Stage Of Endometriosis Research Articles

O-192 Concomitant autoimmunity in endometriosis-affected women and In Vitro Fertilization (IVF) outcomes: a cohort study

Abstract Study question To evaluate whether the presence of concomitant autoimmunity in endometriosis patients may affect In Vitro Fertilization (IVF)/Intracytoplasmic Injection (ICSI) outcomes. Summary answer In ‘normo-responders’ patients autoimmunity did not affected ovarian response to gonadotrophin stimulation yet was the only significant negative predictor of cumulative pregnancy rate (CPR). What is known already In the last years, endometriosis has been redefined as a multifactorial disease with a complex pathogenesis. In this setting, a role of both innate and adaptive immune systems have been proposed in endometriosis development. The coexistence of endometriosis and autoimmunity is well-documented. Also, an increased risk of more severe stages of endometriosis in patients with autoimmunity has been recently reported. Even if autoimmunity has been associated with lower pregnancy rates and higher miscarriage rates, whether the presence of autoimmunity in endometriosis patients could act as an additive factor worsening IVF/ICSI response is still not known. Study design, size, duration Single-center, retrospective, cohort study. First IVF/ICSI cycles of endometriosis patients with or without autoimmunity carried out from 2007 to 2021 at the Fertility Unit of IRCSS San Raffaele Hospital(Milan) were included. Patients with endometriosis and concomitant autoimmunity were age-matched to endometriosis only controls. Only patients with a complete disease control following endometriosis treatment were admitted to IVF/ICSI. A total of 471 patients were enrolled. The study was conducted according to STROBE guidelines for observational studies. Participants/materials, setting, methods Endometriosis diagnosis was surgical/histopathological, yet also ovarian endometriosis at ultrasound assessment by expert operators was included. Autoimmunity was assessed by blood tests for auto-antibodies and/or rheumatological records. Stratified analysis by “expected” ovarian response at baseline according to AFC and/or AMH were performed. Expected ‘poor-responders’ were defined according to Bologna Criteria. The primary outcome was CPR. Secondary outcomes included oocytes retrieved, metaphase II(MII)oocytes and ovarian sensitivity index(OSI), the latter defined as:(number of retrieved oocytes/total gonadotrophin dose)×1000. Main results and the role of chance 113/471 cases with endometriosis and concomitant autoimmunity and 358/471 age-matched endometriosis only controls were enrolled. The mean age was 35.70±3.75 and 35.95±3.72 (p = 0.543) in cases and controls respectively. No baseline differences in endometriosis disease stage (p = 0.414), surgical treatment for endometriosis prior to IVF (p = 0.617), BMI (p = 0.866) or type of infertility (p = 0.255) were observed when comparing the two groups. In “expected normo-responders”, cases with autoimmunity had significantly higher numbers of oocytes retrieved (p = 0.007), MII oocytes (p = 0.007) and OSI index (p = 0.013) when compared to controls with endometriosis only; the CPR was 12.5% in cases vs. 17.5% in controls, thus comparable between the two groups (p = 0.143). In “expected poor-responders” no significant differences were observed neither in the number of oocytes retrieved and MII oocytes, nor in OSI index; the CPR was 12% in cases with concomitant autoimmunity compared to 7.75% in controls with endometriosis only (p = 0.256). In the generalized linear models (GLMs) of independent predictors associated with CPR, in expected ‘normo-responders’ autoimmunity was the only significant negative predictor of CPR (p = 0.004) whereas in ‘poor-responders’ only age negatively affected CPR (p = 0.001). Limitations, reasons for caution This study has a retrospective design. The interpretation of results is based on the validated yet still debated definition of poor-responders according to Bologna Criteria. Results should be interpreted with caution until replicated by future research providing multi-centric and prospective design, larger sample size and more standardized data collection. Wider implications of the findings Autoimmunity does not seem to impact neither ovarian reserve nor ovarian response to gonadotropin, as it may act a ‘competitive’ rather than ‘additive’ risk factor for infertility in endometriosis. However, in ‘normo-responders’ autoimmunity seems to reduce the chances of pregnancy following IVF/ICSI perhaps impairing endometrial receptivity and embryo implantation. Trial registration number Due to the retrospective design of the study, full IRB approval at the institution was not needed.

