Stage Of Endometriosis Research Articles

8627 Evaluating the Feasibility of Assigning 2021 AAGL Endometriosis Classification Scores to Pre-Operative MRI Imaging

<h3>Study Objective</h3> To evaluate the feasibility of applying the AAGL 2021 Endometriosis Classification system to pre-operative MRI findings in order to predict surgical complexity. <h3>Design</h3> A retrospective chart review of patients who had a pelvic MRI performed for the indication of pelvic pain and underwent surgery for presumed endometriosis. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> 190 charts were reviewed of patients referred for an MRI for pelvic pain. Of those patients, 47 had both an MRI and subsequently underwent pelvic surgery. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> Of the 190 charts reviewed, 48 patients had both an MRI and underwent pelvic surgery. Using the AAGL Endometriosis Classification system, patients were assigned a score for their MRI and operative findings. When measurements were not specified in the MRI report, they were reviewed on the images or assigned based on terminology of "mild" and "severe." Scores for operative findings were based on explicit use of the scoring system (14.89%) or deduced from the operative and pathology reports. Scores differed significantly for overall AAGL score (t(46) = 3.964, p = 0.00026) with a mean difference between operative and MRI scores of 6.55 (mean operative score of 16.3, SD = 12.54; mean MRI score 9.74, SD = 8.42). Scores differed significantly for stage of endometriosis (t(46) = 4.15, p = 0.0001) with a mean difference between operative and MRI scores of 0.809 (mean operative score of 2.4, SD = 1.48; mean MRI score 1.57, SD = 1.28). <h3>Conclusion</h3> Use of the AAGL Classification system has been implemented to better assess surgical complexity of endometriosis cases. Assigned scores for MRI results, however, differ significantly from operative findings suggesting that there are limitations to the adoptability of this system to imaging findings. Future consistent use of the scoring system in operative reports may improve consistency and more detailed imaging reports may improve accuracy of assigning scores to pre-operative imaging.

8977 The Use and (Potential) Misuse of the AAGL Endometriosis Classification System

<h3>Study Objective</h3> To demonstrate use and (potential) misuse of the AAGL 2021 Endometriosis Classification Scoring System, an anatomy-based surgical complexity scoring system - with the goal of optimizing future endometriosis staging. <h3>Design</h3> A case report applying the new AAGL 2021 Endometriosis Classification and use of the App. <h3>Setting</h3> A university hospital based in Detroit, Michigan; Wayne State University/ Detroit Medical Center. <h3>Patients or Participants</h3> A case report of a Stage 2 Endometriosis based on the Scoring System with a patient presenting for infertility. <h3>Interventions</h3> Application and utilization of the AAGL 2021 Endometriosis Classification for a Stage 2 Endometriosis Classification. <h3>Measurements and Main Results</h3> Scoring system demonstrated feasibility, applied utility to the correlation that was discussed regarding the Scoring System, but also limitations and potential misuses of the scoring system. <h3>Conclusion</h3> The AAGL Endometriosis Scoring System is a feasible intraoperative scoring system correlated with pain. It is critical to be cognizant of staging parameters while scoring the endometriotic lesions and remaining consistent.

Comparison of the Recently Published “AAGL Endometriosis Classification” with Other Staging Systems to Predict Surgical Complexity

<h3>Study Objective</h3> We aim to assess the performance of the "2021 AAGL Endometriosis Classification" compared with revised American Society of Reproductive Medicine (rASRM), Ultrasound Based Endometriosis Staging System (UBESS) and modified Ultrasound Based Endometriosis Staging System (mUBESS) to predict AAGL levels of surgical complexity. <h3>Design</h3> Multicenter retrospective diagnostic accuracy study. <h3>Setting</h3> 2 gyneacology units in metropolitan Sydney, Australia. <h3>Patients or Participants</h3> Patients with suspected endometriosis who underwent laparoscopy between January 2016 and October 2021 (n=272). <h3>Interventions</h3> Database of patients with comprehensive surgical data including location & severity of endometriosis & surgical procedure performed was analysed. AAGL surgical complexity level (A to D) was pre-determined by consensus between three observers. For the three stage UBESS to be compared with the four levels of AAGL surgical complexity, levels B and C were merged. rASRM stage 1, 2, 3 and 4 predicted AAGL level A, B, C and D, respectively. UBESS stage 1, 2 and 3 predicted AAGL level A, B/C and D, respectively. mUBESS stage 1, 2, 3 and 4 predicted AAGL level A, B, C and D, respectively. The performance of all staging systems was assessed using kappa, accuracy, sensitivity, specificity, positive predictive value (PPV,) negative predictive value (NPV) and likelihood ratios. <h3>Measurements and Main Results</h3> Across all diagnostic accuracy measurements there was no clear difference between the four staging tools. For overall comparison, kappa/weighted kappa scores respectively were: For AAGL 0.42 & 0.55, for rASRM 0.41 & 0.55, for UBESS 0.44 & 0.57 and for mUBESS 0.47 & 0.58. <h3>Conclusion</h3> Across all tools, there was good concordance for mild and severe disease to predict surgical skill level. For intermediate disease there was weak concordance. There was no clearly superior tool.

