Revised American Fertility Society Research Articles

Study on transvaginal hydrolaparoscopic pelvic adhesiolysis in the infertile women

To investigate the safety and efficacy of transvaginal hydrolaparoscopic pelvic adhesiolysis (THLPA) treatment in the infertile women. From May 2007 to Sep. 2008, 30 infertile patients underwent THLPA. The dye-test, hysteroscopy, and dye-test using catheterization of tubal ostium by hysteroscopy were performed at the same time. Pelvic adhesions were scored according to the revised American Fertility Society classification of endometriosis (1985). The adhesions were graded as mild (score 1-9), moderate (10-19), and severe (>/= 20). Twenty-four cases were in mild adhesions, 5 moderate adhesions, and 1 severe adhesion. The duration of the operation and discharge, pelvic adhesions score, tubal patency, complications, and pregnancy rate were investigated. (1) THPLA: the majority of pelvic adhesions in all patients were successfully performed adhesiolysis. Only a little filmy adhesions of proximal peritube of 7 tubes and proper ligament of 5 ovaries and cohesive adhesions of 4 ovaries did not underwent surgical lysis. (2) Tubal patency: 35 tubes were of proximal occlusion by dye-test, of which 21 (60%, 21/35) were unobstructed and 4 (11%, 4/35) were partly unobstructed after the dye-test using catheterization of the tubal ostium by hysteroscopy. (3) The duration of operation: the overall operative time were (32 +/- 6) minutes in mild adhesion, (52 +/- 6) minutes in moderate adhesion, and 83 minutes in severe adhesion. Of which the time of THLPA were (11 +/- 5) minutes in mild adhesion, (35 +/- 7) minutes in moderate adhesion, and 62 minutes in severe adhesion, respectively. (4) The duration of discharge: the postoperative discharge time was 120 - 175 minutes. No complications occurred. (5) The rate of pregnancy: in the (15.8 +/- 4.3) months' follow-up, the rate of pregnancy was 45% (13/29), which one patient lost follow-up. THLPA is safe, efficacious and not being hospitalized management. When compared with laparoscopy, it is simpler, more economic, and less minimally invasive approach. The appropriate indication of THLPA is to treat filmy, especially mild pelvic adhesions. It could partly avoid transabdominal operative laparoscopy for the infertile women.

A dose-ranging study to determine the efficacy and safety of 1, 2, and 4 mg of dienogest daily for endometriosis

Objectives To compare the efficacy and safety of dienogest at doses of 1, 2, and 4 mg/day orally in the treatment of endometriosis. Methods An open-label, randomized, multicenter, 24-week comparative trial in women with histologically confirmed endometriosis. Efficacy was assessed by second-look laparoscopy and patient-reported symptoms. Statistical tests included χ 2 and Wilcoxon signed rank tests. Results Dienogest reduced mean revised American Fertility Society scores from 11.4 to 3.6 (n = 29; P < 0.001) in the 2-mg group and from 9.7 to 3.9 (n = 35; P < 0.001) in the 4-mg group. Dienogest at 2 and 4 mg/day was associated with symptom improvements in substantial proportions of women. Both dienogest doses were generally well tolerated, with low rates of treatment discontinuation due to adverse events. The 1-mg dose arm was discontinued owing to insufficient bleeding control. Conclusion Dienogest at 2 mg once a day is recommended as the optimal dose in future studies of endometriosis.

Association of interleukin 1beta gene (+3953) polymorphism and severity of endometriosis in Turkish women

