Endometriosis Fertility Index Score Research Articles

An Ultrasound-Based Preoperative Evaluation of the Endometriosis Fertility Index: A Further Step towards Personalized Treatment.

Background: The Endometriosis Fertility Index (EFI), is a crucial validated surgical tool used for predicting fertility outcomes in women with endometriosis. This study aims to assess the concordance between a preoperative clinical and instrumental EFI evaluation (uEFI) and the EFI score obtained during an exploratory laparoscopy prior to surgery (sEFI). Methods: This study presents preliminary data from a broader observational cohort study. The Least Function score for the uEFI was calculated using a modified version of the original surgical EFI by incorporating a clinical examination, advanced ultrasound, and hysterosalpingo-foam sonography (HyFoSy). Results: The preoperative estimation of the EFI (uEFI) demonstrated a high concordance (k = 0.695, ρs = 0.811) with the sEFI. Remarkably, the surgical interventions led to a significant improvement in the EFI values, with 80% of the intermediate EFI transitioning to a high level, thereby highlighting the positive impact of surgery on fertility outcomes. Conclusion: This study highlights the accuracy of preoperative EFI estimation (uEFI) and its strong agreement with intraoperative assessment. It underscores the potential of a preoperative management tool to guide the allocation of infertile women with endometriosis to operative laparoscopy, direct assisted reproductive technology (ART), or spontaneous attempts at pregnancy.

Role of TNF superfamily members lymphotoxin-α, sCD40L, and TNF-α in endometriosis-related infertility

Introduction: TNF-α, LT-α, and sCD40L belong to the TNF superfamily and play a pivotal role in chronic inflammatory disease. Yet, these soluble molecules are largely unexplored in endometriosis cases with infertility. The present study aimed to evaluate serum and peritoneal fluid levels of these molecules and correlate its level to the endometriosis severity. Methods: Peripheral blood and peritoneal fluid samples were obtained from 87 infertility cases who underwent laparoscopy, consisting of 44 endometriotic women and 43 non-endometriotic women. The levels of TNF-α, LT-α, and sCD40L were determined using ELISA. Results: Serum and peritoneal TNF-α levels were significantly elevated in the endometriosis group compared to the control group ( p = 0.028; p = 0.027), but not the sCD40L and LT-α level. Serum and peritoneal TNF-α levels were significantly different between late-endometriosis (stage III or IV) compared to the control group ( p = 0.026, p = 0.041, respectively). Moreover, the serum LT-α level was significantly higher in late-endometriosis cases compared to the early-endometriosis (stage I or II) cases ( p = 0.03) and showed a positive correlation with endometriosis rASRM score ( p = 0.001). ROC curve analysis showed a significant diagnostic value of serum LT-α in differentiating the late cases to the early endometriosis patients (AUC = 0.751, p = 0.007). A negative correlation between LT-α and total Endometriosis Fertility Index (EFI) score was also observed ( p = 0.012). Conclusion: Severe endometriosis and lower EFI score are associated with higher serum LT-α level. Serum LT-α is a potential staging biomarker among endometriosis cases. Serum and peritoneal TNF-α levels were elevated in women with severe endometriosis among infertility cases. Further study should address the role and predictive value of LT-α in endometriosis-related infertility.

Effects of localization of uterine adenomyosis on clinical features and pregnancy outcome

The purpose of this study was to implore the association among clinical features, long-term fertility outcomes and the anatomical location of adenomyosis identified by ultrasound. We collected data of non-pregnant patients between 20 and 40 years old who had undergone surgical exploration for benign gynecological conditions at our institution between January 2010 and December 2017. A total of 158 women met the inclusion criteria and were allocated into three groups according to the ultrasound-determined adenomyosis anatomical location: anterior (Group A), posterior (Group B), both posterior and anterior (Group C). 44.3% (70/158) adenomyosis was located at the posterior side. History of miscarriage and parity were significantly higher in Group C (p = 0.036 and 0.001 respectively). Group C also had a higher concurrence rate of ovarian endometrioma (OEM) (80.4%, p = 0.002), pelvic adhesion (80.4%, P = 0.003) and the revised American Fertility Society (rAFS) Score (median64, range2-100, P < 0.001), while a significantly lower rate of concurrent peritoneal endometriosis (P = 0.01). Group B showed a relative higher rate of coexistent heavy menstrual bleeding (28.6%, p = 0.04) and oviduct obstruction (24.3%, P = 0.038). Group A had a higher proportion of coexistent leiomyoma (53.1%, P = 0.002). There were no significant differences between group A, B, and C in terms of pain symptoms, endometrial polyps, operation time, and endometriosis fertility index score and other basic characters (p > 0.05). During the follow-up, 59.2% (61/103) patients had clinical pregnancies, and 26.2% (16/61) of them experienced pregnancy loss. Total in vitro fertilization and embryo transfer pregnancy rate was 64.6% (42/65) and spontaneous pregnancy rate was 50.0% (19/38). The Kaplan–Meier curves demonstrated significant lower cumulative pregnancy rate in Group C than Group A and Group B (p = 0.01). Severe obstetric complications such as placenta previa, placenta accreta, preeclampsia, and preterm birth were only found in women with adenomyosis located in the posterior side. In conclusion, types of adenomyosis based on sonographic location had different clinical features and pregnancy outcome. Patients with adenomyosis lesion in both anterior and posterior sides had higher combination of OEM, pelvic adhesion and rAFS score.