7943 Modification of the “Aagl Endometriosis Classification” to a 3-Stage System: Diagnostic Accuracy & Inter-Observer Reproducibility Study

<h3>Study Objective</h3> We aim to assess the performance of a modified AAGL (mAAGL) endometriosis classification system and its inter-observer reproducibility. <h3>Design</h3> Retrospective diagnostic accuracy & inter-observer reproducibility study. <h3>Setting</h3> 2 gynecology units in metropolitan Sydney, Australia. <h3>Patients or Participants</h3> Patients with suspected endometriosis who underwent laparoscopy between January 2016 and October 2021 (n=272). <h3>Interventions</h3> Patients with complete surgical data included. The original 4-stage American Association of Gynecologic Laparoscopists (AAGL) staging system was modified to three stages by merging AAGL stages 2 and 3 and surgical complexity levels B and C. Three observers independently apportioned an AAGL stage 1-3, blinded to surgical skill level (A, B and C). End points were diagnostic performance of each observer to predict level of surgical complexity for each stage, i.e., mAAGL stage 1 to predict level A, mAAGL stage 2 to predict level B, mAAGL stage 3 to predict level C. Inter-observer reproducibility was assessed using OR of a higher grade, between each pair of observers. <h3>Measurements and Main Results</h3> 272 surgical cases analyzed. The diagnostic accuracy for all observers to predict each level in terms of sensitivity, specificity, PPV and NPV were: stage 1 to predict level A: 98.0-98.7%, 60.2-64.2%, 75.0-76.9% & 96.3-97.5%; stage 2 to predict level B: 31.1-36.9%, 97.0-98.2%, 86.5-92.6% & 69.8 – 71.9%; stage 3 to predict level C: 90.0-95.0%, 90.1-91.7%, 41.8 - 47.5% & 99.1-99.6%. Inter-observer reproducibility between observer 1 & 2 was 0.81, between observer 1 & 3 was 0.69 and between observer 2 & 3 was 0.43. Overall percentage agreement between observers 1 & 2 was 93.4%, between 1 & 3 was 93.4% & between 2 & 3 was 96.3%. <h3>Conclusion</h3> The mAAGL system appears to perform well for both low and high stage endometriosis disease. The 4-stage AAGL staging system could be improved by merging AAGL stages 2 and 3 and in turn using a 3-stage system.

Significance of metabolomic disorders in infertility and miscarriage in patients with endometriosis

BACKGROUND: Despite numerous studies, the causal relationships of endometriosis, associated infertility and miscarriage have not yet been clarified.&#x0D; AIM: This article discusses the significance of insulin-like growth factor 1, matrix metalloproteinase 9 and activin A levels in the blood serum and peritoneal fluid of patients of reproductive age with endometriosis in the clinical aspects of infertility and miscarriage and as per stages of the disease.&#x0D; MATERIALS AND METHODS: The overall group consisted of patients with endometriosis (group I: stages III, n = 25; group II: stages IIIIV, n = 38). The control group comprised patients without the disease (group III: n = 25). The stage of endometriosis was classified during laparoscopy in accordance with revised American Society for Reproductive Medicine classification (1996).&#x0D; RESULTS: In endometriosis, primary infertility predominated (up to 40.8% of cases), while secondary infertility occured in 21.2% of cases. Primary infertility accounted for 68.0% of cases in stages III versus 39.5% of cases in stages IIIIV. Secondary infertility accounted for 28.0% versus 23.0% of cases, respectively. In minimal stages of the disease, non-developing pregnancies (12.0%) and spontaneous miscarriages (4.0%) occurred in 16.0% of cases. In severe stages, these nosologies occurred in an equal percentage of cases (5.2%).&#x0D; The group of patients with endometriosis showed multidirectional changes in activin A levels in the blood serum and peritoneal fluid, a decrease in matrix metalloproteinase 9 level by 27% in the peritoneal fluid and an increase in insulin-like growth factor 1 level by 36% in the blood serum. In minimal stages of endometriosis, the tendencies of changes in the parameters remained intact as compared to the overall group, the correspondence of matrix metalloproteinase 9 levels to the control values in the blood serum and peritoneal fluid being noteworthy. Stages IIIIV of the disease implied more significant changes as compared to the control or the overall group of patients. We found a decrease in insulin-like growth factor 1 level by 56% in the peritoneal fluid, a decrease in activin A level by 19% in the blood serum with an increase in the parameter by 27% in the peritoneal fluid, and a decrease in matrix metalloproteinase 9 level by 4% in the peritoneal fluid.&#x0D; CONCLUSIONS: Modifications of the studied compounds activin A, MPP-9 and IPFR-1 are associated with infertility and miscarriage in patients with endometriosis.