P-304 Sexual function in women with endometriosis: an online survey

Abstract Study question What factors are associated with sexual function in women with endometriosis? Summary answer In this study, the most important variables associated with sexual function were dyspareunia (especially deep and introital dyspareunia combined), infertility, fatigue, and psychological comorbidities. What is known already Endometriosis is a chronic gynaecologic disease that affects women of reproductive age, with negative consequences on multiple life domains, including sexuality. Although it has been demonstrated that endometriosis-related sexual issues may negatively affect women’s intimate relationships, their subjective experience remains overlooked, either in research or clinical practice. In this regard, the impact of dyspareunia (especially deep dyspareunia) has been highlighted in several studies, but the role of symptoms other than pain, such as fatigue, infertility, and psychological comorbidities, has not been yet clarified. Moreover, little is known about how women deal with dyspareunia and the quality of doctor-patient communication. Study design, size, duration This observational study was conducted between 8 November and 21 December 2021 in collaboration with the largest Italian patient association, Associazione Progetto Endometriosi (APE [Endometriosis Project Association]). Data were collected through a self-administered online survey hosted on Qualtrics (Qualtrics Ltd.). Women were invited to participate in the study via APE’s Facebook page and newsletters. The online survey was anonymous, and women were allowed to complete it only after providing their electronic consent. Participants/materials, setting, methods Participants were 612 women (age: 36.41 ± 6.72 years) with a surgical or clinical diagnosis of endometriosis and a sexual partner. They completed the Female Sexual Function Index (FSFI), the Hospital Anxiety and Depression Scale (HADS), and the Rosenberg Self-Esteem Scale (RSES). Demographic and gynaecologic data – including endometriosis stage, type of lesions, symptoms (e.g., pelvic pain, fatigue, infertility), treatment –, and information regarding women’s subjective experience of dyspareunia were collected using a researcher-made questionnaire. Main results and the role of chance Dyspareunia was experienced by 524 (86%) women. Sexual dysfunction (FSFI total score < 26.55) was reported by 479 (78%) participants. Multiple regression analyses revealed that sexual function (FSFI total score) was associated with dyspareunia (β = −.108, P = .008), infertility (β = −.082, P = .040), fatigue (β = −.108, P = .021), and symptoms of anxiety and depression (HADS total score; β = −.127, P = .021). Women with sexual dysfunction were more likely to report rectovaginal endometriotic lesions (59% vs. 47%, P = .016) and stage 4 endometriosis (43% vs. 32%, P = .002), to experience deep and introital dyspareunia combined (50% vs. 21%, P < .001), with greater symptoms of anxiety and depression (F [2,595] = 21.812, P < .001, Wilk’s Λ = .932, η2p = .068) and lower self-esteem (t [589] = 5.111, P < .001). Women with dyspareunia and sexual dysfunction reported greater fear of pain and consequent inability to relax during intercourse, avoidance of sex, worries about their sexual life, sexual dissatisfaction, and feelings of guilt towards the partner (Ps < .001), along with poorer support and understanding from doctors (P = .006) than women with dyspareunia who did not report sexual dysfunction. Limitations, reasons for caution This is one of the largest studies on sexual function in women with endometriosis. However, there are reasons for caution when interpreting our results due to the self-reported nature of all the data (including medical information) and the risk of selection bias due to our recruitment strategy. Wider implications of the findings Our results clearly indicate that the majority of women with endometriosis experience sexual problems that are mostly (but not solely) due to dyspareunia. The assessment of sexual function should be included in routine clinical practice with these patients, also considering its association with psychological symptoms and self-esteem. Trial registration number Not applicable

O-028 Small extracellular vesicles (sEV) in peritoneal fluid and peripheral blood as biomarkers of endometriosis

Abstract Study question Can we identify lesion-derived endometriosis-specific sEV cargo in peritoneal fluid of women with endometriosis, and detect the same endometriosis-specific cargo in sEV from peripheral blood? Summary answer Endometriosis-specific sEV are present in PF. Identification in peripheral blood is challenging due to low abundance in comparison to blood-borne sEV. What is known already Endometriosis is characterised by intraperitoneal lesions of endometrial tissue. Although ultrasound detection of severe endometriosis is possible, the final diagnosis currently relies on invasive laparoscopy as the gold standard, which leads to a delay of 8-10 years after women first present to their GPs with symptoms. We have previously shown that the peritoneal fluid (PF) of women with endometriosis contains endometriosis-specific sEV. If these can be traced in blood samples, endometriosis-specific sEV could serve as biomarkers of endometriosis, particularly for stages I and II, which are difficult to detect by ultrasound. Study design, size, duration This is an observational pilot study of 29 patients in total. From March 2021 until August 2021, we collected PF samples from 11 controls and 16 endometriosis cases and blood samples from 12 controls and 11 endometriosis cases. Of these, 19 were paired samples (blood and PF from the same participant). Participants/materials, setting, methods Women >18 years of age undergoing laparoscopic surgery for endometriosis or unrelated conditions were invited to participate (HREC 08078B/HREC 10148B). Exclusion criteria were pregnancy, malignancy, and menopause. Purified, validated sEV were analysed by label based quantitative proteomics Tandem Mass Tag (TMT). Data analysis was performed using Proteome Discoverer v2.4 (Thermo Fisher), statistical analysis using the R (LIMMA), with a protein false discovery rate of 1% and a quantitative threshold of an adjusted p-value <0.05. Main results and the role of chance We ascertained the identity of sEV by TEM and NTA (mode size 121.8 ± 18.0 nm (blood, n = 5) and 155.9 ± 37.2 (PF, n = 6)), and signals for syntenin and ALIX in immunoblots as well as expression of CD9, CD63 and CD81 in capture bead-flow cytometry. Proteomics analysis identified 9145 proteins groups across all sample groups, of these proteins 5,429 are consistently quantifiable, with 602 significantly different between comparisons (adjusted P-value <0.05). PCA showed separation of samples by type rather than batch. Fractionated analysis by SPS-MS3 methodology identified 7064 protein groups, with 3408 proteins consistently quantified across sample groups. Of these, 602 were found to differ significantly across all comparisons. In PF, 533 proteins changed significantly in abundance (245 up and 288 down), while in blood, four proteins changed in abundance. Limitations, reasons for caution The main limitation of the study is in its small sample size, which meant that we could not stratify data according to endometriosis stage. Due to limited amount of protein within sEV samples, not all assays could be done on all samples. Wider implications of the findings Our findings suggest that our methodology makes it feasible to define a protein signature of endometriosis based on sEV cargoes drawn from blood samples. This would represent a non-invasive biomarker of endometriosis and could help diagnose the condition, or rule out endometriosis as the origin of symptoms in the future. Trial registration number not applicable