Postoperative Pregnancy Outcomes Following Laparoscopic Surgical Management in Women with Stage III/IV Endometriosis: A Single-Center Follow-Up Study.

The effects of laparoscopic surgical management in women with stage III/IV endometriosis remain controversial. The standard extent of resection for stage III/IV endometriosis with deep endometriosis to treat endometriosis-associated infertility is debatable. This study aimed to assess the postoperative pregnancy outcomes following a routine surgical intervention for stage III/IV endometriosis patients. Patients with stage III/IV endometriosis who underwent conservative laparoscopic surgery at our hospital between January 2010 and December 2018 were retrospectively analyzed. Statistical analyses were performed to determine the correlations between endometriosis features and postoperative pregnancy outcomes. Of 256 patients enrolled, 94 wished to conceive. Exclusion criteria: ≥40 years, adenomyosis, partners with infertility issues. Finally, 71 women were included. The overall postoperative pregnancy rate was 76.1% (n = 54): 49 and five from non-assisted reproductive technology (ART) and ART, respectively. The postoperative pregnancy rate in patients diagnosed with infertility presurgery (40/71) was 70.0% (n = 28): 24 (non-ART) and four (ART). The endometriosis fertility index (EFI) score was higher in the pregnant than in the nonpregnant group (P = 0.03). The EFI score and surgical score of EFI were higher in the non-ART than in the ART group (P = 0.04; P = 0.02); in the infertile group, they were higher in the pregnant than in the nonpregnant group (P = 0.018; P = 0.027). Our postoperative pregnancy rate after conservative laparoscopic surgery for patients with stage III/IV endometriosis compared favorably with previous reports. EFI was a significant predictor of postoperative pregnancy. Our surgical approach to maintain a high surgical score of EFI might help treat endometriosis-associated infertility.

Outcomes between non-IVF and IVF treatment after laparoscopic conservative surgery of advanced endometriosis with Endometriosis Fertility Index score >3.

Surgical excision of advanced endometriosis has been demonstrated to improve women's pain symptoms and quality of life in women in randomized placebo-controlled trials, but there is no strong evidence regarding the live birth rate. The revised American Fertility Society (r-AFS) classification for endometriosis has a limited predictive ability for fertility outcomes after surgery; therefore, EFI scoring has been advised for predicting conception after endometriosis surgery. No randomized controlled trials have investigated fertility outcomes in patients with advanced endometriosis after surgery. This study aimed to determine the outcomes of in vitro fertilization (IVF) or non-IVF treatments after conservative surgery for advanced endometriosis in patients with good prognosis Endometriosis Fertility Index (EFI) scores (>3). This prospective cohort study was conducted between April 2014 and April 2019 at a tertiary research hospital. In total, 113 women with suspected preoperative advanced endometriosis were enrolled in this study. A total of 90 women with advanced endometriosis underwent laparoscopic surgery. Fourteen patients with EFI score of ≤3 and 3 of them who had bilateral tubal occlusion were also excluded. Seventy-three women were included in this study. The remaining 30 women in the non-IVF group and 32 women in the IVF group were analyzed. The main outcome measures were cumulative pregnancy rates and live birth rates in both groups. Women who underwent IVF treatment were older than women (30 ± 3.41) who had non-IVF treatment (26.5 ± 3.07) after laparoscopic surgery (P < .001). The remaining baseline characteristics of the patients in both groups were similar. Clinical pregnancy, abortion, and live birth rates were similar in both the groups after 36 months of follow-up. This study demonstrated that cumulative pregnancy and live birth rates were similar to those of non-IVF or IVF treatments after conservative surgery for advanced endometriosis, if patients had good prognosis EFI scores. Furthermore, non-IVF treatments resulted in nearly the same clinical pregnancy results as IVF treatment within 1 year after surgery.

EFFORT study: Comparing impact of operation and assisted reproductive technologies on fertility for women with deep infiltrating endometriosis – study protocol for a multicentre randomised trial

IntroductionDeep infiltrating endometriosis (DIE) affecting the rectum or sigmoid colon is associated with infertility, severe pain and decreased quality of life. As most women with DIE are young, many have...

Reproductive and postsurgical outcomes of infertile women with deep infiltrating endometriosis