Comparison of Morphological and Digital-Assisted Analysis for BCL6 Endometrial Expression in Women with Endometriosis.

BCL6 (B-cell lymphoma 6) is a proto-oncogene and transcriptional repressor initially described as being involved in B-cell lymphoma. Recently, this factor has been identified as a promising tissue biomarker which could be used to diagnose women affected by endometriosis. Previous studies used HSCORE for BCL6 staining quantification in the endometrium. However, this semi-quantitative technique of analysis has some limitations, including a lack of objectivity, robustness, and reproducibility that may lead to intra- and inter-observer variability. Our main goal was to develop an original computer-assisted method to quantify BCL6 staining from whole-slide images reliably. In order to test the efficiency of our new digital method of quantification, we compared endometrial BCL6 expression between fertile and infertile women without or with different stages of endometriosis by using the widely used HSCORE analysis and our new automatic digital image analysis. We find a higher expression of BCL6 in the endometrium of infertile women with endometriosis and women with stage IV endometriosis. Furthermore, we demonstrate a significant correlation between the two types of independent measurements, indicating the robustness of results and also the reliability of our computer-assisted method for BCL6 quantification. In conclusion, our work, by using this original computer-assisted method, enables BCL6 quantification more objectively, reliably, robustly, and promptly compared to HSCORE analysis.

Clinical practice guidelines for endometriosis in Japan (The 3rd edition).

Clinical practice guidelines for endometriosis in Japan (The 3rd edition).

Obstetric and perinatal outcomes in women with endometriosis

Key content Endometriosis in pregnancy is associated with an increased risk of spontaneous miscarriage, pre‐eclampsia, postpartum haemorrhage, caesarean section, placenta praevia, fetal growth restriction, prematurity and adverse neonatal outcomes. Women with mild disease are considered as having ‘low‐risk endometriosis’ (LRE) and can expect a normal pregnancy and labour. The ‘high‐risk endometriosis’ (HRE) group may require additional antenatal and intrapartum specialist care. Learning objectives To understand the pathophysiologic basis of adverse obstetric and perinatal outcomes in pregnant women with endometriosis. To understand the obstetric outcomes in relation to the severity and staging of endometriosis. To appreciate the risk of spontaneous haemoperitoneum in pregnancy (SHiP) associated with endometriosis in pregnancy.

The role of cytokeratin 19 levels in the determination of endometriosis stages

Objective/Aim Endometrisosis, one of the most common gynecological disease, is characterized by the presence of endometriotic tissue outside of uterine cavity. The development and the validation of a simple blood biomarker specific and sensitive for endometriosis may facilitate the rapid and the accurate diagnosis of the disease and thus early treatment. Cytokeratin expression changes during epithelial differentiation and this expression is important for the modulation and the control of cell cycle regulation, tumor cell motility and apoptosis. Cytokeratin 19 (CK-19) is expressed in most simple epithelial cells and their malignant counterparts. The aim of this study is to investigate serum CK-19 expression levels in patients with endometriosis and to determine the diagnostic role of CK-19 levels in differentiating various stage of endometriosis. Methods Ctytokeratin-19 expression and level were studied in 70 endometriosis patients and 50 volunteers by ELISA and RT-PCR. ROC analysis was performed by comparing all stages with each other and with the control group. Results The CK-19 levels were significantly higher in the endometriosis groups than that of the control group by ELISA and RT-PCR. A significant (p < .05) difference was observed in endometriosis patients according to the stages. Conclusion Based on our data, it suggests that Cytokeratin-19 may have a potential role in the development of endometriosis.

Is ovarian cystectomy for atypical ovarian endometrioma safe?: A single center study.

Ovarian atypical endometriosis (AE) is a premalignant lesion, and its potential to progress to endometriosis-associated ovarian cancer emphasizes its significance. However, the true risk of malignancy in AE remains unclear. Therefore, this study aimed to investigate the clinical outcomes of ovarian AE after ovarian cystectomy. We retrospectively reviewed the medical records and histopathological reports of 41 patients who had been diagnosed with ovarian AE between January 2011 and April 2020. We reviewed age, obstetric history, age at menarche, preoperative CA 125 level, C-reactive protein level, erythrocyte sedimentation rate, endometriosis stage, mean follow-up duration, postoperative hormonal therapy, and prognosis, including recurrence of endometriosis and malignant transformation. Among 41 patients with pathologically diagnosed ovarian AE, 26 were followed up after cystectomy only. The average follow-up period was 58.27 ± 33.22 months in cystectomy only patients. The mean age of the patients with cystectomy only versus that of patients with endometriosis-associated ovarian carcinoma was 32.73 ± 6.10 versus 48.29 ± 4.35 (P < .01) years. The preoperative CA 125 level was 115.63 ± 219.06 versus 225.75 ± 163.39 (P < .051) U/mL. Patients with endometriosis-associated ovarian carcinoma or other diseases and those who underwent oophorectomy were excluded. After surgery, hormone therapy was administered to 22 of 26 patients, and the remaining 4 patients were followed up without additional treatment. Endometriosis recurrence occurred in 5 patients, 1 of whom underwent second-line laparoscopic ovarian cystectomy. However, no malignant transformations were observed. Ovarian AE has a low possibility of malignant transformation. Conservative treatment is recommended after appropriate ovarian cystectomy, such as enucleation.

