Ureterolysis was performed in 59 patients, and an ureteroneocystostomy was performed in 9 patients. A double-J stent was placed in 37 patients with UE. Only 1 patient developed acute pyelonephritis postoperatively. During more than 2years of follow-up, no patient experienced recurrence. The variables of rAFS stage IV, USL DIE lesion ≥ 3cm in diameter and previous surgery for endometriosis significantly increased the risk of UE. Laparoscopic ureterolysis and ureteroneocystostomy are feasible and safe procedures with low complication and recurrence rates.

The Prevalence of Incidental Endometriosis in Women Undergoing Laparoscopic Ovarian Drilling for Clomiphene-Resistant Polycystic Ovary Syndrome: A Retrospective Cohort Study and Meta-Analysis.

To evaluate the incidence of endometriosis in polycystic ovary syndrome (PCOS) patients who did not present with any endometriosis symptoms and underwent laparoscopic ovarian drilling (LOD) for clomiphene citrate (CC) resistance, 225 and 630 women with CC-resistant PCOS without classic endometriosis symptoms were included in a retrospective study and a meta-analysis, respectively. All women underwent LOD. The main outcome parameter was the prevalence of incidental endometriosis. Laparoscopy revealed endometriosis in 38/225 (16.9%) women (revised American Fertility Society (rAFS) stage I: 33/38, 86.8%; rAFS stage II: 5/38, 13.2%). When women with CC-resistant PCOS without endometriosis were compared, lower body mass index (BMI) and lower 25-hydroxy-vitamin D levels were associated with the presence of endometriosis at laparoscopy (odds ratios (OR): 0.872, 95% confidence intervals (95%CI): 0.792–0.960; p = 0.005 and OR: 0.980, 95%CI: 0.962–0.999; p = 0.036; respectively). The inclusion criteria for the meta-analysis were fulfilled by 4/230 reports about LOD. After correction for study heterogeneity, the pooled prevalence of incidental endometriosis was 7.7% in women with CC-resistant PCOS. In conclusion, the rate of incidental endometriosis in women with CC-resistant PCOS might reflect the prevalence of asymptomatic endometriosis. All cases were affected by minimal or mild disease. Since the literature lacks reports on associated clinical outcomes, the relevance of this entity in such patients should be the subject of further studies.

Plasminogen activator inhibitor-1 (PAI-1) expression in endometriosis.

PurposeDeep infiltrating endometriosis (DIE) is defined as an endometriotic lesion penetrating to a depth of >5 mm and is associated with pelvic pain, but the underlying mechanisms are unclear. Our objective is to investigate whether plasminogen activator inhibitor-1 expression (PAI-1) in endometriotic tissues is increased in women with DIE.MethodsIn this blinded in vitro study, immunohistochemistry and Histoscore were used to examine the expression of PAI-1 in glandular epithelium (GECs) and stroma (SCs) in a total of 62 women: deep infiltrating uterosacral/rectovaginal endometriosis (DIE; n = 13), ovarian endometrioma (OMA; n = 14), superficial peritoneal uterosacral/cul-de-sac endometriosis (SUP; n = 23), uterine (eutopic) endometrium from women with endometriosis (UE; n = 6), and non-endometriosis eutopic endometrium (UC; n = 6). The following patient characteristics were also collected: age, American Fertility Society stage, hormonal suppression, phase of menstrual cycle, dysmenorrhea score and deep dyspareunia score.ResultsPAI-1 expression in GECs and SCs of the DIE group was significantly higher than that of SUP group (p = 0.01, p = 0.01, respectively) and UE group (p = 0.03, p = 0.04, respectively). Interestingly, increased PAI-1 expression in GECs and SCs was also significantly correlated with increased dysmenorrhea (r = 0.38, p = 0.01; r = 0.34, p = 0.02, respectively).ConclusionsWe found higher expression of PAI-1 in DIE, and an association between PAI-1 and worse dysmenorrhea.