T2*-Weighted Imaging Performance in the Detection of Deep Endometriosis among Readers with Different Experience: Comparison with Conventional MRI Sequences.

Magnetic resonance imaging (MRI) is an effective technique for the diagnosis and preoperative staging of deep infiltrative endometriosis (DIE). The usefulness of MRI sequences susceptible to chronic blood degradation products, such as T2*-weighted imaging, remains uncertain. The present study aims to evaluate the diagnostic performance of these sequences in addition to the conventional protocol for DIE assessment. Forty-four MRI examinations performed for clinical and/or ultrasound DIE suspicion were evaluated by three readers with variable experience in female imaging. The inter-observer agreement between the reader who analysed only the conventional protocol and the one who also considered T2*-weighted sequences was excellent. The less experienced reader diagnosed a significantly higher number of endometriosis foci on the T2*-weighted sequences compared with the most experienced observer. T2*-weighted sequences do not seem to provide significant added value in the evaluation of DIE, especially in less experienced readers. Furthermore, artifacts caused by undesirable sources of magnetic inhomogeneity may lead to overdiagnosis.

Platelet-to-Lymphocyte Ratio and CA125 Level as a Combined Biomarker for Diagnosing Endometriosis and Predicting Pelvic Adhesion Severity.

Adhesion is a significant biological characteristic of endometriosis, and accurate evaluation of the pelvic adhesion is necessary for surgical treatment. Serum CA125 is yet the most common used biomarker in the diagnosis and follow-up of patients with endometriosis despite of its high false-positive rate and low specificity. Herein, we aimed to examine the diagnostic value of the combination of the platelet-to-lymphocyte ratio (PLR) and CA125 for patients with different stages of endometriosis and their correlations with pelvic adhesion. We retrospectively analyzed the clinical data and blood count parameters of patients with both endometriosis and other benign ovarian tumors. The mean level of CA125, the PLR and the combined marker (the CA125 level multiplied by the PLR) in the EMs group were significantly higher than those in the Cyst group (P < 0.05). ROC curve analysis was used to compare the diagnostic values of serum PLR, CA125, and the combined marker in ovarian endometriosis. The cut-off value of the PLR was 176.835, with 28.3% sensitivity and 96.9% specificity. The cut-off value of CA125 was 31.67 U/mL, with 84.1% sensitivity and 87.4% specificity. The cut-off value of the combined marker was 3894.97, with 83.4% sensitivity and 95.8% specificity. It was found that the severity of adhesion in endometriosis was positively correlated with the PLR (r = 0.286, P < 0.01), CA125 (r = 0.276, P < 0.01), and combined marker (r = 0.369, P < 0.01). The combined marker showed the highest AUC value (0.751, 95% CI: 0.666–0.837), with a sensitivity of 56.0% and a specificity of 89.6%, and the cut-off value was 9056.94. Besides, the levels of CA125, PLR, and their combination were significantly elevated in patients with endometriosis. The combined marker was not only positively correlated with pelvic adhesion but also showed a greater diagnostic value and specificity than CA125 alone. These findings indicate that the combined marker may be a potential inflammatory biomarker playing an important role in the diagnosis and assessment of adhesion in endometriosis.

Endometriosis and irritable bowel syndrome: similarities and differences in the spectrum of comorbidities.

