Deep Infiltrating Endometriosis Research Articles

Diagnostic Performance of Transvaginal Sonography vs. Magnetic Resonance Imaging for Rectovaginal Septum Deep Infiltrating Endometriosis: A Head-to-Head Comparative Meta-Analysis

ObjectiveWe aimed to compare the diagnostic performance of transvaginal sonography (TVS) versus magnetic resonance imaging (MRI) in identifying deep infiltrating endometriosis (DIE) in the rectovaginal septum (RVS) of affected patients. Data sourcesAn extensive search was conducted in the PubMed, Embase databases to identify available publications up to November 2023. Studies evaluating the diagnostic performance of TVS and MRI for DIE in patients with rectovaginal septum involvement were all included. Methods of study selectionSensitivity and specificity analyses employed the DerSimonian and Laird method, complemented by the Freeman-Tukey double arc-sine transformation. Additionally, the study quality was rigorously evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) method. Tabulation, integration, and resultsThe meta-analysis encompassed 8 articles with a total of 721 patients. It revealed that the overall sensitivity of TVS was 0.51 (95% CI: 0.31-0.72), contrasted with 0.74 (95% CI: 0.66-0.82) for MRI. This finding suggests a higher sensitivity of MRI compared to TVS (P = 0.04). Conversely, the overall specificity was 0.97 (95% CI: 0.94-1.00) for TVS and 0.93 (95% CI: 0.84-0.99) for MRI, indicating a comparable level of specificity between the two modalities (P = 0.22). ConclusionOur meta-analysis reveals that MRI exhibits higher sensitivity and comparable specificity to TVS in patients with DIE of the RVS. However, the limited number of articles included may affect the evidence of these results. Therefore, further research with larger sample sizes and prospective designs is essential to validate these findings.

The correlation between ultrasonographic findings and clinical symptoms of pelvic endometriosis

ObjectiveConsidering the importance of endometriosis and its relatively high prevalence among women, this study sought to investigate clinical and Transrectal and transvaginal ultrasounds (TVS) findings of disease.MethodsThis descriptive-analytical study was performed based on medical records of 155 women with endometriosis admitted to Rasool-e Akram Hospital in Tehran for a TVS. All the sonography data and patients’ information were collected into checklists and analyzed in SPSS-25 software (IBM).ResultsThe mean age of participants was 32.4 ± 6.1 years, ranging from 18 to 50 years. Endometrioma was prevalent in 129 patients (84.8%). Size of endometrioma (diameter) was more than 3 cm in 79.9% of patients, and 3 cm or fewer in 20.1% of cases. Bladder, intestinal, vaginal, and rectosigmoid involvements with endometriosis implants were observed in 4 (2.6%), 54 (35.5), 3 (0.2%), and 51 (33.5) of patients, respectively. A total of 64.5% of patients were diagnosed with incomplete stenosis of the Douglas pouch and 35.5% had complete stenosis. Deep infiltrating endometriosis (DIE) was less than 1 cm in 20.7%, 1 to 3 cm in 42.3%, and over 3 cm in 37% of patients. The most common manifestations of endometriosis Obliteration of the Douglas pouch, endometrioma, and DIE. In addition, imaging modalities have shown promising results, indicating the necessity to use transvaginal ultrasound as the first line of diagnosis in patients with clinically suspected endometriosis.

MRI classification of uterosacral ligament involvement in endometriosis: the Hôtel-Dieu classification.

This study aimed to establish the first-ever MRI classification of uterosacral ligament (USL) involvement in deep infiltrating endometriosis (DIE), based on reliable preoperative MRI features correlated with positive predictive values (PPVs) determined through histopathological analysis. Twenty-two women underwent surgery with histopathology due to symptoms highly suggestive of endometriosis. The 22 preoperative MRIs were analysed retrospectively, blinded to histopathology, and a classification of the preoperative aspect of USLs linked to PPVs was designed. According to their aspects, 6 radiological types of USL were identified. The "L-category" corresponded to linear types with regular or irregular margins, including types 1, 2, 3A, and 3B. The "N-category" corresponded to haemorrhagic or nodular types, including types 4, 5A, 5B, and 6. For the L-category, PPVs ranged from 75% to 88%, depending on the USL radiological type. For the N-category, PPVs were 100% for each type. In women with endometriosis symptoms, MRI underestimated USL involvement, especially for type 1. Among the 6 uteri with lateral deviation, only one false-positive result concerning the stretched USL was induced. In women with endometriosis symptoms, our MRI classification identified 2 USL categories, corresponding to 2 kinds of PPV; in these symptomatic patients, a normal MRI does not rule out a DIE diagnosis. Our MRI classification of USL involvement in endometriosis may be used as a non-invasive staging of the disease, making it much clearer for clinicians and patients. Hence, we are able to propose a suitable diagnostic and therapeutic procedure for each radiological type.