Hysteroscopic treatment of Asherman's Syndrome

Objective: To assess achievement of hysteroscopic treatment for Asherman’s Syndrome(AS), also called ‘intrauterine adhesions(IUAs) or Intrauterine synechiae’. Method: Retrospectively,27 patients with AS were enrolled in our study at ankara liv hospital between 2017-2019 . These patients were evaluated with hysteroscopically then they had adhesiolysis at the same session. Monopolar knife was used for adesiolysis and the operation was gone on until adequate cavity enlargement was achieved. Intrauterine device (IUD) was placed in the new occurred cavity and combined hormonal therapy(high dose estrogen and progesteron) was given for two months. American Fertility Society classification was used for scoring of IUAs. After IUD was taken out, they were called and their menstrual pattern and fertility status were learned. If their symptoms were recurred they were hysteroscopically evaluated again. Results: 27 patients were hysteroscopically diagnosed as AS . 15of them had reproductive problems and other 12 patients had only menstrual abnormality. 13 patients had pregnancy related curettage, 4 patients had dilatation and curratage(D&C) for their menstrual problems. After hysteroscopic treatment, 6 of 12 patients with only menstrual abnormality had normal menstual pattern, 2 of them did not have normal period but a little bit better(from amenorrhoea to hypomenorrhoea). 8 of 15 infertile patients had positive pregnancy test(live born:6, spontaneous abortion:2). And also all these pregnant womens were seconder infertile patients. Conclusions: Hysteroscopy is the most useful technique for diagnosis and treatment for Asherman’s Syndrome. And also, hysteroscopic procedure has positive effect on pregnancy rate and menstrual regularity

The levels of matrix metalloproteinase-9 and neutrophil gelatinase-associated lipocalin in different stages of endometriosis

This study was designed to explore matrix metalloproteinase-9 (MMP-9), neutrophil gelatinase-associated lipocalin (NGAL) levels and MMP-9/NGAL ratio in women with and without endometriosis diagnosed surgically and/or histopathologically. The correlation between biomarkers and the severity of the disease is analysed. The revised American Fertility Society classification system was used to determine the severity of endometriosis. Serum MMP-9 and Ca125, urine NGAL levels were measured in all participants. Serum MMP-9 levels were significantly higher in the study group (n = 60) compared to controls (n = 31) (15.0 pg/mL (6.0–143.0) vs. 12.0 (4.0–18.0), respectively; p=.002). MMP-9 levels were significantly higher in severe endometriosis compared to mild endometriosis subgroups (p<.001). No significant difference was found between NGAL levels in study and control groups (p>.05). The diagnostic value of MMP-9 and NGAL is not superior than CA-125 for endometriosis. Nevertheless, MMP-9 might be a potential predictive marker for advanced stage of the disease.Impact StatementWhat is already known on this subject? The gold standard diagnostic test for diagnosis of endometriosis is laparoscopy combined with histopathological confirmation of eutopic endometrial glands and/or stroma. Both invasiveness and possible accompanying complications limit the preference regarding the surgical approach. Among non-invasive markers none has been accepted as gold standard neither for diagnosis nor for determining the severity of the disease. MMPs are extracellular endopeptidases, which have a significant role in degradation and remodelling of extracellular matrix for cellular migration and invasion. Among these, MMP-9 has been shown to be higher in eutopic/ectopic endometrial tissue in women with endometriosis and has been suggested to have a role in pathogenesis of endometriosis by promoting invasion of the endometriotic lesions. NGAL is an acute phase protein, which is involved in a variety of physiological and pathophysiological processes. The molecule has also been revealed to correlate with endometriosis pathophysiology through the epithelial–mesenchymal transition process which is the basis for the onset of endometriosis. But also, NGAL which composes a complex with MMP-9 (MMP-9 and NGAL complex), has been shown to protect MMP-9 from autodegradation in vitro which might be a contributing factor for endometriosis pathophysiology.What the results of this study add? MMP-9 cut-off level for prediction of severe endometriosis is a novel finding obtained from this study with acceptable sensitivity and specificity. On the other hand, NGAL seems to have no significant value either for diagnosis of for determining severity of the disease. After all, MMP-9 might be an easy use acceptable biomarker for endometriosis but further studies on larger populations are needed.What the implications are of these findings for clinical practice and/or further research? MMP might be a potential non-invasive predictive marker for advanced stage disease.

It Is Necessary to Purpose an Add-on to the American Classification of Endometriosis? This Disease Can Be Compared to a Malignant Proliferation While Remaining Benign in Most Cases. EndoGram® Is a New Profile Witness of Its Evolutionary Potential.