Do the spectrum and prevalence of comorbidities of endometriosis and irritable bowel syndrome (IBS) overlap? Despite several overlapping symptoms, the most significantly associated comorbidities of endometriosis and IBS are different and are rather related to the organ systems primarily involved in the index diagnosis. Endometriosis and IBS both have several similar unspecific symptoms, such as recurrent abdominal pain, cramping and anxiety, and both diseases affect young women and are associated with a number of comorbidities causing a poor quality of life. However, a detailed study, revealing the full spectrum of endometriosis and IBS comorbidities in the same study population, is lacking. This article presents a retrospective in silico analysis of the data from a large nationwide biobank-based cohort consisting of 121 773 women. After excluding all first- and second-degree relatives, the data of up to 65 421 women were analyzed. International Classification of Disease-10 diagnosis main codes associated with endometriosis (N80) and IBS (K58) diagnoses were identified from the Estonian Biobank dataset by linking with the Estonian Health Insurance Fund and other relevant registries. The associations between N80 and K58 and other diagnosis codes were tested using logistic regression, adjusting for age at recruitment and 10 genetic principal components to account for potential population stratification. Bonferroni correction was applied to account for multiple testing. Both women with endometriosis and IBS suffered from more conditions compared to the control group, with 226 and 428 diagnosis codes statistically significantly more frequent in women with respective diagnosis compared to controls. Women suffering from both conditions had 275 significantly associated comorbidities. A remarkable proportion of women with IBS or endometriosis suffered also from endometriosis (9.0%) or IBS (13.6%), respectively. In endometriosis, the most prevalent diagnoses were related to diseases of the genitourinary system (33 N-category codes) and in women with IBS, the most associated diagnoses were related to digestive disorders and gastrointestinal tract (52 codes from K-category). Among the most significant diagnoses in endometriosis were uterine leiomyomas (D25), menstrual disorders (N92) and infertility (N97) (P < 1 × 10-315 for all), and in IBS, lactose intolerance (E73), gastritis and duodenitis (K29) and functional dyspepsia (K30) were in the top list of most significant comorbidities (P < 1 × 10-315 for all). The information about the severity stages of endometriosis and subtypes of IBS was not available for analysis. The findings may not be fully extrapolated to all female populations, because all participants were from one geographic area and had good access to health services. These findings support previous studies that have found a high prevalence of pre-selected comorbidities in women with endometriosis and IBS. However, taking into account the differences in the full spectrum of comorbidities of endometriosis and IBS may aid in diagnosing these disorders. Women and healthcare providers need to be aware that women with endometriosis are at high risks of complications during pregnancy and should be carefully monitored. This research was funded by the Estonian Research Council (grant PRG1076), Horizon 2020 innovation grant (ERIN, grant no. EU952516), Enterprise Estonia (grant no. EU48695), MSCA-RISE-2020 project TRENDO (grant no. 101008193) and by the European Union through the European Regional Development Fund (Projects no. 2014-2020.4.01.15-0012 and no. 2014-2020.4.01.16-0125). The authors have no conflicts of interest to declare. N/A.

Factors Affecting the Postoperative Bowel Function and Recurrence of Surgery for Intestinal Deep Endometriosis.

ObjectiveThis study aims to evaluate the factors associated with complications and long-term results in the surgical treatment of intestinal deep endometriosis and to figure out the optimized treatment measures for bowel endometriosis.MethodsA retrospective study was performed in a single center in China. Medical charts were reviewed from 61 women undergoing surgical treatment for bowel endometriosis between January 2013 and August 2019 in the Department of General Gynecology, Women’s Hospital School of Medicine Zhejiang University. Multivariate regression analysis was utilized to investigate the impact of the stages of endometriosis and surgical steps (independent risk factors) on complications (and postoperative bowel dysfunction). The clinical characters, surgical procedures, postoperative treatment, complications, and recurrence rate were summarized and analyzed by using Lasso regression.ResultsSurgery type was the most important independent risk factor related to postoperative abnormal defecation in intestinal deep endometriosis patients (P < 0.05, OR = 34.133). Infection is the most important independent risk factor related to both postoperative complications (OR = 96.931) and recurrences after conservative surgery (OR = 4.667). Surgery type and age were significantly related to recurrences after conservative surgery.ConclusionsWe recommended conservative operation especially full-thickness disc excision to improve the quality of life of intestinal deep endometriosis patients. In addition, prevention of infection is very important to reduce the postoperative complications rate and the recurrence rate.

Estro-Progestins and Pain Relief in Endometriosis

Endometriosis is a benign, hormone-responsive chronic disease that affects women of reproductive age; long-term treatment to balance satisfactory tolerability with clinical efficacy is necessary for these patients. The first-line therapy for endometriosis is predominantly medical treatment, in order to improve symptoms or prevent post-surgical disease recurrence. Multiple factors including age and women preference, pain severity, and endometriosis stage must be considered in the choice of the most suitable therapy. Estrogen-progestogins are generally used as first-line hormone therapies among different medical options currently effective for endometriosis management. Several studies have shown that they are able to improve pain symptoms in most patients, are well tolerated, and are inexpensive. Combined hormonal contraception treatment, administered cyclically or continuously, with different types of hormones and route of administration, results in clinically noticeable decrease in dysmenorrhea, noncyclic pelvic pain, dyspareunia, and recurrence rate after surgery, and also in quality of life improvement.

Maintenance Therapy for Preventing Endometrioma Recurrence After Endometriosis Resection Surgery—A Systematic Review and Network Meta-analysis

(Abstracted from J Minim Invasive Gynecol 2022;29:602–612) Endometriosis is one of the most common gynecologic disorders, affecting approximately 10% of reproductive-age women and presenting with dysmenorrhea, noncyclic pelvic pain, dyspareunia, and infertility. Approximately 17% to 55% of women with endometriosis will also develop an endometrioma, which is usually an advanced disease stage of endometriosis.

Endometriosis diagnosis, staging and typology and adverse pregnancy outcome history.