Strengths and limitations of diagnostic tools for endometriosis and relevance in diagnostic test accuracy research.

Endometriosis is a chronic systemic disease that can cause pain, infertility and reduced quality of life. Diagnosing endometriosis remains challenging, which yields diagnostic delays for patients. Research on diagnostic test accuracy in endometriosis can be difficult due to verification bias, as not all patients with endometriosis undergo definitive diagnostic testing. The purpose of this State-of-the-Art Review is to provide a comprehensive update on the strengths and limitations of the diagnostic modalities used in endometriosis and discuss the relevance of diagnostic test accuracy research pertaining to each. We performed a comprehensive literature review of the following methods: clinical assessment including history and physical examination, biomarkers, diagnostic imaging, surgical diagnosis and histopathology. Our review suggests that, although non-invasive diagnostic methods, such as clinical assessment, ultrasound and magnetic resonance imaging, do not yet qualify formally as replacement tests for surgery in diagnosing all subtypes of endometriosis, they are likely to be appropriate for advanced stages of endometriosis. We also demonstrate in our review that all methods have strengths and limitations, leading to our conclusion that there should not be a single gold-standard diagnostic method for endometriosis, but rather, multiple accepted diagnostic methods appropriate for different circumstances. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Polymorphisms of TNF-alpha (− 308), IL-1beta (+ 3954) and IL1-Ra (VNTR) are associated to severe stage of endometriosis in Mexican women: a case control study

BackgroundEndometriosis is an estrogen-dependent and chronic inflammatory disease affecting up to 10% of women. It is the result of a combined interaction of genetic, epigenetic, environmental, lifestyle, reproductive and local inflammatory factors. In this study, we investigated whether single nucleotide polymorphisms (SNPs) mapping to TNF-alpha (TNF, rs1800629) and IL-1beta (IL1B, rs1143634) and variable number tandem repeat polymorphism mapping to IL1-Ra (IL1RN intron 2, rs2234663) genetic loci are associated with risk for endometriosis in a Mexican mestizo population.MethodsThis study included 183 women with confirmed endometriosis (ENDO) diagnosed after surgical laparoscopy and 186 women with satisfied parity and without endometriosis as controls (CTR). PCR/RFLP technique was used for genotyping SNPs (rs1800629 and rs1143634); PCR for genotyping rs2234663.ResultsWe found no statistical differences in age between groups nor among stages of endometriosis and the CTR group. We observed no difference in genotype and allele frequencies, nor carriage rate between groups in none of the three studied polymorphisms. The prevalence of TNF*2-allele heterozygotes (p = 0.025; OR 3.8), TNF*2-allele (p = 0.029; OR 3.4), IL1B*2-allele heterozygotes (p = 0.044; OR 2.69) and its carriage rate (p = 0.041; OR 2.64) in endometriosis stage IV was higher than the CTR group. Surprisingly, the carriage rate of IL1RN*2-allele (ENDO: p = 0.0004; OR 0.4; stage I: p = 0.002, OR 0.38; stage II: p = 0.002, OR 0.35; stage III: p = 0.003, OR 0.33), as well as the IL1RN*2-allele frequencies (ENDO: p = 0.0008, OR 0.55; I: p = 0.037, OR 0.60; II: p = 0.002, OR 0.41; III: p = 0.003, OR 0.38) were lower than the CTR group. Women with endometriosis stage IV (severe) had frequencies more alike to the CTR group in the IL1RN*2 allele frequency (31.2% vs. 27.2%) and carriage rate (37.5% vs. 41.9%).ConclusionAlthough these polymorphisms are not associated with the risk of endometriosis, Mexican mestizo women with severe stage of endometriosis have higher frequencies of TNF*2-, IL1B*2- and IL1RN*2-alleles, which may explain a possible correlation with disease severity rather than predisposition or risk.

Pregnancy outcomes in women with endometriosis and/or ART use: a population-based cohort study.