Establishment of an Experimental Mouse Model of Endometrioma to Study its Related Infertility.

Endometrioma (OMA), a subtype of endometriosis characterized by the formation of endometriotic cysts in the ovaries, affects 17-44% of individuals diagnosed with endometriosis. Women with OMA often experience compromised fertility, yet the exact mechanisms underlying OMA-associated infertility remain unclear. Notably, existing animal models simulate superficial peritoneal endometriosis (SUP) and deep infiltrating endometriosis (DIE), leaving a notable gap in research focused on OMA. In response to the gap of knowledge, this paper introduces a pioneering OMA-simulating mouse model and provides a comprehensive description of the techniques and procedures employed in the model. With a high success rate of 83% and ovarian lesion specificity, this model holds significant promise for advancing our understanding of OMA, particularly in the context of infertility. It offers a valuable platform for conducting targeted research into OMA-associated fertility challenges, potentially paving the way for improved diagnostic and therapeutic strategies in the field of reproductive medicine.

“Robot-Assisted Partial Cystectomy for Deep Infiltrating Endometriosis of the Bladder With the Hugo RAS System”

ObjectiveInvolvement of the lower urinary tract is found in 0.2 to 2.5% of all deep infiltrating endometriosis (DIE) [1,2]. The bladder is the most affected organ with a prevalence of up to 80% of cases [3]. Patients with bladder endometriosis are often symptomatic (dysuria, hyperactive bladder, recurrent urinary tract infections, and hematuria). Surgery is the gold standard treatment for this condition when medical therapy fails [1,2]. Several studies have shown the feasibility, effectiveness, and safety of the laparoscopic approach [4] but data about robotic-assisted approach are missing in literature. Currently, novel platforms are entering the market and the Hugo™RAS (Medtronic, Minneapolis, USA) is a new system (HRS) consisting of an open console with 3D-HD screen and a multimodular bedside units. Even if some series are already available for radical cystectomies for oncologic purposes [5], a full description of DIE surgery performed with HRS is still lacking. Aim of this video-article is to show our technique and surgical setup to carry out a complex case of anterior compartment DIE. DesignA step-by-step explanation of surgical technique with narrated video footage. SettingTertiary Level Academic Hospital “IRCCS Azienda Ospedaliero—Universitaria di Bologna” Bologna, Italy. InterventionA 36-year-old nulliparous woman affected by DE was referred to our center due to severe dyspareunia, dysuria with hematuria and postvoiding pain not responsive to oral progestins. The preoperative work up consisted of a gynecological examination, pelvic ultrasound and MRI that showed the presence of an endometriotic nodule of the bladder base. All possible therapeutic strategies and related complications have been discussed with the patient before the signature of the informed consent. To carry out the procedure a “straight” port placement in a “compact” docking configuration [6] was installed. After developing the paravesical spaces bilaterally, the bladder nodule was approached in a latero-medial direction then a partial cystectomy with macroscopical free margins was performed. A double layer horizontal running suture with barbed thread was used to repair the bladder wall. ConclusionTo the best of our knowledge, this is the first case of bladder endometriotic nodule excision performed with HRS. We explained our technique and robotic set-up to successfully manage a compelx case of DIE of the bladder.

A 24-months Follow-up Study of Individuals with Endometriosis using Transvaginal Ultrasound