Endometriosis is regarded as a complex trait, in which genetic and environmental factors contribute to the disease phenotype. We investigated whether the interleukin (IL) 1beta (+3953) polymorphism is associated with the severity of endometriosis. Diagnosis of endometriosis was made on the basis of laparoscopic findings. Stage of endometriosis was determined according to the Revised American Fertility Society classification. 118 women were enrolled in the study. 78 women did not have endometriosis, 6 women had stage I, 3 had stage II, 13 had stage III and 18 had stage IV endometriosis. Polymerase Chain Reaction (PCR), Restriction Fragment Length Polymorphism (RFLP), and agarose gel electrophoresis techniques were used to determine the IL 1beta (+3953) genotype. Frequencies of the IL-1beta (+3953) genotypes in the control group were: CC, 0.397; TT, 0.115; CT, 0.487. Frequencies of the IL-1beta (+3953) genotypes in cases were: CC, 0.375; TT, 0.225; CT, 0.400. We found a 2.22 fold increase in TT genotype in the endometriosis group. However, the difference was not statistically significant (P > 0.05). We also observed an increase in the frequency of IL-1beta (+3953) T allele in the endometriosis group. However, the difference was not statistically significant. We also investigated the association between IL-1beta (+3953) polymorphism and the severity of endometriosis. The frequencies of CC+CT genotypes in stage I, III and IV endometriosis patients were 83.3, 84/6 and 72.2%, respectively; and TT genotypes were 16.7, 15.4 and 27.8%, respectively. We observed a statistically insignificant increase in TT genotype in stage IV endometriosis (P > 0.05). We suggest that IL-1beta (+3953) polymorphism is not associated with endometriosis in Turkish women.

Pain Symptoms and Peritoneal Fluid Cytokine and Marker Concentrations in Women with and without Endometriosis

Purpose Endometriosis is not only associated with infertility, it is also a common cause of pain in women, leading to work absenteeism and a reduced quality of life. The objective of this study was to confirm the increased peritoneal fluid (PF) concentration of several cytokines in endometriosis patients, to investigate their association with pain levels, and to identify new biological markers in the PF which are neurostimulatory and thus responsible for the appearance and severity of different types of pain. Methods Our sample group included 111 patients with histologically confirmed endometriosis and 47 controls undergoing laparoscopy for reasons of abdominal pain or infertility. They rated their pain during menstruation, during sexual intercourse and general lower abdominal pain prior to undergoing surgery in our clinic using a visual analogue scale. During laparoscopy, PF was aspirated. Marker cytokine concentrations were measured by immunoassay and correlated to the Revised American Fertility Society (rAFS) stage of endometriosis and to the pain level using non-parametric methods. Results Differences were found between the correlations of the peritoneal fluid levels of many cytokines with dysmenorrhea or lower abdominal pain, and with the presence of severe endometriosis (rAFS III+IV). Glycodelin and osteoprotegerin (OPG) show the strongest associations with menstrual pain, while IL-8, MCP-1 and OPG were correlated to the stage of endometriosis. Low density cytokine protein arrays did not contribute to finding new markers for endometriosis and pain. Conclusions These findings illustrate the large variation of cytokine levels between patients. Glycodelin, IL-8 and OPG are the most likely targets for further investigations towards their future clinical use.

Assessment of tubal disorder as a risk factor for repeat ectopic pregnancy after laparoscopic surgery for tubal pregnancy

HEADING AIMS: We evaluated tubal disorders, including peritubal adhesions, as risk factors for repeat ectopic pregnancy (REP) after laparoscopic linear salpingotomy (LS) or salpingectomy for tubal pregnancy. This was a retrospective clinical study in a university hospital. Of 43 women monitored for at least 6 months after LS, 28 (65%) subsequently conceived. In 24 (86%) of these women the pregnancy was intrauterine, and four (14%) had REP. Of 40 women with a unilateral tube monitored for at least 6 months after salpingectomy, 24 (60%) conceived. In 17 (71%) of these women the pregnancy was intrauterine, and seven (29%) had REP. There was no significant difference between groups in postoperative pregnancy or REP rates. There was no significant difference in the mean adhesion score by revised American Fertility Society stage points (re-AFS) at operation and the site of subsequent pregnancy in either the LS or the salpingectomy group, although the mean re-AFS score was significantly higher in women who had REP (3.1) than in those whose subsequent pregnancy was intrauterine (0.4). There was no significant difference in postoperative pregnancy or REP rates following previous LS or salpingectomy. The re-AFS score appeared to be an accurate predictor of the prognosis of subsequent pregnancies.