STUDY QUESTIONWhat is the association between endometriosis and adverse pregnancy outcomes with ART use and non-use?SUMMARY ANSWEREndometriosis and ART use are both associated with increased risk of preterm birth, antepartum haemorrhage, placenta praevia and planned birth (caesarean delivery or induction of labour).WHAT IS KNOWN ALREADYThere are contradictory findings on the association between endometriosis and adverse pregnancy outcomes, and many large studies have not considered the effect of ART use.STUDY DESIGN, SIZE, DURATIONPopulation-based cohort study of 578 221 eligible pregnancies during 2006–2015, comparing pregnancy outcomes across four groups (No endo/no ART, No endo/ART, Endo/no ART and Endo/ART).PARTICIPANTS/MATERIALS, SETTING, METHODSAll female residents of New South Wales, Australia aged 15–45 years and their index singleton pregnancy of at least 20 weeks gestation or 400 g birthweight. Linked hospital, pregnancy/birth and mortality data were used. Modified Poisson regression with robust error variances was used to estimate adjusted risk ratios (aRRs) and 99% CIs, adjusting for sociodemographic and pregnancy factors.MAIN RESULTS AND THE ROLE OF CHANCECompared to women without endometriosis who had pregnancies without ART use, there was increased risk of preterm birth (<37 weeks) in all groups [No endo/ART (aRR 1.85, 99% CI 1.46–2.34), Endo/no ART (aRR 1.24, 99% CI 1.06–1.44), Endo/ART (aRR 1.93, 99% CI 1.11–3.35)] and antepartum haemorrhage [No endo/ART (aRR 1.99, 99% CI 1.39–2.85), Endo/no ART (aRR 1.31, 99% CI 1.03–1.67), Endo/ART (aRR 2.69, 99% CI 1.30–5.56)] among pregnancies affected by endometriosis or ART use, separately and together. There was increased risk of placenta praevia [No endo/ART (aRR 2.26, 99% CI 1.42–3.60), Endo/no ART (aRR 1.66, 99% CI 1.18–2.33)] and planned birth [No endo/ART (aRR 1.08, 99% CI 1.03–1.14), Endo/no ART (aRR 1.11, 99% CI 1.07–1.14)] among pregnancies with endometriosis or ART use, separately. There was increased risk of placental abruption [No endo/ART (aRR 2.36, 99% CI 1.12–4.98)], maternal morbidity [No endo/ART (aRR 1.67, 99% CI 1.07–2.62)] and low birthweight (<2500 g) [No endo/ART (aRR 1.45, 99% CI 1.09–1.93)] among pregnancies with ART use without endometriosis. There was decreased risk of having a large-for-gestational age infant [Endo/no ART (aRR 0.83, 99% CI 0.73–0.94)] among pregnancies with endometriosis without ART use.LIMITATIONS, REASONS FOR CAUTIONEndometriosis is often under-diagnosed and women with a history of hospital diagnosis of endometriosis may represent those with more symptomatic or severe disease. If the effects of endometriosis on pregnancy are greater for those with more severe disease, our results may over-estimate the effect of endometriosis on adverse pregnancy outcomes at a population level. We were unable to assess the effect of endometriosis stage or typology on the study outcomes.WIDER IMPLICATIONS OF THE FINDINGSThese results suggest that women with endometriosis including those who used ART to achieve pregnancy are a higher-risk obstetric group requiring appropriate surveillance and management during their pregnancy.STUDY FUNDING/COMPETING INTEREST(S)This study was supported by the Prevention Research Support Program, funded by the New South Wales Ministry of Health. The funder had no role in the design, data collection and analysis, interpretation of results, manuscript preparation or the decision to submit the manuscript for publication. The authors have no conflicts of interest.TRIAL REGISTRATION NUMBERN/A.

Reoperation and pain-related outcomes after hysterectomy for endometriosis by oophorectomy status