Study ObjectiveTo investigate the progression of deep infiltrating endometriosis (DIE) using transvaginal ultrasound surveillance of patients undergoing conservative management. DesignRetrospective single cohort. SettingAustralian tertiary university hospital Patients122 women with endometriosis proven on transvaginal ultrasound who had not undergone surgical management. InterventionsThe progression of endometriosis lesions demonstrated on transvaginal ultrasound in women receiving conservative management over the course of 24 months. Measurements and Main Results122 patients fulfilled the inclusion criteria. All women had two ultrasounds that were performed at least 6 months apart. The median follow up time was 490.5 days (255.4 - 725.6). At second scan, 22% (95% CI: 15-30%) of cohort experienced an increase in the number of endometriosis nodules compared to first scan, with 51% (95% CI: 42-60%) remaining static while 27% (95% CI: 19-35%) experienced a decrease. While there was no statistically significant difference in the volumes of uterosacral ligament, retro cervical and bowel endometriosis, endometrioma volumes were significantly lower at second scan (Median = 3.24 mL, IQR = 0.6 - 16.87) as compared to the first scan (Median = 7.41 mL, IQR = 2.04 - 28.95), p<0.001. ConclusionIndividuals with deep infiltrating endometriosis are unlikely to see significant disease progression over time. Both surgical and non-surgical interventions are effective in managing endometriosis in terms of endometriotic nodule size and number, as measured by ultrasound.

Acupuncture for pain and pain-related disability in deep infiltrating endometriosis.

To evaluate the efficacy of acupuncture in relieving symptoms (dysmenorrhea, dyspareunia, pelvic pain and dyschezia) intensity, improving functional disability, reducing the number of days per months of dysmenorrhea, the frequency and the efficacy of analgesic use in deep infiltrating endometriosis (DIE). The safety profile was also evaluated. The study sample was 34 patients with DIE; for 2 months (T-2, T-1) the women recorded diary notes on the numbers of days of menstruation, the presence, intensity, and disability related to dysmenorrhea, dyspareunia, pelvic pain, and dyschezia. They then received a total of 15 acupuncture treatments over 6 months (T1-T6; once a week for 12 weeks, then once a month for 3 months). Dysmenorrhea intensity was decreased during treatment. A decrease of at least 50% in number of days of dysmenorrhea, and a decrease in moderate-to-severe disability starting from T1 to T6 was recorded for 58.6% of patients. Dyspareunia intensity steadily decreased starting at T2; the percentage of women with moderate-to-severe disability declined from 73.3% at T-2, to 36.9% at T3, T4, and T5. A decrease in pelvic pain score was noted starting at T1; the percentage of disability decreased from 83.3% at T-2 to 33.3% at T3 and T6. The intensity of dyschezia decreased from T-2 to T3 and T4 and then increased slightly. Analgesic drug use was lower during treatment and its efficacy appeared to be greater. The limitations notwithstanding our study-findings show that acupuncture was safe and effective in reducing pain intensity and symptoms-related disability. Larger-scale studies are needed to compare acupuncture and pharmacotherapy for endometriosis-related pain.

Dienogest in conjunction with GnRH-a for postoperative management of endometriosis.

Objective: The aim of this study is to assess the postoperative efficacy of the combined administration of dienogest (DNG) and gonadotropin-releasing hormone agonists (GnRH-a) in patients diagnosed with endometriosis (EMS), while acknowledging the extensive use of DNG in the extended therapeutic management of EMS. Methods: In this retrospective study, a cohort of 154 patients who underwent conservative surgical intervention for EMS were scrutinized. The cohort was stratified into two distinct groups based on their prescribed pharmacological regimens. Group A, 70 patients received postoperative oral administration of DNG at a dosage of 2mg/day, whereas Group B, 84 patients underwent treatment involving 3 to 4 injections of GnRH-a post-surgery, followed by DNG therapy. Parameters assessed included pelvic pain visual analog scale (VAS) scores, quality of life metrics (EHP-5), and the incidence of adverse reactions within both groups. Results: Both groups exhibited sustained low VAS scores following the prescribed treatments. The predominant occurrence of adverse bleeding patterns manifested predominantly within the initial 6months of the treatment. Notably, Group B demonstrated a significantly diminished of experiencing frequent and irregular bleeding in comparison to the DNG group (20.0% vs. 8.3%, 12.9% vs. 3.6%, p < 0.05). The administration of GnRH-a did not exacerbate the impact on bone health. Subsequent to health promotion interventions, the incidence of weight gain in both groups declined to 7.1% during the 6-month follow-up (p < 0.05). Group B exhibited a 100% satisfaction rate with the treatment, concomitant with a noteworthy reduction in EHP-5 scores (p < 0.05). Patients with deep infiltrating endometriosis (DIE) nodules displayed marginally higher postoperative VAS scores than their non-DIE counterparts (0.89 ± 0.96 vs. 0.49 ± 0.78). However, with sustained medication use, pain scores within the DIE group exhibited a continual decrease, maintaining a low level of 0.29 ± 0.67 at 12months and beyond. Conclusion: The short-term adjunctive use of GnRH-a prior to DNG treatment postoperatively in patients with EMS proves efficacious in mitigating early adverse bleeding, enhancing patient adherence, and improving overall quality of life. Notably, this therapeutic approach demonstrates favorable safety profiles and is equally effective in patients with DIE.