Correlation between pelvic adhesions and pain symptoms of endometriosis

To study the incidence of pelvic adhesions in endometriosis (EM) and the relationship between pelvic adhesions and pain symptoms. The incidence of pelvic adhesions, dysmenorrhea, chronic pelvic pain, dyspareunia, dyschizia in 480 patients with EM were studied retrospectively to evaluate the correlation between pelvic adhesions and the degree of pain symptoms. In accordance with the revised American Fertility Society classification (r-AFS), it was observed that 155 cases were in Stage I, 33 cases were in stage II, 108 cases were in stage III and 184 were cases in stage IV. (1) Among 480 cases with EM, 72.3% (347/480) of patients have pelvic adhesions simultaneously, of which 25.2% (39/155) patients were in Stage I, 78.8% (26/33) patients were in Stage II, 90.7% (98/108) patients were in Stage III and 100.0% (184/184) patients were in Stage IV. It was found that positive correlation existed between the degree of pelvic adhesions and clinical staging of EM (r(s) = 0.870, P < 0.01). (2) 61.0% (293/480) of patients presented dysmenorrhoea, of which the percentages of mild, moderate and severe dysmenorrhea were 52.2% (153/293), 26.6% (78/293), 21.2% (62/293), respectively. The rate of patients presenting chronic pelvic pain (CPP), dyspareunia and dyschezia were 23.8% (114/480), 15.4% (74/480) and 7.1% (34/480), respectively. (3) Ovarian adhesions was positively correlated with dysmenorrhea and CPP (r(s) = 0.367 and 0.267, P < 0.01). Adhesion of the bottom and posterior wall of uterus was positively correlated with dysmenorrhea and CPP (r(s) = 0.336, 0.164, P < 0.01); adhesions of fallopian tubes were positively correlated with dysmenorrhea, CPP and dyschezia (r(s) = 0.283, 0.225 and 0.159, P < 0.01). Adhesions of rectum was positively correlated with dysmenorrhea (r(s) = 0.101, P < 0.05). In addition to dyspareunia, the degree of pelvic adhesions was positively correlated with dysmenorrhea, CPP and dyschezia (r(s) = 0.470, 0.273, 0.132, P < 0.01). Pelvic adhesions are characteristic lesions of endometriosis, the site and degree pelvic adhesions are closely correlated with pain symptoms.

Rectovaginal Endometriosis–Characteristics of Operative Treatment and Factors Predicting Bowel Resection

Study Objective The purpose of this study was to characterize operative treatment of patients with rectovaginal endometriosis (RVE), with special emphasis on factors predicting bowel resection. Design A total of 153 symptomatic cases undergoing radical resection of RVE at our institution between January 2000 and May 2004 were reviewed. Univariable and multivariable association models were used in connection with various factors associated with bowel resection. Setting Tertiary referral center. Measurements and Main Results In all, 57 (37%) patients were treated laparoscopically, and 96 (63%) patients via laparotomy. Gastrointestinal and/or urologic surgeon was present in 30% of cases. A total of 54 (35%) patients underwent bowel resection. The median (range) operating times were 145 (75–315) minutes and 100 (20–300) minutes for patients with and without bowel resection, respectively (p <.0001). Four (2.6%) major complications occurred. In the univariable association model, the risk of bowel resection was increased among patients with previous surgery for endometriosis (OR 2.74, 95% CI 1.35–5.54), intestinal symptoms (OR 2.55, 95% CI 1.29–5.02), and revised American Fertility Society score IV (OR 4.71, 95% CI 2.06–10.78). Preoperative use of combined oral contraceptives was associated with a lower risk of bowel resection (OR 0.32, 95% CI 0.15–0.66). Conclusion Operative treatment of RVE is demanding; a multidisciplinary approach is often needed. Patients with intestinal symptoms and those with a history of endometriosis surgery are at increased risk of bowel resection.

Surgical treatment of endometriosis: location and patterns of disease at reoperation

To assess the behavior of revised American Fertility Society stages I and II endometriosis after surgical treatment, by observation of location of pelvic involvement at reoperation. Prospective study. Tertiary referral center at a university-based hospital. Thirty-nine women with persistent or recurrent chronic pelvic pain after laparoscopic excision or ablation of histologically confirmed endometriosis who underwent a second laparoscopy. Laparoscopic pelvic mapping and surgical treatment of endometriosis, followed by repeat laparoscopic pelvic mapping of endometriosis at a second laparoscopy. Superficial peritoneal endometriosis (revised American Fertility Society stage I-II) endometriosis recurred in 37% of pelvic regions after surgical treatment. Endometriosis was more likely to recur in a treated pelvic region than an adjacent or distant pelvic region (relative risk 2.54; 95% confidence interval 1.63-3.97). A region adjacent to a previously affected pelvic region that was unaffected by endometriosis at the initial laparoscopy was more likely to have endometriosis at the second laparoscopy than a pelvic region distant from the treated pelvic region (relative risk 1.29; 95% confidence interval 0.84-2.0). Unaffected regions at initial laparoscopy had a low probability of having new endometriosis (11%) in the second laparoscopy. Recurrence of histologically proven endometriosis after surgical excision is more likely to cluster close to the original area of involvement, reflecting either incomplete excision at the initial surgery or a nonrandom favored implantation of new endometrial implants in adjacent peritoneum. Further studies are needed to elucidate the pathophysiology and mechanisms of recurrence of endometriosis.