More research is needed that compares the outcomes between those who underwent a hysterectomy for endometriosis with conservation of one or both ovaries and those who underwent a hysterectomy with bilateral salpingo-oophorectomy. This study aimed to compare the rate and types of reoperations (primary outcome) and use of other pain-related health services (secondary outcomes) among people who underwent a hysterectomy with conservation of both ovaries, those who underwent a hysterectomy with unilateral salpingo-oophorectomy, and those who underwent a hysterectomy with bilateral salpingo-oophorectomy. This was a population-based, retrospective cohort study of 4489 patients aged 19 to 50 years in British Columbia, Canada, who underwent a hysterectomy for endometriosis between 2001 and 2016. Index surgeries were classified as hysterectomy alone (conservation of both ovaries), hysterectomy with unilateral salpingo-oophorectomy, or hysterectomy with bilateral salpingo-oophorectomy. Reoperation rate was the primary outcome. Secondary outcomes (measured at 3-12 months and 1-5 years after hysterectomy) included physician visits for endometriosis and pelvic pain, prescriptions filled for opioids, and use of hormonal suppression medications and hormone replacement therapy. Reoperation rates were low across all groups, with 89.5% of all patients remaining reoperation free by the end of follow-up (median of 10 years; interquartile range, 6.1-14.3 years). Patients who underwent a hysterectomy alone were more likely to undergo at least 1 reoperation when compared with those who underwent a hysterectomy with bilateral salpingo-oophorectomy (13% vs 5%; P<.0001), most commonly an oophorectomy or adhesiolysis. When oophorectomy as reoperation was removed in a sensitivity analysis, this difference was partially attenuated (6% of hysterectomy alone group vs 3% of hysterectomy with bilateral salpingo-oophorectomy group undergoing at least 1 reoperation). All groups were very similar in terms of rates of physician visits for endometriosis or pelvic pain and the number of days of opioid prescriptions filled. Furthermore, the rate of hormonal suppression medication use was similar among the groups, whereas the rate of prescriptions filled for hormone replacement therapy after hysterectomy with bilateral salpingo-oophorectomy was 60.6% of patients who filled at least 1 prescription at 3 to 12 months after index surgery. Patients who underwent a hysterectomy with bilateral salpingo-oophorectomy had a lower reoperation rate than those who underwent a hysterectomy with conservation of one or both ovaries. However, there was little difference between the groups for the secondary outcomes measured, including physician visits for endometriosis and pelvic pain, opioid use, and use of hormonal suppression medications, suggesting that persistent pelvic pain after hysterectomy for endometriosis may not differ substantively based on ovarian conservation status. One limitation was the inability to stratify patients by stage of endometriosis or to determine the impact of endometriosis stage or the presence of adnexal disease or deep endometriosis on the outcomes. Moreover, hormone replacement therapy prescriptions was not filled by about 40% of patients after hysterectomy with bilateral salpingo-oophorectomy, which may have significant health consequences for these individuals undergoing premature surgical menopause. Therefore, strong consideration should be given to ovarian conservation at the time of hysterectomy for endometriosis.

Association Between Fallopian Tube Length and Genital Endometriosis in Infertile Patients Retrospective Cohort Study

Background: Information about the prevalence of fallopian tube pathology in the early stages of endometriosis is scarce. The aim of our study was to examine the association between genital endometriosis and the lengths of fallopian tubes in infertile women. Settings and Design: retrospective cohort study. Methods: We studied 651 infertile patients in the 20–40 year age group, who visited a Reproductive Clinic for treatment between 2012–2018. After laparoscopy, endometriosis (detected by histomorphology) was indicated in 472 cases and absent in 179 cases. The length of the fallopian tubes was estimated in 193 primary infertile women with endometriosis. We excluded patients from the study who had surgical intervention on their tubes. Appearance of tubes and fimbriae was assessed in 177 patients without endometriosis and in 461 patients with endometriosis. Results: The proportion of women with shorter (&lt;8 cm) right and left fallopian tubes was significantly greater in those with endometriosis. Conversely, the proportion of women with longer (&gt;12 cm) left fallopian tubes was significantly higher in the group of patients without endometriosis. Correlation analysis showed significant positive correlations of endometriosis with: a short (&lt;8 cm) right fallopian tube-r = –0.504** (p &lt; 0.001); Significant negative correlationsof endometriosis were with: a medium (8–12 cm) length right fallopian tube-r = –0.639** (p &lt; 0.001); a long (&gt;12 cm) left fallopian tube-r = –0.596** (p &lt; 0.001); Conclusions: Infertile women with minimal or mild endometriosis have been shown to have anatomical and structural changes in the fallopian tubes and fimbriae compared to those without endometriosis. The presence of genital endometriosis (I;II stage) maybe associated with shorter fallopian tubes.

COVID-19 susceptibility in endometriosis patients: A case control study.

ProblemStarting from November 2019, the world has had to face a devastating pandemic caused by SARS‐CoV‐2. Various studies have identified potential risk factors facilitating the infection, however it has not been demonstrated whether endometriosis might represent one of them.The purpose of this study was to evaluate if patients with endometriosis had a higher risk of contracting COVID‐19 infection and, in such case, whether they developed a more severe infection than the general population. Furthermore, this study evaluated the possible correlation with the stage of endometriosis, based on the r‐ASRM score, and the potential worsening of the disease during the SARS‐CoV‐2 infection.Method of studyA case‐control study was conducted from March 2020 to April 2021 at Macedonio Melloni Hospital, in Milan. A total of 401 women were recruited. The cases were 201 women with clinical or surgical diagnosis of endometriosis. The control group consisted of 200 women, without the disease. All women completed a self‐administered questionnaire which evaluated their demographic and clinical characteristics, as well as a potential diagnosis of Covid‐19.ResultsComparison between the two groups showed that women with endometriosis had a higher frequency of COVID‐19 than the control subjects (23% vs. 13.5%, P = .014), with a greater prevalence of fever (14.4% vs. 6%, P = .008) and myalgias or arthralgias (11.4% vs. 4.5%, P = .01).In multivariable logistic regression analyses, women with endometriosis had a higher risk of contracting SARS‐CoV‐2 infection (OR = 2.11, 95% IC: 1.20–3.80), regardless the stage of the disease.ConclusionEndometriosis increases the susceptibility to COVID‐19, and women who suffer from it should be considered as fragile patients, worthy of prior access to SARS‐CoV‐2 vaccination campaign.