Bladder endometriosis – diagnostic and management challenges: A case report

Background: Urinary tract endometriosis (UTE) is the presence of endometriotic implants in the bladder,ureter, kidneys, or urethra. It affects ~1% of women with endometriosis and occurs more commonlyamong those with deep infiltrative endometriosis. Bladder endometriosis is the most commonpresentation, comprising 85% of cases. Concomitant involvement of the bladder and ureter is rare,comprising 1.4% of all cases. The clinical presentation involves lower urinary tract symptoms, thatworsen during menses. Timely diagnosis and treatment are crucial in ameliorating symptoms andpreventing complications, such as obstructive nephropathy. This is a case of bladder endometriosis withureteral involvement, outlining management challenges, reviewing evidence on managementapproaches, and highlighting the experience gained from this case in managing complex UTE.Case presentation: A 38-year-old female presented with a longstanding history of pelvic pain, dysuria,and new-onset voiding difficulty. She had undergone two prior surgical procedures for endometriosis,including a total abdominal hysterectomy. Her physical examination was normal. Ultrasound revealed a3-cm intracavitary bladder mass, which was described as likely endometriosis on magnetic resonanceimaging. On cystoscopy the mass was noted to be larger, encasing the left ureteric meatus. Alaparoscopic cystostomy was performed, with partial resection of the mass and placement of a temporaryureteric stent. After three months of medical treatment with dienogest, cystoscopy revealed a significantreduction in size with sub-centimeter residual avascular tissue. This was resected avoiding the ureter andureteric meatus. A new ureteric stent was placed. A repeat cystoscopy three months later revealed goodhealing with no residual endometriosis. The stent was removed, and a retrograde pyelogram confirmedno meatal stenosis or ureteric obstruction. She has remained symptom-free.Conclusion: Medical and surgical options are available for bladder endometriosis, with partialcystectomy being the gold standard. The initial approach is dependent on the size of the lesion and theextent of ureteric involvement. A staged approach that combines medical or surgical management canensure optimal outcomes while reducing surgery-associated morbidity in complex cases.

The expanding role of sonography for the diagnosis of deep infiltrating endometriosis: Results of a large case series

AbstractObjectiveTo investigate the value of the sonographic identification of deep infiltrating endometriosis (DIE) in women presenting with complaints suggestive of DIE. Sonography findings were correlated with subsequent surgical exploration, and histologic verification.MethodsA retrospective observational case series was investigated to document the ability of the use of sonography to accurately detect the presence of deep infiltrating endometriosis. The clinical observations were performed consistent with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations for observational studies. Recognizing the real‐world office setting for this may introduce the importance of the practical clinical aspects of diagnostic procedures in general.ResultsThree‐dimensional transvaginal sonography was able to accurately identify deep invasive endometriosis in 92% of the 100 women subjectively complaining of the associated symptoms of endometriosis, who underwent sonography, surgical exploration, and pathologic analysis. Additional sonographic evidence of pelvic pathology was found during the course of this investigation, perhaps complementing other means for diagnosing endometriosis.ConclusionThree‐dimensional transvaginal sonography is a diagnostic tool that can effectively identify deep infiltrating endometriosis, which may otherwise go undetected and untreated. These findings should encourage the use of sonography for the detection of this subtype of endometriosis.