High prevalence of endometriosis in infertile women with normal ovulation and normospermic partners

To determine the prevalence of histologically proven endometriosis in a subset of infertile women. Retrospective case series with electronic file search and multivariable logistic regression analysis. Tertiary academic fertility center. Two hundred twenty-one infertile women without previous surgical diagnosis for infertility with regular cycles (variation, 21-35 days) whose partners have a normal semen analysis. Diagnostic laparoscopy and, if necessary, operative laparoscopy with CO(2) laser excision. The prevalence of endometriosis and of fertility-reducing nonendometriotic tubal and/or uterine pathology. The prevalence of endometriosis was 47% (104/221), including stage I (39%, 41/104), stage II (24%, 25/104), stage III (14%, 15/104), and stage IV (23%, 23/104) endometriosis, and was comparable in patients with (54%, 61/113) and without (40%, 43/108) pelvic pain. The prevalence of fertility-reducing nonendometriotic tubal and/or uterine pathology was 29% in all patients (15% in women with and 40% in women without endometriosis). A multivariate logistic regression model including pain, ultrasound data, age, duration of infertility, and type of fertility was not or not sufficiently reliable for the prediction of endometriosis according to the revised American Fertility Society (rAFS) classifications I-II and rAFS III-IV, respectively. Reproductive surgery is indicated in infertile women belonging to the study population, regardless of pain symptoms or transvaginal ultrasound results, since half of them have endometriosis and 40% of those without endometriosis have fertility-reducing pelvic pathology.

Cyclooxygenase-2 overexpression in ovarian endometriomas is associated with higher risk of recurrence

Cyclooxegenase-2 expression was evaluated by immunohistochemistry in endometrioma tissue samples taken from 109 patients, of whom 53 had recurrence by 30 months after surgery and 56 did not. Cyclooxegenase-2 overexpression, along with previous medical treatment of endometriosis and the presence of adhesion, is predictive of recurrence of ovarian endometrioma within 30 months after surgery, with a resultant sensitivity of 72.5% and a specificity of 72.4%, suggesting that there are intrinsic and identifiable biomarkers that confer recurrence risk.

Association of polymorphisms of the MMP-2 and TIMP-2 genes with the risk of endometriosis in North Chinese women

We investigated whether three polymorphisms in the matrix metalloproteinase-2 (MMP-2; -1306C-->T and -735C-->T) and tissue inhibitor of metalloproteinase-2 (TIMP-2; -418G-->C) genes were related to the risk of endometriosis in reproductive-aged women with and without endometriosis. Our results indicate that the TIMP-2 -418C/C homozygote may be a protective factor against the development of endometriosis in North Chinese women.

Adhesion Reformation After Laparoscopic Adhesiolysis: Where, What Type, and in Whom They Are Most Likely to Recur