BackgroundThis study aimed to summarize and analyze clinical characteristics and reproductive outcomes in postoperative deep infiltrating endometriosis (DIE).MethodsThis retrospective cohort study included 55 reproductive-aged patients who were diagnosed with DIE, wished to conceive and underwent resection surgery at the Obstetrics and Gynecology Hospital, Fudan University, from January 2009–June 2017. Those with any plausible infertility factor or abnormalities in the partner’s semen analysis were excluded. Patient characteristics, preoperative symptoms, infertility history, intraoperative findings and reproductive outcomes were followed up and recorded. Risk factors for reproductive outcomes were identified for women who became pregnant versus those who did not by univariate logistic regression. Additionally, pre- and postoperative endometriosis health profile questionnaire-30 (EHP-30), Knowles–Eccersley–Scott Symptom questionnaire (KESS), Cox Menstrual Symptom Scale (CMSS) and Female Sexual Function Index (FSFI) scores were used to evaluate the effect of DIE surgery on quality of life.ResultsThe average age was 30.22 ± 3.62 years, with no difference between the pregnancy and nonpregnancy groups. The average follow-up time was 26.57 ± 14.51 months. There were 34 pregnancies (61.82%): 24 (70.59%) conceived spontaneously and 10 (29.41%) by in vitro fertilization (IVF). Twenty-eight patients (82.35%) had term deliveries. The interval between operation and pregnancy was 10.33 ± 5.6 (1–26) months. Univariate analysis showed that a lower endometriosis fertility index (EFI) score (EFI < 8) was a risk factor for infertility (OR: 3.17 (1.15–10.14), p = .044). For patients with incomplete surgery, postoperative gonadotropin-releasing hormone agonist (GnRHa) administration improved the pregnancy rate (p < 0.05). Regarding quality of life, there was significant improvement (p < 0.05) in the postoperative EHP-30, KESS and CMSS scores compared with preoperative scores in both groups. Although there was no obvious difference in FSFI scores, significant improvement in dyspareunia was observed (p < 0.05).ConclusionsOverall, the postoperative pregnancy rate of DIE patients was 61.82%. Surgical management of DIE for patients with complaints of pain and with pregnancy intentions was feasible and effective. Long-term expectant treatment should not be advised for patients with lower EFI scores (EFI < 8), and postoperative IVF–ET may be a good choice. More cases should be enrolled for further study, and randomized studies are required.

Analysis of recurrence factors associated with conservative surgery for ovarian-type endometriosis.

BackgroundTo investigate the factors associated with postoperative recurrence in patients with ovarian-type endometriosis (EMS) who were treated with conservative surgery and to provide ideas for preventing disease recurrence in advance of treatment.MethodsThe study included data from 289 inpatients with ovarian-type EMS who underwent conservative laparoscopic surgery in the Department of Gynecology, Changzhou Maternal and Child Health Care Hospital, Nanjing Medical University, from 2018 to 2020. We collected general clinical data, postoperative recurrence, drug treatment, and follow-up information. The factors associated with recurrence were analyzed using SPSS 26.0 software.ResultsA total of 289 patients were included in this study, including 49 patients with recurrence and 240 without recurrence. In the univariate analysis of recurrence, revised American Fertility Society (r-AFS) score, preoperative dysmenorrhea, EMS fertility index (EFI) score, combined myoma, and postoperative pregnancy affected postoperative recurrence of patients. The critical value of r-AFS was 70 according to the subject receiver operating characteristic curve (ROC), and the Youden index was 0.513. R-AFS >70 had a sensitivity of 57.1%, specificity of 94.2%, the positive predictive value of 66.7%, the negative predictive value of 91.5%, and diagnostic accuracy of 87.9% for the diagnosis of recurrent ovarian endometrioid cysts. Using multifactorial binary logistic regression, results showed that r-AFS score >70 [odd ratio (OR) =1.042; 95% confidence interval (CI): 1.028–1.055; P<0.05], myoma (OR =2.995; 95% CI: 1.429–6.275; P<0.05), and preoperative dysmenorrhea (OR =1.994; 95% CI: 1.071–3.713; P<0.05) were risk factors for recurrence. EFI score (OR =0.785; 95% CI: 0.661–0.931; P<0.05), postoperative pregnancy (OR =0.349; 95% CI: 0.132–0.920; P<0.05) were protective factors for recurrence. The differences were statistically significant, and the remaining differences were not statistically significant.ConclusionsPreoperative r-AFS level, preoperative dysmenorrhea, and combined myoma are risk factors for postoperative recurrence, so patients with an r-AFS score over 70 should be more alert to possible recurrence. Moreover, EFI score and postoperative pregnancy are protective factors for postoperative recurrence. Postoperative patients should routinely take medication for prevention, and patients with the intention to become pregnant should be encouraged to conceive as soon as possible to reduce recurrence.

Endometriosis fertility index predicts pregnancy in women operated on for moderate and severe symptomatic endometriosis

ABSTRACT Endometriosis Fertility Index (EFI) is a clinical staging system created to predict spontaneous pregnancy outcomes in patients with endometriosis. The present study aimed at evaluating the performance of EFI in symptomatic patients, submitted to laparoscopy for moderate and severe endometriosis associated to infertility in a Brazilian population. Seventy-seven women with endometriosis and pelvic pain, who desired to become pregnant, were selected from a tertiary care unit between those operated on between May 2007 and March 2017. All of them were submitted to laparoscopy for the surgical treatment of endometriosis and allowed to attempt natural conception for 36 months or immediately referred to in vitro fertilization (IVF). EFI was calculated according to surgical description and clinical information in medical records. Pregnancy rates and live birth rates after natural conception or IVF are reported and correlated to EFI. Fifty-three women tried natural conception and 24 were referred to IVF. Of the 53 who tried natural conception, 29 achieved pregnancy (54.7%) and 28 had live birth (52.8%). The majority of pregnancies (82.7%) occurred in the first 12 months after surgery and 75% of the patients who became spontaneously pregnant had EFI ≥ 7. Of the 24 patients referred to IVF, 13 became pregnant (54.1%) and 10 had live birth (41.7%). Infertility duration of 36 months or more and the presence of endometrioma increased the probability of having EFI ≤ 5. The overall live birth rate (LBR) for patients with low EFI scores (2–4) was 17% compared with 83.8% for those with higher EFI scores (6–9). EFI predicts pregnancy rates in patients operated on for moderate and severe endometriosis. Scores seem also to predict pregnancy rates after IVF.