Women with endometriosis may have an increased risk of adverse pregnancy outcomes. Research has focused on infertility clinic populations limiting generalisability. Few studies report differences by endometriosis severity. We investigated the relationships between endometriosis diagnosis, staging and typology and pregnancy outcomes among an operative and population-based sample of women. Menstruating women ages 18-44 years enrolled in the ENDO Study (2007-2009), including the operative cohort: 316 gravid women undergoing laparoscopy/laparotomy at surgical centres in Utah and California; and the population cohort: 76 gravid women from the surgical centres' geographic catchment areas. Pregnancy outcomes were ascertained by questionnaire and included all pregnancies prior to study enrolment. Endometriosis was diagnosed via surgical visualisation in the operative cohort and pelvic magnetic resonance imaging in the population cohort. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) were estimated using generalised linear mixed models for pregnancy outcomes, adjusting for women's age at study enrolment and at pregnancy, surgical site, body mass index and lifestyle factors. Women in the operative cohort with visualised endometriosis (n=109, 34%) had a lower prevalence of live births, aPR 0.94 (95% CI 0.85, 1.03) and a higher prevalence of miscarriages, aPR 1.48 (95% CI 1.23, 1.77) compared with women without endometriosis. The direction and magnitude of estimates were similar in the population cohort. Women with deep endometriosis were 2.98-fold more likely (95% CI 1.12, 7.95) to report a miscarriage compared with women without endometriosis after adjusting for women's age at study enrolment and at pregnancy, surgical site and body mass index. No differences were seen between endometriosis staging and pregnancy outcomes. While there was no difference in number of pregnancies among women with and without endometriosis in a population-based sample, pregnancy loss was more common among women with endometriosis, notably among those with deep endometriosis.

Endometriosis in women undergoing ovarian tissue transplantation due to premature menopause after gonadotoxic treatment or spontaneous premature ovarian failure.

Cryopreservation of ovarian tissue with subsequent transplantation is an efficient option for restoring fertility in women at risk of premature ovarian failure. The association between infertility and endometriosis is well recognized. Although endometriosis usually ends with the onset of natural or iatrogen menopause due to declining estrogen levels, endometriosis can in rare cases occur after menopause. This study aims to investigate women with premature menopause who were diagnosed with endometriosis during laparoscopy for ovarian tissue transplantation, and to address the questions of how endometriotic lesions after cytotoxic treatment and premature menopause might be explained, whether endometriosis affects pregnancy rates, and whether there is an association between endometriosis and the original cancer. Seventeen patients who had undergone ovarian tissue transplantation to restore their fertility and who were diagnosed with endometriosis during transplantation were included in this retrospective study. The endometriosis foci were completely removed and ovarian tissue was transplanted into the pelvic peritoneum. Preexisting conditions, use of hormonal preparations, endometriosis stage pain assessment, as well as pregnancy and live birth rate were evaluated. The mean age of the patients was 29.5 ± 6.3 years (range 14-39) at the time of ovarian tissue harvest and 34.6 ± 4.3 years (range 28-40) at transplantation. Prior to transplantation, four patients had taken hormone replacement therapy, four women oral contraceptives and two patients' tamoxifen. Twelve women had stage I endometriosis and five stage II endometrioses according to the rASRM classification. Four patients reported dysmenorrhea. None of the women complained of general pelvic pain or dyspareunia. The pregnancy rate in the study population was 41.2%, with a live birth rate of 35.3%. The pregnancies occurred in three cases after spontaneous conception, in four women after a natural cycle IVF/ICSI. This study highlights the under-researched association between endometriosis in women entering premature or early menopause either after gonadotoxic treatment or due to primary ovarian insufficiency. As more and more patients seek to have their cryopreserved ovarian tissue transplanted to fulfill their desire to have children, specialists will inevitably encounter women with this condition.

ENDO_STAGE Magnetic Resonance Imaging: Classification to Screen Endometriosis.

Introduction: Transvaginal sonography is the first-line imaging technique to diagnose endometriosis, but magnetic resonance imaging is more accurate in staging the extent of lesions, especially for deep pelvic endometriosis. The revised American Society for Reproductive Medicine and Enzian classifications are commonly used to stage the extent of endometriosis. However, a review underlined their weaknesses in terms of complexity, lack of clinical reproducibility and low correlation with surgical complications and fertility outcomes. Thus, to this day, in clinical practice, there is a lack of consensual, standardized or common nomenclature to stage the extent of endometriosis, posing a worldwide challenge. Objectives: The aims of our study were to: (i) develop a new classification (entitled Endo-Stage MRI) based on patterns of endometriosis as observed with magnetic resonance imaging; (ii) compare results with those of the rASRM classification; (iii) estimate the Endo-Stage MRI accuracy to predict the rate of surgical complications; and (iv) propose an Endo-Stage MRI system of triage (low, intermediate, high) that correlates with the risk of surgical complications. The goal is to improve the effectiveness of care pathways and allow for the planning of a multidisciplinary approach when necessary. Patients and methods: A single-center observational study using available clinical and imaging data. According to anatomical locations and the extent of endometriotic lesions, a standardized classification comprising six stages of severity (0–5) was designed. Results: A total of 751 patients with pelvic endometriosis underwent surgery from January 2013 to December 2018 in a tertiary care university hospital. Their Endo-Stage MRI classification was correlated with: (i) the rate of overall complications (grade I–IV Clavien-Dindo classification, (ii) the rate of major complications (grades III–IV) and (iii) the rate of voiding dysfunction requiring self-catheterization lasting more than one month. According to the Endo-Stage MRI classification, stages 0, 1, 2, 3, 4 and 5 were observed in 26 (3%), 156 (21%), 40 (5%), 22 (3%), 290 (39%) and 217 (29%) patients, respectively. Using the proposed Endo-Stage MRI system as triage, low (stages 0–2), intermediate (stages 3–4) and high-risk (stage 5), complications were observed in 29 (13%), 109 (34.9%) and 103 (47.4%) patients, respectively. In multivariate analysis, the Endo-Stage MRI system of triage was strongly predictive of surgical complications and achieved higher accuracy than the revised American Society for Reproductive Medicine classification (AUC: 0.78 (95% CI, 0.76–0.80) vs. 0.61 (95% CI, 0.58–0.64)). Conclusion: Our study proposes a new imaging classification of endometriosis coined Endo-Stage MRI classification. The results suggest that when applied to a clinical situation, it may improve care pathways by providing crucial information for identifying intermediate and/or high-risk stages of endometriosis with increased rates of surgical complications. To make this classification applicable, a multicentric validation study is necessary to assess the relevancy and clinical value of the current anatomical MRI classification.