Robotic surgery in gynaecology: Scientific Impact Paper No. 71 (July 2022).

The use of robotic-assisted keyhole surgery in gynaecology has expanded in recent years owing to technical advances. These include 3D viewing leading to improved depth perception, limitation of tremor, potential for greater precision and discrimination of tissues, a shorter learning curve and improved comfort for surgeons compared with conventional keyhole and open abdominal surgery. Robotic-assisted keyhole surgery, compared with conventional keyhole surgery, improves surgical performance without increasing operating time, minimises blood loss and intra- or postoperative complications, while reducing the need to revert to abdominal surgery. Moreover, surgeons using a robot experience fewer skeletomuscular problems of their own in the short and long term than those operating without a robot as an additional tool. This Scientific Impact Paper looks at the use of a robot in different fields of gynaecological surgery. A robot could be considered safe and a more effective surgical tool than conventional keyhole surgery for women who have to undergo complex gynaecology surgery or have associated medical issues such as body-mass index (BMI) at 30 kg/m2 or above or lung problems. The introduction of the use of robots in keyhole surgery has resulted in a decrease in the number of traditional open surgeries and the risk of conversion to open surgery after traditional keyhole surgery; both of which should be considered when examining the cost-benefit of using a robot. Limitations of robotic-assisted surgery remain the associated higher costs. In womb cancer surgery there is good evidence that introducing robotics into the service improves outcomes for women and may reduce costs.

Effects of Macrophage Inflammatory Protein 1 Alpha and Beta Chemokine Concentrations in the Progression of Endometriosis

Objective: The aim of this study was to understand the pathophysiologic mechanisms of macrophage inflammatory protein 1 alpha (MIP1a) and beta (MIP1b) chemokines in endometriosis, and to understand the immuno-pathophysiology underlying the progression of this disease. Methods: Analyses and conclusions outlined in this study were based on in vitro experiments conducted using supernatants collected from cultured lymphocytes taken from women with endometriosis and from healthy donors. The study group included 30 patients meeting the outlined inclusion criteria who were diagnosed at various clinical stages of endometriosis following a laparoscopic procedure and subsequent histopathological examination. The control group were 50 patients with infertility but without endometriosis. Blood samples were taken and the resulting buffy coat was used to establish lymphocyte cultures. After plating the cells, phytohaemagglutinin (PHA) was added and after 24 hours of incubation, supernatants were collected by centrifugation and subjected to analysis. Results: MIP1a and MIP1b levels in PHA-stimulated lymphocyte cultures from women with endometriosis were elevated when compared to controls, and this difference was highly statistically significant for both cytokines (p = 0.00001 and p = 0.000026, respectively). Additionally, we analyzed the correlation between the occurrence of endometriosis and PHA-stimulated chemokine concentration in lymphocyte culture supernatants. Both MIP1a and MIP1b exhibited a statistical significance with the presence of endometriosis (p = 0.00001). Conclusions: In this study, we observed a significant increase in secretion of selected chemokine factors in in vitro cultures of lymphocytes from women diagnosed with endometriosis. This feature may indicate an essential role for these chemotactic factors in the pathogenesis of endometriosis. To fully understand the influence of MIP1a and MIP1b on disease progression, it will be necessary in future studies to determine chemokine concentrations at each stage of endometriosis.