Correlation Between Levels of Interleukin-6 in Peritoneal Fluid With Degree of Pain, Adhesion, and Endometriosis Fertility Index Score in Endometriosis

Introduction : Endometriosis is a benign gynecological disorder characterized by the presence of endometrial tissue and stroma outside the uterine cavity. Several theories have been proposed to explain the occurrence of endometriosis, one of which is the theory of inflammation. Endometriosis lesions can produce inflammatory cytokines, resulting in their increased levels in the peritoneal fluid. This process causes disruption in pelvic anatomy, ovarian function, prostaglandin production and growth factor production that causes pain, adhesions and infertility. Interleukin-6 (IL-6) is an important and potential inflammatory cytokine in assisting the diagnosis of endometriosis. These cytokines act as activating macrophages that can stimulate endometrial cell proliferation and modulate the secretion of other cytokines such as IL-10, IL-13 and TNF-α which augments the inflammatory process. High levels of IL-6 in the peritoneum are relatedto advanced endometriosis associated with pain, severe pelvic adhesions and embryotoxic effects leading to infertility. The effect of IL-6, both local and systemic, on the growth of endometriosis lesions and its associated symptoms is great that this cytokine is considered an important marker.Objective : This study aims to determine the relationship between local inflammatory factors (IL-6 in peritoneal fluid) obtained during laparoscopy with the degree of pain, the degree of adhesions and the correlation with the Endometriosis Fertility Index (EFI) score in endometriosis patients.Material and methods : This is a quantitative analytic research with a cross sectional study design which was conducted on 22 patients with endometriosis. Prior to the laparoscopy, historical factor (EFI score) was recorded and an assessment of the pain scale was performed by filling out a questionnaire. Intraoperatively, the peritoneal fluid was obtained. If the peritoneal fluid was found, it was taken directly with a volume of 3-5 cc using 10 cc syringe. If no fluid was found, peritoneal rinsing was performed using 0.9% NaCl fluid, then 3-5 cc fluid was aspirated using a 10 cc syringe. Subsequently, an examination was carried out using the RayBio Human IL-6 ELISA Kit. During the laparoscopy procedure, the degree of adhesion of the pelvic organs was assessed by looking at the shape and how the adhesions can be separated. Surgical factor (EFI score) was assessed intraoperatively to obtain data for the least function score, AFS endometriosis score and AFS total score. Statistical analysis was performed using paired t test and correlation test.Results : The mean age of the respondents was 34.86 ± 6.11 years, 81.8% were nulliparous, 100% were married, 100% experienced both primary and secondary infertility and 81.8% had no prior pregnancy history. In the study, it was found that IL-6 levels of peritoneal fluid were higher in patients with the degree of severe pain (P &lt;0.05) compared to moderate with the results of 32.58 ± 7.31 pg/ml and 25.39 ± 2.70 pg/ml. IL-6 levels were found to be higher in grade three adhesions than grade two (P &lt;0.05) with results of 32.78 ± 6.65 pg/ml and 23.86 ± 2.18 pg/ml. The mean peritoneal fluid IL-6 levels were 30.75 ± 7.01 pg/ml and the mean EFI score was 4.09 ± 2.09. The correlation of IL-6 levels in peritoneal fluid with EFI score showed a value of r = -0.448 which had moderate strength and a negative pattern, indicating that the higher the IL-6 level of peritoneal fluid, the lower the EFI score (P &lt;0.05).Conclusion : There is a relationship between IL-6 levels of peritoneal fluid in endometriosis with the degree of pain and the degree of adhesion, where IL-6 levels were found to be higher in the degree of severe than moderate pain (P &lt;0.05), higher in third degree adhesions than second degree ( P &lt;0.05). There was a correlation between IL-6 levels of peritoneal fluid with EFI score (P &lt;0.05) with a negative pattern of moderate strength analysis results (r = -0.448).Keywords: Endometriosis, Interleukin-6, Degree of Pain, Degree of Adhesion, Endometriosis Fertility Index Score

Estimation of the Endometriosis Fertility Index prior to operative laparoscopy.