Dysmenorrhea pattern in adolescences informing adult endometriosis

BackgroundEndometriosis (EMs) is a chronic and progressive disease that, if diagnosed late, can lead to infertility and deep infiltrating endometriosis (DIE). Dysmenorrhea is the most prominent symptom of EMs. However, limited research exists on the specific correlation between dysmenorrhea patterns and EMs. Early prevention of EMs is essential to effectively manage the progression of the disease, and is best detected during adolescence. Our objective was to associate the development of EMs with dysmenorrhea patterns during adolescence and quantify the risk of adult EMs for adolescent girls, with the aim of supporting primary intervention strategy planning.MethodsThis case–control study examined predictors for adult EMs based on dysmenorrhea patterns in adolescents. We collected 1,287 cases of 641 EMs and 646 healthy females regarding their basic demographic information, adolescent menstrual characteristics, adolescent dysmenorrheal patterns, and adolescent lifestyles. Age-matching (1-to-1) was employed to control for the confounding effect of age between the groups. Least Absolute Shrinkage and Selection Operator (LASSO) and logistic regression models were utilized to identify predictors for adult EMs. The predictive value of the model was evaluated using the area under the receiver operating characteristic curve (AUC) and the C-index, while Hosmer–Lemeshow Test assessed the goodness of fit of the model. Data from one additional cohort in Shenzhen hospitalized with EMs were used to external validation were analyzed.ResultsIndividuals who always experienced dysmenorrhea had a risk of adult endometriosis 18.874 (OR = 18.874; 95%CI = 10.309–34.555) times higher than those occasional dysmenorrhea, The risk of developing EMs was 5.257 times higher in those who experienced dysmenorrhea more than 12 months after menarche than in those who experienced dysmenorrhea less than 6 months after menarche (OR = 5.257, 95% CI = 3.343–8.266), AUC in the external validation cohort was 0.794(95%CI: 0.741–0.847). We further found that high-intensity physical activity and sun-sensitive skin of burning were influential factors in high-frequency dysmenorrhea. The AUC value for the internal evaluation of the model was 0.812 and the AUC value for the external validation was 0.794.ConclusionOur findings revealed that the frequency of dysmenorrhea during adolescence contributed to the development of adult endometriosis. The frequency and onset of dysmenorrhea in adolescence were promising predictors for adult EMs. Both internal and external validation proved the model's good predictive ability.Trial registrationhttp://www.chictr.org.cn/, TRN: ChicTR2200060429, date of registration: 2022/06/01, retrospectively registered.

Deep Infiltrating Endometriosis in Adolescence: Early Diagnosis and Possible Prevention of Disease Progression.

Endometriosis has a prevalence of 10% worldwide in premenopausal women. Probably, endometriosis begins early in the life of young girls, and it is commonly diagnosed later in life. The prevalence of deep infiltrating endometriosis (DIE) in adolescence is currently unknown due to diagnostic limits and underestimation of clinical symptoms. Dysmenorrhea is a common symptom in adolescents affected by DIE, often accompanied by dyspareunia and chronic acyclic pelvic pain. Ultrasonography-either performed transabdominal, transvaginal or transrectal-should be considered the first-line imaging technique despite the potential for missed diagnosis due to early-stage disease. Magnetic resonance imaging should be preferred in the case of virgo patients or when ultrasonographic exam is not accepted. Diagnostic laparoscopy is deemed acceptable in the case of suspected DIE not responding to conventional hormonal therapy. An early medical and/or surgical treatment may reduce disease progression with an immediate improvement in quality of life and fertility, but at the same time, painful symptoms may persist or even recur due to the surgery itself. The aim of this narrative review is to report the prevalence of DIE in adolescents, describe the pathogenetic theories and discuss the management in adolescent women, including the challenging road to diagnosis and the treatment alternatives.

Women with Endometriosis-Who Is at Risk for Complications Associated with Pregnancy and Childbirth? A Retrospective Case-Control Study.

Women with endometriosis (EM), particularly the manifestations of adenomyosis (AM) and deep infiltrating endometriosis (DIE), suffer from pain and sterility. DIE also appears with several specific obstetric complications. To determine the risk profile, we designed a retrospective case-control study. Primary outcomes were defined as the risk of preterm birth and caesarean delivery (CD). Primiparous singleton pregnancies in women with DIE were compared with controls without EM. We matched for mode of conception and maternal age. A total of 41 women diagnosed with DIE and 164 controls were recruited. A total of 92.7% of the cases were also diagnosed with AM. Preterm birth occurred in 12.2% of cases and in 6.7% of controls. The difference was not statistically significant (OR: 1.932; 95% CI: 0.632-5.907). The rate of CD was similar in both groups. Remarkably, placental implantation disorders in the form of placenta praevia were eight times more frequent in women with DIE (9.8%) than in controls (1.2%, OR: 8.757; 95% CI: 1.545-49.614). Neonatal outcome was similar in both groups. Four out of fourteen cases reported abdominal wall endometriosis after CD. Women with DIE/AM and with placenta praevia are at risk of bleeding complications. After CD, they can develop abdominal wall EM. We therefore suggest evaluating the birth mode in each woman with DIE/AM.