Analysis of preoperative and postoperative quality of life, sexual function, and sleep in patients with endometriosis: a prospective cohort study.

Endometriosis affects the quality of life, sleep, and sexual life of patients due to pain. This study compared the scores of endometriosis patients in these three areas before and after surgery. Patients between the ages of 18 and 60 with a prediagnosis of endometriosis were enrolled. Postoperative histopathological diagnosis of endometriosis was confirmed in all patients. This study included 56 patients who completed pre- and postoperative (three months) evaluation of quality scale questionnaires: a visual analog scale for pelvic pain, the Pittsburgh Sleep Quality Index, Morningness-Eveningness Questionnaire, Endometriosis Health Profile-30 Questionnaire, and Female Sexual Function Index were administered prior to and 3months after each patient's surgery. Among the 56 female patients included in this study, statistically significant improvement was observed in pain scores, quality of life, sexual function, and sleep of all patients regardless of endometriosis stage. Endometriosis is a disease that progresses, with increasing pain scores; it has negative effects on the quality of life, sexual function, and sleep of patients. Surgical or medical treatment can be performed considering the complaints and fertility status of the patients.

Epidemiology of Endometriosis in Tamil Nadu, India

Endometriosis is an enigmatic disease of women of the reproductive age group. Pain and infertility are the main symptoms. This paper attempts to study the incidence of endometriosis among infertility patients undergoing laparoscopy. Following parameters such as age, SE status, body mass index (BMI), type of infertility, parity, symptoms, family history, menstrual history, medical history, ultrasound (USG) findings, stages of endometriosis, associated findings, and laparoscopy findings were analyzed. Incidence of endometriosis was higher between 26 and 35 years and at all ages stage 3 and stage 4 endometriosis were higher than stage 1 and stage 2. Endometriosis is more common in higher socio-economic class and in women with lower BMI and primary infertility. Among all the symptoms of endometriosis, dysmenorrhea is the most common and most important pointer towards the diagnosis of endometriosis. There is also higher incidence of family history among endometriosis patients. Menstrual cycles are invariably regular. Diagnosis of endometriosis is mainly through USG and rarely magnetic resonance imaging is performed to confirm the presence of endometriosis. In early stages of endometriosis, USG may not show any positive findings. USG can pick up endometriomas, deep infiltrative endometriosis, adenomyosis, and associated findings such as polycystic ovary syndrome, fibroids, and Mullerian anomalies. Laparoscopy is the gold standard in the diagnosis and treatment of endometriosis. Staging is done based on laparoscopy and simultaneously treatment is also carried out. Stage 1 and 2 patients underwent cauterization of the lesions. Advanced stages of endometriosis underwent cystectomy, adhesiolysis, and excision of the deep lesions and ultimately the pelvic anatomy is regained. Women were planned for further fertility treatment based on the staging of the disease.

Transcriptomic analysis of cumulus cells shows altered pathways in patients with minimal and mild endometriosis

Endometriosis is a chronic inflammatory disorder that is highly associated with infertility. This association seems to be related to oocyte impairment, mainly in the initial stages of endometriosis (minimal and mild), where no distortions or adhesions are present. Nonetheless, invasive oocyte analyses are not routinely feasible; thus, indirect assessment of oocyte quality is highly desirable, and, in this context, cumulus cells (CCs) may be more suitable targets of analysis. CCs are crucial in oocyte development and could be used as an index of oocyte quality. Therefore, this prospective case–control study aimed to shed light on the infertility mechanisms of endometriosis I/II by analyzing the CCs’ mRNA transcription profile (women with endometriosis I/II, n = 9) compared to controls (women with tubal abnormalities or male factor, n = 9). The transcriptomic analyses of CCs from patients with minimal and mild endometriosis revealed 26 differentially expressed genes compared to the controls. The enrichment analysis evidenced some altered molecular processes: Cytokine-cytokine receptor interactions, Chemokine signaling, TNF signaling, NOD-like receptor signaling, NF-kappa B signaling, and inflammatory response. With the exception of CXCL12, all enriched genes were downregulated in CCs from patients with endometriosis. These findings provide a significant achievement in the field of reproductive biology, directing future studies to discover biomarkers of oocyte quality in endometriosis.