Can the Endometriosis Fertility Index (EFI) be estimated accurately before surgery? The EFI can be estimated accurately based on mere clinical/ultrasound information, with some improvement after adding data from diagnostic laparoscopy. The EFI is a validated clinical instrument predicting the probability of pregnancy after endometriosis surgery without the use of ART. Being an end-of-surgery-score, it implies the decision for operative laparoscopy to be made in advance-hence, its role in the pre-surgical decision-making process remains to be established. Single-cohort prospective observational study in 82 patients undergoing complete endometriosis excision (between June and December 2016). Two methods were used to estimate the final EFI: type A based on non-surgical clinical/ultrasound findings only, and type B based on the combination of non-surgical clinical/ultrasound findings and diagnostic laparoscopy data. To calculate EFI type A, an algorithm was created to translate non-surgical clinical/imaging information into rASRM (revised American Society of Reproductive Medicine)-and EFI points. EFI type A and type B estimates were assessed for their clinical and numerical agreement with the final EFI score. Agreement was defined as clinical if EFI scores were within the same range (0-4, 5-6, 7-10), and numerical if their difference was ≤1. All 82 patients underwent complete laparoscopic CO2-laser excision of any rASRM stage of endometriosis in the Leuven University Fertility Centre (LUFC) of University Hospitals Leuven, a tertiary referral centre for both endometriosis and infertility. An anonymized clinical research file was created. For each patient, three different data sets were created, in order to allow the estimation of the (surgical part) EFI and of the rASRM scores, defined as follows: 'Estimated type A' contained only non-surgical clinical/imaging data, 'Estimated type B' included type A information plus the information of the diagnostic laparoscopy and 'Final EFI' included information of type A, type B and all intra-operative information required to calculate the final EFI. To calculate EFI type A without surgical information, a set of rules was used to translate pre-surgical clinical/imaging information into (rASRM and EFI points). Scoring was done by one person (C.T.), with a time interval of 4 weeks between sessions for each EFI type. Next to the EFI, also rASRM score and stage were calculated. Agreement rate between estimated EFI type A and final EFI was high for both the clinical (0.915; 95% CI 0.832-0.965) and numerical definition (0.878; 95% CI 0.787-0.940). Agreement rates between estimated EFI type B and final EFI were even higher (clinical (0.988; 95% CI 0.934-1.000), numerical (0.963; 95% CI 0.897-0.992)). Type A estimation is dependent on high-level gynaecological ultrasound expertise, which may not be available in all clinics. A small number of patients had no prior clinical, ultrasound (hard markers) or surgical confirmation of the diagnosis of endometriosis. When applying the estimated EFI type A in clinical practice, a priori assumptions of the presence or absence of endometriosis will need to be made in adjunct to the estimation of the estimated type A EFI when counselling patients on the potential benefit of an (at least diagnostic) laparoscopy. The level of agreement for type A or B should also be taken into account when counselling patients on the type of efforts undertaken to attempt to diagnose or rule out endometriosis. As this study reports, the EFI can be estimated accurately based on clinical/ultrasound data only without the need for any surgical data. This means that the EFI could be used as an instrument to guide joint physician-patient decision-making between surgery, ART or other fertility management options for the individualized treatment of women with endometriosis-related infertility. During this study period, C.T. was supported by FWO (Research Fund Flanders, Grant number 1700816N) and UZ Leuven KOF (University Hospitals Leuven, Klinisch Onderzoeksfonds).The LUFC received unrestricted research grants from Ferring Pharmaceuticals and Merck SA. Gedeon Richter and MSD sponsored travel to and attendance at scientific meetings. C.M. received consultancy fees from Lumenis (paid to KU Leuven, no private revenue). T.D. has been vice-president and head of global medical affairs infertility for the multinational pharmaceutical company Merck (Darmstadt, Germany) since 1 October 2015. He continues his academic appointment on a part-time basis as Professor of Reproductive Medicine at the University of Leuven (KU Leuven). T.D. has been vice-president and head of global medical affairs infertility for the multinational pharmaceutical company Merck (Darmstadt, Germany) since October 2015. He is also a Guest Professor in Reproductive Medicine and Biology at the Department of Development and Regeneration, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium, and an Adjunct Professor at the Department of Obstetrics and Gynecology in the University of Yale, New Haven, USA. This work was initiated before he joined Merck KGaA in October 2015, and completed during the subsequent years. study registration number at UZ Leuven Clinical Trial Centre: S59221.

EQUSUM: Endometriosis QUality and grading instrument for SUrgical performance: proof of concept study for automatic digital registration and classification scoring for r-ASRM, EFI and Enzian.