Endometriosis Predictive Models Based on Self-Assessment Questionnaire, Evidence from Clinical Examination or Imaging Findings: A Narrative Review.

The aim of this narrative review is to evaluate existing questionnaires on predictive models for endometriosis. These symptom-based models have the potential to serve as screening tools for adult women to detect endometriosis. A comprehensive search of PubMed and Embase databases was conducted to identify studies on endometriosis screening. The search targeted predictive models for endometriosis localisation, bowel involvement, need for bowel surgery and fertility. Due to the heterogeneity identified, a systematic review was not possible. A total of 23 studies were identified. Among these studies, twelve included measures for general endometriosis, two targeted specific sites, four focused on deep infiltrating endometriosis (DIE), and three addressed the need for endometriosis-related bowel surgery. Many measures combined clinical, imaging and laboratory tests with patient questionnaires. Validation of these models as screening tools was lacking in all studies, as the focus was on diagnosis rather than screening. This review did not identify any fully validated, symptom-based questionnaires for endometriosis screening in adult women. Substantial validation work remains to establish the efficacy of such tools.

Non-invasive diagnostics of endometriosis based on plasma miRNA expression

Aim. To develop a method for noninvasive diagnosis of external genital endometriosis based on plasma microRNA concentrations.Materials and Methods. 80 women of reproductive age who were admitted to the gynecological department for routine laparoscopy were retrospectively examined, according to the results of which and histological examination, the patients were divided into 2 groups: the main group — 54 patients with laparoscopically and histologically confirmed external genital endometriosis (EGE); the control group — 26 patients without EGE. Before laparoscopy, a blood sample was taken from all patients for a molecular-biological study of the expression of 10 microRNAs: miR-183, miR-125b, miR-126, miR-16, miR-15a, miR-200a, miR-20a, miR-21, miR-222 and miR-29b. Identification of the studied and normalizing RNAs (U6 RNA and 103a microRNA) was performed according to the method of Chen et al. The presented values of the expression of the studied microRNAs are given in the form of 2-ΔCt. The expression ratio is given in the form of 2-ΔCt (main)/2-ΔCt (control), if the expression in the group of patients with endometriosis exceeded that in the control group, and in the form of 2-ΔCt (control)/2-ΔCt (main), if vice versa.Results. Comparison of the expression of 10 mi-croRNAs between the two groups revealed statistically significant differences only in miR-183: its expression in patients with EGE was statistically 1.5 times higher than that in women of the control group (p=0.017).We have not detected a difference in the expression of mir-200a, while according to other researchers, representatives of the mir-200 family are among the most frequent whose expression changes with endometriosis. MIR-16 expression also did not differ statistically among the patients we examined, whereas a group of American colleagues revealed its increase in patients with endometriosis and with endometriosis-associated ovarian tumors. We found no difference in mir-21 expression. The results of other researchers are contradictory: some found its increase in endometrioid cysts compared with eutopic endometrium, an increase in the epithelium of the fallopian tubes with their endometriosis compared with unaffected; others did not reveal a difference between the eutopic endometrium of endometriosis patients and healthy women, but showed a decrease in expression in peritoneal foci and foci of deep infiltrative endometriosis compared with eutopic endometrium.The expression of mir-222 was reduced in the patients we examined with endometriosis, which goes against the existing ideas about the pro-oncogenic role of this microRNA. An increase in its expression in cancer of the stomach, bladder, liver, lungs, breast, endometrium, ovaries is described. At the same time, the oncosuppressive effect of mir-222 is also known in prostate cancer, squamous cell carcinoma of the oral cavity.Conclusion. Taking into account the revealed statistically significant difference in microRNA expression by ROC analysis, we determined their effectiveness and specificity in the diagnosis of EGE. Of course, further studies with a large contingent of patients are needed to confirm the diagnostic value of these biomarkers. In addition, our study did not allow us to establish a statistical difference in microRNA expression in patients with impaired fertility. But it is the test that makes it possible to differentiate female infertility — associated with endometriosis and without it, as a rule, tubal-peritoneal genesis — that will become a key tool in the personalized management of patients with infertility.In our work, the distribution of patients by stages of EGE turned out to be uneven (there were no women with stage I at all) and it was not possible to establish a statistical difference in microRNA expression depending on the "length of service" of the disease.