BDNF and TrKB expression levels in patients with endometriosis and their associations with dysmenorrhoea

BackgroundBrain-derived neurotrophic factor (BDNF) is a known regulator of the development and maintenance of chronic pain in various chronic disorders. Together with its high-affinity tyrosine kinase type B (TrKB) receptor, BDNF is extensively expressed in the mammalian female reproductive system. However, BDNF and TrKB expression in different stages of endometriosis and the relationship between the expression of each in ectopic lesions and endometriosis pain remain unclear.MethodsSixty-two women who underwent laparoscopic surgery were enrolled in this study: forty-six diagnosed with ovarian endometrioma (study group) and sixteen diagnosed with ovarian benign tumours (control group). Samples from eutopic endometrium and ovarian endometriotic lesions were obtained at laparoscopic surgery. BDNF and TrKB messenger RNA (mRNA) and proteins levels in the eutopic and ectopic endometrium of both groups were measured by real-time PCR and immunohistochemical staining, respectively. Before the surgery the visual analogue scale (VAS) was used to measure dysmenorrhoea.ResultsBDNF and TrKB expression levels were higher in ovarian endometriotic lesions than in eutopic endometrium and normal endometrium (P < 0.05), and there was no cyclical change. Furthermore, their expression levels were higher in eutopic endometrium than in normal endometrium (P < 0.05), and BDNF and TrKB levels were higher in stage IV ovarian endometriotic lesions than in stage II and III lesions (P < 0.05), with their expression being non-significantly higher in stage III than in stage II (P > 0.05). Additionally, correlation coefficients for the association analysis between the mRNA expression of BDNF or TrKB in eutopic endometrium and the dysmenorrhoea VAS score were r = 0.52 and r = 0.56 for BDNF and TrKB, respectively (P < 0.05). The correlation coefficients for the associations between BDNF and TrKB in both the eutopic and ectopic endometrium were r = 0.82 and r = 0.66, respectively (P < 0.05).ConclusionsBDNF and TrKB are closely related to dysmenorrhoea caused by endometriosis and may be important in the pathobiology or pathophysiology of endometriosis.

IVF Outcome in Patients with Different Stages of Endometriosis: Can AMH Be a Predictor?

Background and Objectives: The role of Anti Mullerian Hormone (AMH) in determining the outcome of in vitro fertilization (IVF) in endometriosis has been controversial. This study was conducted to assess whether AMH can predict poor response in endometriosis patients undergoing IVF and to compare the IVF outcomes among the different stages of endometriosis. Methodology: A retrospective study was conducted among 90 endometriosis patients undergoing IVF using the flexible antagonist protocol from January 2016 to December 2018 at DY Patil Medical College, Navi Mumbai. Serum AMH levels were obtained from different patients, primary outcome being clinical pregnancy rate (CPR) while the secondary outcome included the number of oocytes retrieved, number of mature oocytes obtained, fertilization rates (FR), and number of good quality embryos formed. Data was analyzed with SPSS 16.0. Mann-Whitney U and chi-square tests were used to compare the outcomes of IVF with AMH level in different stages of endometriosis. Receiver Operator Characteristic (ROC) curves were plotted to know the predictive ability of AMH by determining the area under the curve (AUC), P value &lt; 0.05 was considered significant for all statistical tests. Results: AUC was found to be significant for AMH in detecting poor response among those with late staged endometriosis but with poor accuracy (AUC = 0.65, P = 0.02∗). Considering a median AMH level of 1.24 ng/mL with sensitivity and specificity of &gt; 60%, the primary and secondary outcomes were significantly higher among those with median AMH levels of more than 1.24 ng/mL compared to those with the median ≤ 1.24 ng/mL. The significance, however, was mainly found in the late stages of endometriosis (P &lt; 0.05). Fertilization rates, good quality embryos, and CPR did not vary with AMH levels among those with early stages of endometriosis (P &gt; 0.05). The outcomes of IVF did not vary significantly across the different stages of endometriosis except for good quality embryos which were formed in patients with early staged endometriosis (P &lt; 0.05). Conclusion: AMH levels may be a predictor of nonconception with poor accuracy in late stages of endometriosis (III/IV), while good quality embryos were obtained in patients with early stages of endometriosis.

A Randomized Control Trial of Combined Surgical and Hormonal Therapy of Endometriosis