Endometriosis is a curious pathology that has been the topic of many international publications. Its etiology remains mysterious but seems to have multiple causes. It is a complex disease whose lesions are very heterogeneous in where they can occur (deep endometriosis, superficial, ovarian cyst), extent, associated symptoms, evolution or aggressiveness of the disease, and response to treatments. Furthermore, it evolves in pushes, remains autonomous, and is responsible for both superficial and deep lesions that explain its two most well know challenges: pain and infertility. It has always been classified by the size of its anatomical lesions—Acosta classification (1), revised by the American fertility society (AFS) (2), and the American society of reproductive medicine (ASRM) classification with a description of the disease at different stages: minimal (score of 1 to 5), mild (3–12), moderate (16 to 40), and severe (>40) (13). If this classification provides a complete repertoire of implants (anatomic) (10), the attribution of points is arbitrary. In fact, the size of the lesions is not synonymous with the difficulty to treat them surgically. Their location, if deep, is larger than the size of ovarian endometriomas. In addition, small anatomical but evaluative lesions will have a larger impact than big fibrous and stable lesions (Figure 1). Thus, attempts to explain their inflammatory side effects have been proposed (14, 15). The French classification nodule, ovaries, adhesions, tube, and inflammation (FOATI) (10) has had the merit of taking this phenomenon into account. In our opinion, we must go much further and propose an amendment in this classification, taking into account the evolution of the lesions and their deep molecular biology because in reality, the lesions are not at the same stage.

Identification of Predictive Factors in Endometriosis for Improvement in Patient Quality of Life

To investigate predictive factors for change in quality of life (QOL) between pre- and postoperative periods in patients with endometriosis. A prospective and multicenter cohort study. Five districts including a tertiary referral center and private and general public hospitals. Nine hundred eighty-one patients aged 15 to 50 years underwent laparoscopic treatment (preferred approach) for endometriosis between January 2004 and December 2012. Laparoscopic treatment for endometriosis. All revised American Fertility Society stages were included. QOL was evaluated using the 36-Item Short Form Survey questionnaire. Factors influencing changes for each 36-Item Shorty Form Survey domain score between t0 (before surgery) and 1 year after surgery were predicted on the basis of univariate and multivariable analyses. The effect size (ES) method was used to measure changes in QOL. Univariate analysis revealed that 47% of stage IV endometriosis patients presented an improvement in the postoperative Physical Component Summary (PCS) score (ES ≥ 0.8) versus 26%, 31.3%, and 27.5% of patients with stage I, II, and III, respectively (p <.001). Forty-four percent and 38% of patients with chronic pelvic pain (CPP) presented an improvement in postoperative PCS and Mental Component Summary scores (ES>0.8) versus 23% and 24% of patients without CPP, respectively (p <.001). Multivariable analysis (ES > 0.8 vs ES < 0) revealed that women with CPP were more likely to experience greater improvement in postoperative PCS and Mental Component Summary scores than women without CPP (relative risk [RR] = 2.7; 95% confidence interval [CI], 1.7-4.4; p <.001 and RR = 1.8; 95% CI, 1.2-2.8; p <.01, respectively). Accordingly, fertile patients were more likely to show higher rates of improvement in the postoperative PCS score than infertile patients (RR = 1.8; 95% CI, 1.1-3.1; p <.05). Patients presenting with severe endometriosis and who experience higher levels of pain are more likely to show improvement in QOL after surgery. CPP is the most significant independent predictive factor for changes in QOL scores.

A cohort study comparing the severity and outcome of intrauterine adhesiolysis for Asherman syndrome after first- or second-trimester termination of pregnancy

ObjectiveTo compare the clinical characteristics of Asherman syndrome and the outcomes of hysteroscopic adhesiolysis in women after first or second-trimester termination of pregnancy (TOP). MethodsThis was a retrospective descriptive analysis of patients with moderate-to-severe intrauterine adhesiolysis (IUAs) after TOP and treated by hysteroscopic adhesiolysis and followed by “second-look” hysteroscopy 3 months later at The Beijing Obstetrics and Gynecology Hospital (China) between January 2013 and March 2016. The American Fertility Society (AFS) scoring system was used to evaluate the intrauterine adhesions. ResultsA total of 236 patients with 180 first-trimester TOP and 56 s-trimester TOP patients were included. The severe adhesion and amenorrhea rates during the second-trimester group (69.6% and 39.3%, respectively) were significantly higher than those in the first-trimester group (36.7% and 7.2%, respectively). AFS score reduction in the second-trimester group (6.2 ± 2.8) was significantly lower than in the first-trimester group (6.5 ± 2.5). The pregnancy rates in the second-trimester group (21.4%) were significantly lower than that in the first-trimester group (43.3%). The pregnancy rate of severe intrauterine adhesions in second-trimester TOP (10.3%) was significantly lower than in first-trimester TOP (40.9%). ConclusionThese findings suggested that second trimester TOP was associated with more severe intrauterine adhesion and a worse prognosis after hysteroscopic adhesiolysis in women with Asherman syndrome when compared to first-trimester TOP.