Study Objective To assess if the severity or extent of adhesions, the organs involved, or presence of endometriosis predict recurrence or de novo adhesion formation. Design Comparison of adhesion scores at initial operative laparoscopy and at second-look laparoscopy using the revised American Fertility Society adhesion classification system (Canadian Task Force classification I). Setting A university-affiliated reproductive endocrinology and infertility center. Patients In all, 38 women with moderate to severe adhesions who underwent laparoscopic adhesiolysis and second-look laparoscopy. Interventions Adhesion scores were assessed at 6 sites in the peritoneal cavity before initial laparoscopic adhesiolysis and compared with adhesion scores at second-look laparoscopy. Adhesions were evaluated by extent, severity, organ involvement, and presence or absence of endometriosis to evaluate potential determinants of recurrence and de novo adhesion formation. All adhesions were totally removed at initial laparoscopy, all patients received 1000 mL of Ringer’s lactate solution intraperitoneally at the end of procedures, and the same surgeon treated all patients. Measurements and Main Results Adhesion scores decreased in extent [23.3% (p = .005)] and severity [26.3% (p = .001)]. Dense adhesions decreased 31% (p < .000) and filmy adhesions decreased 35% (p = .048). Extent of adhesions assessed at less than one-third, one-third to two-thirds, and more than two-thirds decreased by 33% (p = .002), 42% (p = .000), and 31% (p < .000), respectively. Severity and extent of adhesions of abdominal wall decreased by 45% (p = .003) and 40% (p = .016); of bowel by 33% (p = .002) and 31% (p = .012); and of posterior cul-de-sac by 14% (p = .040) and 9.5% (p = .091), respectively. Severity and extent of adhesions involving both adnexa decreased by 12% to 15%, respectively, which was not statistically significant. Presence of endometriosis did not affect adhesion recurrence. De novo adhesions developed at 48 (21%) of 228 potential sites occurring in 22 of 38 patients, and were most frequent and severe on the adnexa and least on the abdominal wall. Conclusion Both extent and severity of adhesions are significantly reduced by laparoscopic adhesiolysis. Initial extent and severity of adhesions did not predict recurrence; however, the involved organ did, being most frequent on the adnexa and least frequent on the abdominal wall and bowel.

Endometriomas are more frequent on the left side

To investigate whether asymmetry exists in the left- and right-distribution of ovarian cystic lesions in women with endometriosis. We evaluated operative reports of women who underwent surgical treatment of endometrioma(n = 253) from January 1999 to December 2003. We included only those cases that had not been previously operated on (n = 234). Data of all operative findings consisted of a written report and a diagram, fulfilling the revised American Fertility Society Classification of endometriosis. Endometrioma was found in the left ovary in 113 women, in the right ovaryin 67, and bilaterally in 54. Left ovarian unilateral endometrioma was found more frequently (62.8%) than right endometrioma (p < 0.001, odds ratio (OR) 2.8, 95% confidence interval (CI) 1.9, 4.4). The frequencies of left and right ovarian endometrioma were compared with the expected 50% using Pearson's chi(2)-test. The results confirmed asymmetry(p = 0.001). We found 4 cases of ovarian cancer associated with left endometrioma without histological proof of transition. Our results confirm a left lateral predisposition of endometrioma. This predisposition may be caused by the presence of the sigmoid colon in the left side of the pelvis, which decreases peritoneal fluid movement. Our findings may support the transplantation theory of the origin for endometriosis.

Monozygotic triplet pregnancy following egg donation and transfer of single frozen-thawed embryo

To describe a case of monozygotic triplet pregnancy following egg donation and the transfer of a single frozen-thawed embryo. Case report. District general hospital and regional department of fetal medicine in northeast England. A 38-year-old woman with a 2-year history of primary infertility due to severe endometriosis and poor ovarian reserve who conceived after egg donation and transfer of a single frozen-thawed embryo. Transfer of a single frozen-thawed embryo and delivery of three identical female infants by emergency caesarean section because of preterm labor at 32 weeks' gestation. Review of effect of assisted conception on monozygotic twinning rates. Healthy outcome for all three infants. Assisted reproductive treatments may lead to disturbances in zona pellucida architecture and an increase in monozygotic twinning rates. Couples need to be informed of this and the increased risks associated with these pregnancies before they begin with treatment.

Evaluation of Serum CA 125 Levels in Patients with Pelvic Pain Related to Endometriosis

The aim of the study was to investigate the clinical value of the serum CA 125 level for diagnosing and determining the severity of endometriosis and pelvic pain associated with endometriosis. Eighty-six women who underwent operative laparoscopy were enrolled. Sixty-nine women with endometriosis and 17 without endometriosis participated in this study. In all of the patients, endometriosis was diagnosed and classified into stages according to the Revised American Fertility Society (R-AFS) classification. The mean serum CA 125 levels were determined in each patient. We also investigated the relationship between serum CA 125 concentration and the intensity of dysmenorrhea and dyspareunia in the study group. The mean serum CA 125 levels of women with endometriosis were higher than those of the control group (p<0.050). However, the mean serum CA 125 levels were higher in stage IV than in other stages of endometriosis according to the R-AFS classification. On the other hand, the percentage of patients with serum CA 125 levels >35 U/mL was elevated in the subgroups with severe dyspareunia and severe dysmenorrhea versus the asymptomatic subgroup but the differences had no statistical significance. In conclusion, CA 125 serum levels were related to endometriosis and R-AFS score in the evaluated patient series. No correlation was found between serum levels of CA 125 and pelvic pain in patients with endometriosis.