STUDY QUESTIONIs electronic digital classification/staging of endometriosis by the EQUSUM application more accurate in calculating the scores/stages and is it easier to use compared to non-digital classification?SUMMARY ANSWERWe developed the first digital visual classification system in endometriosis (EQUSUM). This merges the three currently most frequently used separate endometriosis classification/scoring systems (i.e. revised American Society for Reproductive Medicine (rASRM), Enzian and Endometriosis Fertility Index (EFI)) to allow uniform and adequate classification and registration, which is easy to use. The EQUSUM showed significant improvement in correctly classifying/scoring endometriosis and is more user-friendly compared to non-digital classification.WHAT IS KNOWN ALREADYEndometriosis classification is complex and until better classification systems are developed and validated, ideally all women with endometriosis undergoing surgery should have a correct rASRM score and stage, while women with deep endometriosis (DE) should have an Enzian classification and if there is a fertility wish, the EFI score should be calculated.STUDY DESIGN, SIZE, DURATIONA prospective endometriosis classification proof of concept study under experts in deep endometriosis was conducted. A comparison was made between currently used non-digital classification formats for endometriosis versus a newly developed digital classification application (EQUSUM).PARTICIPANTS/MATERIALS, SETTING, METHODSA hypothetical operative endometriosis case was created and summarized in both non-digital and digital form. During European endometriosis expert meetings, 45 DE experts were randomly assigned to the classic group versus the digital group to provide a proper classification of this DE case. Each expert was asked to provide the rASRM score and stage, Enzian and EFI score. Twenty classic forms and 20 digital forms were analysed. Questions about the user-friendliness (system usability scale (SUS) and subjective mental effort questionnaire (SMEQ)) of both systems were collected.MAIN RESULTS AND THE ROLE OF CHANCEThe rASRM stage was scored completely correctly by 10% of the experts in the classic group compared to 75% in the EQUSUM group (P < 0. 01). The rASRM numerical score was calculated correctly by none of the experts in the classic group compared with 70% in the EQUSUM group (P < 0.01). The Enzian score was correct in 60% of the classic group compared to 90% in the EQUSUM group (P = 0.03). EFI scores were calculated correctly in 25% of the classic group versus 85% in the EQUSUM group (P < 0.01). Finally, the usability measured with the SUS was significantly better in the EQUSUM group compared to the classic group: 80.8 ± 11.4 and 61.3 ± 20.5 (P < 0.01). Also the mental effort measured with the SMEQ was significant lower in the EQUSUM group compared to the classic group: 52.1 ± 18.7 and 71.0 ± 29.1 (P = 0.04). Future research should further develop and confirm these initial findings by conducting similar studies with larger study groups, to limit the possible role of chance.LIMITATIONS, REASONS FOR CAUTIONThese first results are promising, however it is important to note that this is a preliminary result of experts in DE and needs further testing in daily practice with different types (complex and easy) of endometriosis cases and less experienced gynaecologists in endometriosis surgery.WIDER IMPLICATIONS OF THE FINDINGSThis is the first time that the rASRM, Enzian and EFI are combined in one web-based application to simplify correct and automatic endometriosis classification/scoring and surgical registration through infographics. Collection of standardized data with the EQUSUM could improve endometriosis reporting and increase the uniformity of scientific output. However, this requires a broad implementation.STUDY FUNDING/COMPETING INTEREST(S)To launch the EQUSUM application, a one-time financial support was provided by Medtronic to cover the implementation cost. No competing interests were declared.TRIAL REGISTRATION NUMBERN/A.

Use of the EFI score in endometriosis-associated infertility: A cost-effectiveness study

BackgroundThe management of endometriosis-related infertility is still under debate. The Endometriosis Fertility Index (EFI) score is performant to predict the occurrence of a spontaneous pregnancy following surgery, but was not evaluated in a cost-effectiveness perspective. Our objective was to quantify fertility outcomes, and costs of different care pathways for endometriosis-associated infertility after primary surgery, with a stratification on the EFI score. Study designWe conducted a cost-effectiveness analysis based on a decision-tree model in a Tertiary-care university hospital. Extracted form a prospectively maintained database, 608 patients with endometriosis-associated infertility, who underwent laparoscopic treatment with an evaluation of the EFI score, were discriminated between different strategies: natural conception, immediate IVF-ICSI, delayed IVF-ICSI. The pregnancy rate and the live birth rate were the effectiveness outcomes. We considered direct and indirect costs in each strategies. The analysis was stratified according to the EFI score. ResultsAfter surgery, 163 women with immediate IVF-ICSI (strategy I) were compared with 445 women who had natural conception attempts during a year (strategy II). After a year failure of natural conception attempts, 133 women continuing natural conception attempts (strategy III) were compared with 168 women who had delayed IVF-ICSI (strategy IV). The respective PR and LBR were 62.6 % and 52.1 % for strategy I, and 32.4 % and 23.8 % for strategy II. Compared to strategy II, strategy I was more costly and more effective (Incremental Cost Effectiveness Ratio (ICER): 31,469 €/pregnancy and 33,568 €/live birth)). No added benefit was observed for patients in strategy I with an EFI score [0−3] after two IVF-ICSI cycles. Strategy III was strongly dominant versus strategy IV for patients with an EFI score [9–10]. Compared to strategy III, strategy VI was more costly and more effective (ICER: 79,674 €/pregnancy, 53,188 €/pregnancy and 27,748 €/pregnancy respectively for patients with an EFI score [7–8], [4–6] and [0−3]). ConclusionImmediate IVF-ICSI after surgery is effective but associated with substantial costs for the healthcare system. Taking into account healthcare costs, the EFI is a useful score for helping a couple decide between different care pathways –natural conception, immediate or delayed IVF-ICSI– after surgery for endometriosis-associated infertility.

Negative Sliding Sign during Dynamic Ultrasonography Predicts Low Endometriosis Fertility Index at Laparoscopy

Endometriosis fertility index (EFI) is a robust tool to predict the pregnancy rate in patients with endometriosis who are attempting non-in vitro fertilization conception. However, EFI calculation requires laparoscopy. Newly established imaging techniques such as sliding sign, which is used to diagnose pouch of Douglas obliteration, could provide a promising alternative. The objective of this study was to investigate the practicality of using ultrasound data to predict a low EFI (score ≤6). Observational study from a prospective registry (Endometriosis Pelvic Pain Interdisciplinary Cohort, clinicaltrials.gov #NCT02911090). Analyzed data were captured from December 2013 to June 2017. Tertiary referral center at British Columbia Women's Hospital. We analyzed data for 2583 participants from the Endometriosis Pelvic Pain Interdisciplinary Cohort. In this cross-sectional study, we included 86 women aged <40 years. Dynamic ultrasonography for the sliding sign testing and EFI calculation during laparoscopic surgery. Logistic regression was used to obtain receiver operating characteristic area under the curve (AUC) for the prediction models. Significance was p <.05. Patients with a negative sliding sign were older and had severe endometriosis and longer duration of infertility. Patients with a negative sliding sign had significantly lower total EFI scores and lower surgical factors scores than patients with a positive sliding sign. Logistic regression showed that a negative sliding sign and EFI historic factors score can predict an EFI score ≤6 (sensitivity = 87.9%, specificity = 81.1%, AUC = 0.93 [95% confidence interval, 0.88-0.98]). Adding the diagnosis of endometrioma to the previous prediction model resulted in AUC = 0.95 (95% confidence interval, 0.90-0.995), sensitivity = 84.8%, and specificity = 92.5%. The sliding sign could be a potential alternative to the EFI surgical factors, and it could be used in combination with EFI historic factors and the diagnosis of endometrioma to predict an EFI score ≤6 for patients who are not scheduled for immediate surgery.