Factors That Impact Fertility after Hysteroscopic Adhesiolysis for Intrauterine Adhesions and Amenorrhea: A Retrospective Cohort Study

To identify factors that affect reproductive outcomes after hysteroscopic adhesiolysis in patients with severe intrauterine adhesions (IUAs, scored between 9 and 12 according to the American Fertility Society classification) and amenorrhea. A retrospective cohort study. A university-affiliated hospital. One hundred fifty-one patients with severe IUAs and amenorrhea. Patients were diagnosed via hysteroscopy and underwent at least 1 hysteroscopic adhesiolysis between May 2012 and January 2016. Of 151 patients, 12 were lost to follow-up, and 139 were included in the study with a follow-up period ranging from 2 to 6 years. Of the 139 evaluable patients, 107 (77%) recovered with a normal uterine cavity (free of IUAs), 28 (20.1%) had improved uterine cavity (fewer IUAs), and 4 (2.9%) showed no improvement. Moreover, 79 patients (56.8%) recovered with normal menstruation, 54 (38.9%) showed increased frequency of menstruation, and 6 (4.3%) had persistent amenorrhea. Seventy-seven (55.4%) became pregnant, of whom 13 had a spontaneous miscarriage, 11 birthed prematurely (at 31-36 gestational weeks), 44 experienced term delivery, and 9 were still pregnant at the end of the study. Age >32 years (p = .002, odds ratio [OR] = 3.442), >2 surgeries (p = .027, OR = 2.969), cervical canal adhesions (p = .047, OR = 2.112), and disease course >6 months (p = .037, OR = 2.335) were risk factors for infertility in patients with severe IUAs and amenorrhea. Younger age, earlier treatment within the disease course, fewer cervical canal adhesions, and fewer surgical procedures improve the reproductive outcome in patients with severe IUAs and amenorrhea.

Beneficial Effects of Oral Lactobacillus on Pain Severity in Women Suffering from Endometriosis: A Pilot Placebo-Controlled Randomized Clinical Trial.

BackgroundThis study assessed the effects of a lactobacillus-based medication on pain intensity scores in women with endometriosis.Materials and MethodsThe present randomized pilot placebo-controlled trial was done on eligible women who were surgically and pathologically diagnosed with endometriosis. Thirty-seven participants who had not received hormonal treatment in the last three months, were enrolled and randomized into LactoFem®and placebo groups. Lactobacillus capsules or placebo were administrated orally once a day for 8 weeks. Patients were assessed for pain severity using Visual Analogue Scale (VAS) scores for dysmenorrhea, dyspareunia and chronic pelvic pain at baseline and after 8 and 12 weeks post-intervention.ResultsMean age of participants and mean body mass index (BMI) for the LactoFem®and control groups were compara- ble. All patients had stage 3 and 4 of the disease based on revised American fertility society (AFS) classification of endome- triosis. Mean initial pain scores for dysmenorrhea, dyspareunia and chronic pelvic pain were 6.53 ± 2.88, 4.82 ± 3.76 and 4.19 ± 3.53, respectively in the LactoFem®group and 5.60 ± 2.06, 3.67 ± 2.64 and 2.88 ± 2.80, respectively for the control group; the two groups had comparable scores in this regard. There was more decrease in pain scores for both dysmenorrhea and the overall pain after 8 weeks of treatment in LactoFem®group compared to the control group. The scores for dysmen- orrhea were 6.53 ± 2.88 and 5.60 ± 2.06 in the LactoFem®and control groups, respectively, before intervention but, after 8-week treatment, these values were 3.07 ± 2.49 and 4.47 ± 2.13 (P=0.018), respectively. The changes in overall pain score in the LactoFem® and control group during this period were 7.33 ± 7.00 and 4.11 ± 1.68, respectively (P=0.017).ConclusionThis study showed some beneficial effects of lactobacillus administration on endometriosis-related pain (Registration number: IRCT20150819023684N5).