Aim: To evaluate the three therapy strategies including surgical therapy, hormonal therapy, and combined treatment for the management of endometriosis Study design: A multicentric randomized control trial Place and Duration: This study was conducted in 6 different hospitals of Pakistan, Muhammad Medical and Dental College Ratanabad Mirpurkhas, Social Security Landhi Hospital Karachi, Sindh Government CDF Hospital , Bilawal Medical College for Boys Jamshoro, Ghulam Muhammad Mahar Medical College Sukkur, Bahria International Hospital Karachi, Sandeman Provincial Hospital Quetta Pakistan Pakistan from June 2020 to June 2021. Methodology: The study included 360 participants with genital endometriosis. The age of the patients ranged from 18 years to 45 years. All the patients did not have any previous surgical intervention. The patients were randomly treated with one of the three treatments. A laparoscopic evaluation was done after three months of hormonal and combined therapy. Re-evaluation of surgically treated patients was done after 5 to 6 months. Stage of endometriosis, recurrence of symptoms, and the rate of pregnancy were noted in the re-evaluation phase of the study. Results: The overall cure rate of all types of endometriosis was 56.11% after every regimen of treatment. The cure rate after treatment from combined therapy was 60%. Those treated exclusively by hormone therapy showed a cure rate of 54.17%. A total of 54.17% of patients were cured exclusively by surgical treatment. The rate of recurrence was lowest in the patients given combined therapy. Dyspareunia and dysmenorrhea were significantly reduced. The overall rate of pregnancy was 53% to 64%. The rate of pregnancy was not different among all the groups. Conclusion: After giving hormonal therapy, surgical treatment, and combined treatment, it has been noticed that recurrence was lowest in the combined medical and surgical treatment group. The rate of pregnancy had also got better after all the means of treatment. The highest rate of cure was achieved by combined therapy. Keywords: Endometriosis, laparoscopy, hormone therapy, combined treatment, infertility, recurrence

Assessment of Presentation and Prevalence of Endometriosis in the Population of Kotri Pakistan: A Cross Sectional Study

Aim: The present study aims at the determination of presentation and prevalence of endometriosis in the Kotri Pakistan. Study design: A cross sectional study Place and duration: This study was conducted at SESSI Hospital SITE Kotri, Pakistan from June 2019 to July 2020. Methodology: A total of 800 patients were admitted to the gynecology ward. A total of 160 patients were suspected to have endometriosis as their signs and symptoms were indicative of the disease. The age range of the patients was from 17 to 48 years. All the patients underwent laparotomy or laparoscopy for diagnosis and treatment. Individual proforma was filled for all the patients according to the severity of the disease. The stage of the disease for each patient was identified as per American Fertility Society endometriosis staging. Results: The symptoms of endometriosis were prevalent in 160 (20%) of the 800 patients who had been admitted to the ward. A total of 40 (25%) were diagnosed with endometriosis on laparoscopy/laparotomy. Conclusion: The overall prevalence of endometriosis seen during the study period was 5%. Endometriosis is a common women's health issue in the population of Pakistan. Nonetheless, it is underestimated. Its prevalence is high in patients between the ages of 21 years to 30 years. The most common presentation of endometriosis is infertility. A diagnostic laparoscopy must be performed in patients who present with symptoms suggestive of endometriosis. Timely diagnosis and treatment can help in reproduction. Keywords: Endometriosis, infertility, laparoscopy, laparotomy

Migraine Is More Prevalent in Advanced-Stage Endometriosis, Especially When Co-Occuring with Adenomoysis.

BackgroundEmerging data suggest a significant association between migraine and endometriosis, however the relationship between migraine and endometriosis severity or adenomyosis is unclear. Our objectives were to explore the relationship between migraine and endometriosis, according to the endometriosis severity and co-exist with adenomyosis or not.MethodsThis case-control study of 167 endometriosis patients verified by surgery and 190 patients for other benign gynecological conditions (control subjects) was performed from September 2017 and January 2021. There is 49 adenomyosis detected by transvaginal ultrasound or histologic diagnosis among the endometriosis patients. Besides, we also included 41 adenomyosis but without endometriosis patients as a subgroup. All women completed a self-administered headache questionnaire and diagnosed as migraine according to the International Headache Society classification. The severity and stage of endometriosis was evaluated with revised American Society of Reproductive Medicine (rASRM) score. We used logistic regression to estimate the association between the presence of migraine and endometriosis severity while accounting for important confounders, including age, body mass index (BMI) and family history of migraine. We also estimate the risk of adenomyosis alone and adenomyosis with co-occurring endometriosis in migrainous women.ResultsMigraine was significantly more prevalent in endometriosis patients compared with controls (29.9% vs. 12.1%, p<0.05), but the prevalence was similar between isolated adenomyosis patients and controls (9.8% vs.12.1%, p>0.05). For all endometriosis and control participants, migraineurs were 4.6-times (OR=4.6; 95% CI 2.7-8.1) more likely to have severe endometriosis. However, the strength of the association decreased when the analysis examined in moderate stage (OR=3.6, 95% CI 2.1-6.2). The risk of mild and minimal endometriosis was not significant (OR=1.9, 95%CI 0.9-4.0; OR=1.6, 95% CI 0.8-3.4; respectively). When we divided the endometriosis patients according to whether co-occurring with adenomyosis. We found in migrainous women, the risk of endometriosis co-exist with adenomyosis increased, with nearly fivefold greater odds compared with control (OR=5.4;95% CI 3.0-9.5), and nearly two times higher than the risk of endometriosis without co-exist adenomyosis patients (OR=2.2; 95% CI 1.2-3.8).ConclusionOur study supports the strong association between migraine and endometriosis. We found migrainous women suffer more frequently from sever endometriosis, especially endometriosis with co-occurring adenomyosis. It is advisable to heighten suspicion for patients who presenting with either these conditions in order to optimize therapy.