The microbiome and endometriosis

The objective of this study was to systematically review the literature on the human microbiome in association with endometriosis. PubMed/Medline, Cochrane, and Embase databases were searched for literature published from 1986 to August 2021. All human studies that assessed the microbiome using 16S rRNA sequencing or shotgun sequencing in women with endometriosis were included. Two reviewers independently abstracted data from the selected articles into tables. To assess the quality of included studies, the National Institutes of Health Study Quality Assessment Tools were utilized. This review included 12 case–control studies. Included studies compared the microbiome from various anatomical sources (fecal, vaginal, cervical, peritoneal, endometrial, and intra-lesional) between patients with endometriosis and a heterogeneous set of control patients. Study quality ranged from poor to good, with 8 of 12 studies rated fair. Multiple studies reported a different distribution of bacteria among women with endometriosis across anatomical sites, but the results were highly heterogeneous. Pseudomonas was overrepresented in peritoneal fluid among women with endometriosis across multiple studies but was also observed to be increased in vaginal, endometrial, and intra-lesional samples. Among bacteria noted across different anatomical samples, Gardnerella was found to be increased in cervical but decreased in endometrial, fecal, and vaginal samples of patients with endometriosis, while Atopium was found to be decreased in vaginal and cervical samples from patients with endometriosis. Sphingobium was found to be increased in vagina, endometrium, and peritoneal fluid from patients with endometriosis. Streptococcus was found to be increased in peritoneal, endometrial, and cervical samples from women with endometriosis. Microbiomal comparisons stratified by endometriosis stage or site of endometriosis involvement were limited and highly heterogeneous.Lay summaryThe microbiome, a group of bacteria found in a particular place in the body, has been shown to vary when patients have some diseases, such as cancer or inflammatory bowel disease. Less is known about the microbiome in patients with endometriosis. This review looked at existing studies comparing the bacteria found in patients with endometriosis and others without. Twelve studies were found that assessed the bacteria from swabs collected from different places, including the vagina, cervix, endometrium, peritoneum, feces, and endometriosis lesions themselves. Most of the studies found higher or lower levels of specific bacteria at each of these places, but the findings were often inconsistent. The findings were probably limited by the small numbers of patients involved and variations in the groups studied. More research is needed to find out which bacteria are over- and underrepresented in patients with endometriosis and where they are found.

O-027 Small extracellular vesicle (sEV) protein cargo as potential biomarker for endometriosis

Abstract Study question Can an endometriosis-specific protein signature in small extracellular vesicles (sEV) from peritoneal fluid (PF) be utilised as a non-invasive biomarker of the condition? Summary answer Yes, potentially. We found differences in the concentrations and protein cargo of PF-derived sEV between controls and endometriosis samples, most notably in CD44 expression. What is known already Endometriosis, defined as endometrial-like tissue outside the uterus, causes pain and/or subfertility in 10% of reproductive age women. The cause is unknown, resulting in inadequate diagnostic methods and treatment options. There is no clinically relevant biomarker for endometriosis yet. Small extracellular vesicles (sEV), produced by virtually every cell, have been described in diseases such as cancer, diabetes, and pre-eclampsia, and could similarly be important in endometriosis. We previously identified sEV in PF of women with endometriosis, and here investigated the protein cargo of PF sEV as biomarker of the disease. Study design, size, duration PF samples were obtained from participants in the ENDOX study, Endometriosis CaRe Centre, Nuffield Department of Women’s and Reproductive Health, University of Oxford (REC ref. 09/H0604/58) according to WERF EPHect standards. Women between 18-49 years of age (n = 63) who had undergone diagnostic laparoscopy were classified according to cycle phase (proliferative/secretory/menstrual) and severity of endometriosis (ASRM stages I+II or stages III+IV). Exclusion criteria were hormonal treatment, malignancy, pregnancy, breastfeeding, and inability to understand the consent form. Participants/materials, setting, methods The participant groups were control proliferative, n = 7; control secretory, n = 9; control menstrual, n = 3; StI+II proliferative, n = 8; StI+II secretory, n = 10; St1+II menstrual, n = 7; StIII+IV proliferative, n = 5; StIII+IV secretory, n = 11; StIII+IV menstrual, n = 3. 1 mL PF was centrifuged to remove cells, debris, and microvesicles. sEV were isolated using size exclusion chromatography (SEC) and analysed by nanoparticle tracking analysis (NTA), immunoblotting, and mass spectrometry (LC-MS/MS). Main results and the role of chance We confirmed the presence of exosomes in PF from women at different stages of endometriosis and from disease-free patients at different menstrual cycle phases by NTA, immunoblotting and mass spectrometry. Enriched sEV were positive for ALIX, CD9, and syntenin. The mode size of PF particles from women with endometriosis was 115 ± 15.5 nm, whereas in non-endometriotic women it was 95 ± 17.3 nm (n.s.). sEV concentrations were higher in endometriosis compared to controls, and highest in stage III-IV endometriosis, followed by stage I-II endometriosis and controls, irrespective of menstrual cycle phase (P = 0.0210). sEV concentration in stage III-IV endometriosis decreased consistent with a transition from proliferative to secretory phase. Likewise, PF-derived sEV numbers within stage I-II endometriosis samples increased, as these samples transitioned from proliferative to secretory cycle phases. Proteomic analysis showed distinct distribution patterns of proteins within endometriosis PF-derived sEVs compared to controls. Consistent with earlier studies, we found CD44 as an sEV protein uniquely within the endometriosis population and contributing significantly to the separation of endometriosis and control samples by the highest variable importance projection (VIP) score in our data set. Limitations, reasons for caution The main limitation of this study is the small number of samples across the different groups, and the limited amount of PF per sample. Wider implications of the findings PF-derived sEV differ between endometriosis and control patients. Concentrations vary regardless of cycle phase and disease stage, and this difference appears to be reflected in the proteomics analysis. The presence of CD44 within sEV could help diagnose endometriosis. Trial registration number not applicable