Endometriosis diagnosed by ultrasound is associated with lower live birth rates in women undergoing their first in vitro fertilization/intracytoplasmic sperm injection treatment

ObjectiveTo study the cumulative live birth rate (CLBR) after the first In Vitro Fertilization (IVF) or Intracytoplasmic Sperm Injection (ICSI) treatment in women with or without deep infiltrating endometriosis (DIE) and/or endometrioma diagnosed by transvaginal ultrasonography (TVUS), using the International Deep Endometriosis Analysis (IDEA) group definitions. DesignProspective observational cohort study at a university hospital. SubjectsIn total 1040 subfertile women aged 25- ≤39 years, undergoing their first IVF/ICSI treatment between January 2019 and October 2022. Of these, 234 (22.5%; 95% Confidence Interval (CI), 20.0 – 25.0) women were diagnosed with DIE and/or endometrioma at systematic TVUS prior to starting their treatment. ExposureAll women underwent their first IVF or ICSI treatment. Fresh and/or frozen embryos from the first cycle were used until pregnancy was achieved or no embryos remained. Main Outcome MeasuresCLBR after the first IVF/ICSI cycle in women with or without DIE and/or endometrioma. ResultsThe CLBR after the first IVF/ICSI treatment in the total cohort of women was 426/1040, (41.0%; 95% CI, 38.0 – 44.0). Women with DIE and/or endometrioma had a lower CLBR (78/234, 33.3%; 95% CI, 27.3 – 39.4) compared to women without the disease (348/806, 43.2%; 95% CI, 39.8 – 46.6), p=0.007. The crude relative risk (RR) for cumulative live birth for women with DIE and/or endometrioma was 0.77; 95% CI, 0.63-0.94, and after adjustments were made for age, BMI, s-anti müllerian hormone, stimulation protocol and day for embryo transfer, the adjusted RR was 0.63; 95% CI, 0.48-0.82. There was no difference in the number of retrieved mature oocytes, fertilization rate or good quality embryos between the two groups. ConclusionThe presence of DIE and/or endometrioma diagnosed by TVUS lowers the chance for a live birth in women undergoing their first IVF/ICSI treatment.

Evaluation of Deeply Infiltrating Endometriosis by Preoperative Magnetic Resonance Imaging in Patients with Adenomyosis

Abstract Objectives: Before endometriosis surgery, it is important to identify deep infiltrating endometriosis (DIE) to assess the surgical difficulty. Preoperative magnetic resonance imaging (MRI) was used to determine which findings are useful in predicting DIE. Materials and Methods: Between 2008 and 2016, 54 patients with adenomyosis underwent total laparoscopic hysterectomy at our hospital. We retrospectively evaluated the intraoperative findings and magnetic resonance imaging (MR) images. The MR images were scored based on the presence of five findings: retroflexed uterus, elevated posterior vaginal fornix, intestinal tethering in the direction of the uterus, faint strands between the uterus and intestine, and fibrotic nodules covering the serosal surface of the uterus. Results: Of the five findings, intestinal tethering and faint strands between the uterus and intestine showed a sensitivity of 73% and a specificity of 91%–100%, indicating the usefulness of these findings for detecting deep endometriosis lesions. However, finding a retroflexed uterus did not contribute to DIE lesion detection. The sensitivities of an elevated posterior fornix and fibrotic nodules covering the surface of the uterus were as low as 46%–59%, and their specificities were as high as 84%–91%. Conclusion: Preoperative preparation is essential for patients with intestinal tethering or faint strands between the uterus and intestine on preoperative MRI after obtaining appropriate informed consent.