Patterns of and Risk Factors for Recurrence in Women With Ovarian Endometriomas

To identify risk factors for and the patterns of recurrence of endometrioma and of dysmenorrhea in women with ovarian endometrioma. We evaluated 710 consecutive patients operated on for ovarian endometriomas who were followed up for an average of 22.4 months. Twenty factors were examined to assess their effect on risk of recurrence of endometrioma and of dysmenorrhea using survival analysis. Hazard rate also was estimated to examine recurrence patterns. For recurrence of endometrioma, the revised American Fertility Society (rAFS) score, younger age at surgery, and previous medical treatment of endometriosis were identified to be risk factors. For recurrence of dysmenorrhea, rAFS score was the only risk factor. For both recurrences, there was a constant hazard rate in the first 28-30 months after surgery, indicating that the recurrence in that period is completely random. After that period, the hazard rate increased dramatically. The total rAFS score, but not rAFS stage, is a risk factor for recurrence of both endometrioma and dysmenorrhea, indicating that the rAFS stage has little prognostic value. The existence of a completely random recurrence period may be a universal phenomenon, with its duration and the magnitude of recurrence risk determined by patient characteristics and quality of care. The second phase of much higher recurrence risk may reflect successful reseeding, reimplantation, and regrowth of ectopic endometrium. Therefore, the identification of risk factors as well as patterns of recurrence should shed better light on possible causes for recurrence, which is now poorly understood.

Laparoscopic Helica Thermal Coagulation for the Treatment of Early Endometriosis

Objectives: The aim of this study was to assess the safety and clinical outcome of Helica thermal coagulation (TC) for the treatment of pelvic pain symptoms and infertility caused by early endometriosis. Materials and Methods: A prospective, observational study was conducted at a secondary health care hospital in Cumbria, United Kingdom. Forty-three (43) women, with either pelvic pain symptoms, infertility, or both and diagnosed with minimal or mild endometriosis at laparoscopy, were included in the study. Eleven (11) women complained of pelvic pain symptoms only and 18 had infertility only, whereas 14 complained of both. All women were treated on a day-case basis. The revised American Fertility Society classification was used to stage endometriosis. Laparoscopic Helica TC was used to ablate all visible endometriotic spots. Relief of pelvic pain symptoms and conception were assessed up to 6 months after the procedure. Complications occurring during or after the procedure were recorded. Results: All women completed the study up to 6 months of follow-up. Eighteen (18) of 25 (18/25) women (72%) had satisfactory relief of pelvic pain symptoms at 6 months. The cumulative pregnancy rate was 34% (11/32). Six (6) pregnancies were spontaneous and occurred 1 month after the procedure, whereas 5 pregnancies were recorded at 3–6 months. No surgical complications were encountered. Conclusions: Conservative laparoscopic surgery using Helica TC is simple, very safe, and effective at relieving pelvic pain symptoms and improving fertility in women with early-stage endometriosis. Large, randomized, controlled trials on the efficacy of this procedure are needed. (J GYNECOL SURG 23:45)

Fertilité après chirurgie cœlioscopique de l'endométriose pelvienne chez des patientes en échec de grossesse