Endometriosis fertility index for predicting non-assisted reproductive technology pregnancy after endometriosis surgery: a systematic review and meta-analysis.

Results of studies that have assessed the accuracy of the endometriosis Fertility Index (EFI) for predicting non-assisted reproductive technology (ART) pregnancy are inconsistent. We intended to evaluate the accuracy of EFI for the prediction of non-ART pregnancy. Embase, Medline, Scopus and Web of Science were searched up to 5 October 2019. We included studies that used EFI to predict non-ART pregnancy in women with surgically documented endometriosis. A total of 5547 studies were identified, from which we included 17 studies on 4598 women in the meta-analysis. Eight studies were classified as good quality, and the rest were considered to be of fair quality. Only five (29.41%) studies used appropriate approaches to account for potential confounders. Pooled effect sizes with corresponding 95% CI were calculated using random-effects model. The cumulative non-ART pregnancy rate at 36months was 10% (95% CI: 3, 16%; P<0.001) for women with an EFI of 0-2, which significantly increased to 69% (95% CI: 58, 79%; P<0.001) for women with an EFI of 9-10. Compared with women with an EFI of 3-4 (18%, 95% CI: 12, 24%; P<0.001), the combined cumulative non-ART pregnancy rates were 44% (95% CI: 26, 63%; P<0.001) for women with an EFT of 5-6 and 55% (95% CI: 47, 64%; P<0.001) for women with an EFI of 7-8. Paired comparison by the chi-square test showed a significant difference between all categories (P<0.001). The odds ratio(OR) for EFI was 1.33 (95% CI: 1.17, 1.49, P<0.001) and the summary area under the curve(AUC) was 72% (95% CI: 65, 80%, P<0.001). The current findings highlighted the good performance of the EFI score in predicting the non-ART pregnancy rate. However, these findings should be considered with caution because of the substantial heterogeneity between studies. Review findings show the merits of Endometriosis Fertility Index as having a prognostic ability for non-assisted reproductive technology pregnancy.

2426 Sliding Sign Testing Could be a Potential Alternative to Laparoscopy to Predict Endometriosis Fertility Index (EFI) in Endometriosis Associated Infertility

Study Objective EFI is a robust tool to predict pregnancy rate in endometriosis patients who attempt non-in vitro fertilization conception. However, EFI calculation requires laparoscopy. Sliding sign is a newly established technique that can predict Pouch of Douglas (POD) obliteration with a high degree of accuracy. The objective of this study is to investigate the relationship between sliding sign and the EFI, and to explore the practicality of using sliding sign to predict EFI score less than seven. Design Observational study from a prospective registry (Endometriosis Pelvic Pain Interdisciplinary Cohort (EPPIC), ClinicalTrials.gov#NCT02911090). Analyzed data was captured from December 2013 to June 2017. Setting Tertiary referral center at British Columbia Women's Hospital. Patients or Participants Eighty-six women who are less than 40 years old. Interventions Dynamic ultrasonography for the sliding sign testing and EFI calculation during laparoscopic surgery. Measurements and Main Results Patients with a negative sliding sign(N=26,Group I) were older, had stage IV endometriosis, and a lower median EFI score than patients who had a positive sliding sign (N=60,Group II).Patients in group I had significantly lower surgical factor scores, Regarding the EFI historical factors, group I participants had a longer duration of infertility with no significant difference in parity or age compared to group II. Logistic regression showed that an EFI score Conclusion The sliding sign could be a potential alternative to the EFI surgical factors, and it could be used in combination with EFI historical factors to predict an EFI score

1748 Fertility and Surgical Outcome in Postoperative Deep Infiltrating Endometriosis

Study Objective To analyze clinical characteristics and fertility outcome in postoperative deep infiltrating endometriosis. Design Retrospective cohort study. Follow-up of about 27 months. Setting Tertiary-care university medical center. Patients or Participants 55 patients of productive age who were diagnosed of deep infiltrating endometriosis (DIE), undergone resection surgery and wished to conceive in our hospital from January 2009 to June 2017. Any plausible infertility factor or abnormality of partner's semen analysis were excluded. Interventions Clinical characteristics, fertility and surgical outcome were followed up and analyzed. Measurements and Main Results There were 34 pregnancies (61.82%) with 24 (70.59%) spontaneously and 10 (29.41%) in-vitro fertilization (IVF). 28 patients (82.35%) were term deliveries. The interval between operation and pregnancy was 10.33±5.6 (1-26) months. The pregnancy group had higher EFI (endometriosis fertility index, EFI) scores and more patients had cautery procedure in non-pregnancy group(p Conclusion In our study, the postoperative pregnancy rate of DIE is 61.82%. Surgical management for DIE patients with painful complaints and pregnancy intention were feasible and effective. Once surgery is decided, complete excision of DIE could be the first choice. For incomplete excision cases, administration of postoperative GnRHa is suggested. Postoperative IVF-ET may be a good choice for the patient with lower EFI score (EFI

Fertility performance and the predictive value of the endometriosis fertility index staging system in women with recurrent endometriosis: A retrospective study.