#334 : Tackling Complex Infertility Patient: A Case Report

Background: Infertility is a common problem presented in women with endometriosis especially as it is often associated with poor quality of life. Therefore, surgical Intervention has been considered as the first-line treatment of choice. On the other hand, surgery itself has detrimental effects on ovarian reserve and is associated with ovarian failure. Case Report: We present a case of a 39-year-old woman para 1 with multiple myoma uteri, bilateral endometriosis cyst, left hydrosalpinx, deep infiltrating endometriosis (DIE), and adhesion (Figure 1). She comes with a history of heavy abnormal uterine bleeding, lower abdominal pain, and unable to conceive 11 years after their first child despite adequate unprotected intercourse. The patient was anemic (Hemoglobin 7.30 g/dL) with low Anti Mullerian Hormone (AMH; 0.26 mg/ml). We decided to perform laparoscopic uterine myoma with multiple bilateral endometrial cysts, left salpingectomy, and adhesiolysis (Figure 2). Patient then underwent an ultra-long protocol with three cycles of leuprolide acetate 3.75 mg. Ovum pick-up was performed and we retrieved five M-II oocytes and from embryo culture, two embryos with good and moderate quality were collected for vitrification procedure. Prior frozen embryo transfer, extra acetylsalicylic acid 80 mg once a day and estradiol valerate 4 mg thrice a day were given for 18 days. The patient soon became pregnant after a few weeks of embryo transfer with βHCG of 185 mIU/m. Conclusion: Individualized treatment plans based on the patient’s symptoms and respective reproductive goals are important points to be discussed in endometriosis-associated infertility patients. Surgical intervention before IVF/ICSI is deemed as necessary to preserve ovarian reserve and to restore normal anatomy to increase the success rate of embryo implantation.

Pilot study of treatment of patients with deep infiltrative endometriosis with methotrexate carried in lipid nanoparticles.

Previously, lipid nanoparticles (LDE) injected in women with endometriosis were shown to concentrate in the lesions. Here, the safety and feasibility of LDE carrying methotrexate (MTX) to treat deep infiltrating endometriosis was tested. Prospective pilot study. Perola Byington Hospital Reference for Women's Health. Eleven volunteers (aged 30-47years, BMI 26.15 ± 6.50kg/m2) with endometriosis with visual analog scale pelvic pain scores (VAS) > 7 and rectosigmoid lesions were enrolled in the study. Three patients were treated with LDE-MTX at single intravenous 25mg/m2 dose of MTX and eight patients with two 25mg/m2 doses with 1-week interval. Clinical complaints, blood count, and biochemistry were analyzed before treatment and on days 90, 120, and 180 after LDE-MTX administration. Endometriotic lesions were evaluated by pelvic and transvaginal ultrasound (TVUS) before treatment and on days 30 and 180 after LDE-MTX administration. No clinical complaints related with LDE-MTX treatment were reported by the patients, and no hematologic, renal, or hepatic toxicities were observed in the laboratorial exams. FSH, LH, TSH, free T4, anti-Müllerian hormone, and prolactin levels were also within normal ranges during the observation period. Scores for deep dyspareunia (p < 0.001), chronic pelvic pain (p = 0.008), and dyschezia (p = 0.025) were improved over the 180-day observation period. There was a non-significant trend for reduction of VAS scores for dysmenorrhea. Bowel lesions by TVUS were unchanged. No clear differences between the two dose levels in therapeutic responses were observed. Results support the safety and feasibility of using LDE-MTX in women with deep infiltrating endometriosis as a novel and promising therapy for the disease. More prolonged treatment schemes should be tested in future placebo-controlled studies aiming to establish the usefulness of this novel nanomedicine approach.

MRI of Endometriosis: Single institute experience including MRI classification and Laparoscopic correlation with ENZIAN classification

BackgroundEndometriosis is a chronic gynecological condition affecting women of reproductive age and may cause pelvic pain and infertility. MRI is the best imaging technique for mapping and preoperative staging of endometriosis as it provides a tool for the assessment of deep infiltrating endometriosis. The aim of this study was to evaluate the role of magnetic resonance imaging (MRI) in detection and characterization of endometriosis in correlation between it and the laparoscopic findings according to ENZIAN classification.MethodsWe assessed 100 patients by MRI dedicated pelvis protocol for endometriosis with an assessment of the ovaries, uterus, uterosacral ligaments (USL), broad ligaments, and round ligaments, cul-de-sac, rectosigmoid colon, bladder, ureters, and rectovaginal septum. All these patients are submitted for laparoscopy, and then, data from both investigations were correlated.ResultsMRI provided a road map for surgeons before laparoscopy. The sensitivity of MRI was 87.5% in small deep infiltrating endometriosis (DIE) (grade A1) and 100% in large DIE (A2). MRI detected 82.3% of uterosacral ligament involvement, specificity 80%. Detection rate in rectal involvement was 71.4%, specificity 75%. There was 100% sensitivity and specificity in adenomyosis and urinary bladder endometriosis.ConclusionsPreoperative detection of endometriotic lesions is recommended using a dedicated MRI endometriosis protocol to choose the surgical approach and for proper multidisciplinary teamwork planning.