To evaluate fertility outcome after laparoscopic management of endometriosis in an infertile population. A retrospective analysis of 64 patients presenting more than one year infertility and a pregnancy-wish associated with minimal to severe endometriotic lesions (stage I to IV according to the revised American Fertility Society (rAFS) classification), treated using laparoscopic surgery in order to remove the entire lesions. We excluded women under 20 years and over 40, as well as those with other infertility factors (tubal non endometriosis-related, hormonal or sperm). Fertility of the remaining 34 patients was studied in relation to endometriosis stage and to pregnancy's mode (spontaneous or induced). Pregnant women percentage was 65% (22 patients) within a 8.5 months (quartiles: 3; 15.5) [range: 1; 52] post-surgical time, and 86.5% pregnancies issued with a delivery. The rate of pregnant women depended on stage of endometriosis (89% for stages I-II, and 56% for stages III-IV). Sixty percent pregnancies were spontaneous within a 5 months (3; 9) [1; 52] post-surgical time to pregnancy average. When pregnancies were obtained with assisted reproductive techniques, the median post-surgical time to pregnancy was 12 months (9; 22) [2; 31]. Among women with stages I-II endometriosis, the median post-surgical time to pregnancy was 2 months when spontaneous and 20.5 months when induced (P=0.007). In case of stages III-IV endometriosis, pregnancy's delay was 8 and 12 months respectively (P=0.79). Among the 21% women who had had an induced pregnancy failure before surgery, 71% became pregnant and 80% spontaneously. Eighteen patients (53%) had an ovarian endometrioma and 50% of them became pregnant. Among the 4 patients who had colorectal endometriosis requiring colorectal resection, 1 pregnancy was obtained. These findings suggest that in a context of more than one year infertility only related to endometriosis, it is reasonable to offer these patients a complete operative laparoscopic treatment of their lesions, which enables 65% of them to be pregnant within a 8.5 months post-surgical median time to pregnancy and spontaneously in 60%. In case of stages I-II endometriosis we suggest a spontaneous pregnancy try during 8 to 12 months before starting induced pregnancy therapeutics instead of stages III-IV endometriosis where induced methods should be used after only 6 or 8 months.

Endometriosis: frequency and correlation between symptomatology and disease stage.

To determine the frequency of endometriosis in general gynecological and infertile women presenting to hospital and to correlate symptomatology and stage of disease. Cross-sectional study. Gynecology Department of Mother and Child Health Center, Pakistan Institute of Medical Sciences, Islamabad, from March 2000 to March 2002. Fifty patients with diagnosis of endometriosis on laparoscopy were included in the study. The degree of pain symptoms was graded according to 1-4 point verbal rating scale designed by Biberoglu and Behrman. Endometriosis was staged according to Revised American Fertility Society (R-AFS) scoring on laparoscopy. Correlation coefficient-Spearman rank order correlation test was applied to analyze data. The frequency of endometriosis in infertile women was 24% (33) and in women with general gynecological complaints, it was 23% (17). There was a significant positive correlation between chronic pelvic pain and R-AFS scoring. Increasing severity of pelvic pain was also positively correlated with presence of endometrioma and complete obliteration of pouch of Douglas. No correlation between dysmenorrhoea and R-AFS scoring could be detected. Dysmenorrhoea was strongly and positively correlated with the presence of superficial implants. Dyspareunia was found to have positive correlation with R-AFS score and also with complete obliteration of pouch of Douglas. The frequency of endometriosis in infertile women was 24% (33) and in women with general gynecological complaints, it was 23% (17). Chronic pelvic pain and dyspareunia had strong positive correlation with R-AFS score while dysmenorrhoea had no such correlation.

Evaluation of serum CA 125 levels in patients with pelvic pain related to endometriosis

The aim of the study was to investigate the clinical value of the serum CA 125 level for diagnosing and determining the severity of endometriosis and pelvic pain associated with endometriosis. Eighty-six women who underwent operative laparoscopy were enrolled. Sixty-nine women with endometriosis and 17 without endometriosis participated in this study. In all of the patients, endometriosis was diagnosed and classified into stages according to the Revised American Fertility Society (R-AFS) classification. The mean serum CA 125 levels were determined in each patient. We also investigated the relationship between serum CA 125 concentration and the intensity of dysmenorrhea and dyspareunia in the study group. The mean serum CA 125 levels of women with endometriosis were higher than those of the control group (p<0.050). However, the mean serum CA 125 levels were higher in stage IV than in other stages of endometriosis according to the R-AFS classification. On the other hand, the percentage of patients with serum CA 125 levels >35 U/mL was elevated in the subgroups with severe dyspareunia and severe dysmenorrhea versus the asymptomatic subgroup but the differences had no statistical significance. In conclusion, CA 125 serum levels were related to endometriosis and R-AFS score in the evaluated patient series. No correlation was found between serum levels of CA 125 and pelvic pain in patients with endometriosis.