This study presents the postoperative pregnancy rate of women with recurrent endometriosis and evaluates the predictive value of the endometriosis fertility index (EFI) for the pregnancy.A total of 107 women who wished to conceive after surgery for recurrent endometriosis from January 2007 to December 2016 were included. The EFI score was calculated postoperatively. The receiver operator characteristic (ROC) curve was plotted to determine the most promising contributor to predicting pregnancy, and Kaplan–Meier (K–M) analysis was used to estimate the cumulative pregnancy rate (CPR).A total of 61 pregnancies were registered in 58 women and the remaining 49 patients failed to become pregnant. The EFI score was strongly associated with the postoperative fertility prognosis. The CPRs during the first 2 and 3 years postoperatively were 51.86% and 66.38%, respectively, and increased to 71.98% within the first 5 years postoperatively in patients with EFI scores ≥5. However, the CPR was 26.00% during the first 2 years after surgery in individuals with EFI scores <5, and there was no increase in the CRP thereafter.Women suffering from recurrent endometriosis still experienced a probability of natural pregnancy, especially patients with EFI scores ≥5. The EFI score had good predictive power for postoperative pregnancy in these patients.

Clinical Outcome Analysis and Correlation of Reproductive Outcome with Endometriosis Fertility Index in Laparoscopically Managed Endometriosis Patients: A Retrospective Cohort Study.

Background:Laparoscopy is important for management of endometriosis patients with estimation of endometriosis fertility index (EFI) which can predict reproductive outcome.Aims:This study aims to evaluate clinical outcome in laparoscopically managed pelvic endometriosis and correlation of reproductive outcome with EFI.Setting and Design:Retrospective cohort study carried out in the Department of Obstetrics and Gynecology.Materials and Methods:Our study included 123 patients who had undergone laparoscopic management of endometriosis from January 2017 to March 2018. Case files were retrieved and meticulously analyzed. All patients were contacted and interviewed. Symptomatic relief and pregnancy in infertility patients were recorded. EFI was calculated.Statistical Analysis:Data analyses were carried out using statistical software STATA version 12.0. P < 0.05 was considered statistically significant.Results and Conclusions:A total of 123 cases were enrolled; the most common complaint was infertility 107 (86.99%); the mean age was 32.4 years. EFI was found to be (6 to 10) in 28(26.2%) patients, EFI of (4 to 5) in 49 (45.8%) and EFI of (0 to 3) in 30 (28.0%). Post surgery, dysmenorrhoea was relieved in 56 (65.88%) patients, menstrual irregularities were relieved in 45 (76.27 %) patients, dyspareunia in 32 (54.24%) and chronic pelvic pain in 24 (40.5%) patients. 8 (40%) patients with low EFI conceived, 20 (58.82%) with moderate, and 26 (96.29%) with high EFI conceived. EFI score showed statistically significant positive correlation with pregnancy outcome P = 0.001, higher the EFI score, better the reproductive outcome. Laparoscopic surgeries are important for managing patients of endometriosis. It provides significant symptomatic relief, and EFI estimation can be done, which is a good tool to predict reproductive outcome of infertility patients with endometriosis.

Use of the Endometriosis Fertility Index to Predict Natural Pregnancy after Endometriosis Surgery: A Single-Center Study

Aims: Our objective was to predict natural pregnancy after endometriosis surgery using the endometriosis fertility index (EFI). Methods: A retrospective medical records review was conducted, examining patients surgically treated for endometriosis at a single center in Korea between January 2009 and February 2015. In total, 68 women attempting natural conception were analyzed by assessing age, preoperative serum CA-125, body mass index, revised American Fertility Society (rAFS) stage, EFI, and pregnancy outcome. Kaplan-Meier estimates and log-rank tests were used to generate cumulative natural pregnancy rate curves based on an EFI cut-point. A receiver-operating characteristic (ROC) curve was plotted for EFI. Results: Seventy-seven patients attempted conceptions, resulting in 33 natural and 9 assisted conceptions. Excluding assisted conceptions, the mean EFI scores of 68 women who were not pregnant and pregnant were 5.43 ± 0.36 and 6.88 ± 0.28 respectively. The relation between EFI and natural pregnancy was significant (cumulative overall pregnancy rate, p = 0.006), whereas rAFS stage was not (univariate logistics, p = 0.853). The cut-point for maximum natural pregnancy outcomes was 6 (area under ROC curve = 0.710, 95% CI 0.586–0.835). Conclusion: The EFI is a reliable staging system for predicting natural pregnancy after endometriosis surgery. EFI scores can be used to guide postoperative treatment of women with endometriosis.