Search Results (18)

Background: Endometrioma recurrence after laparoscopic cystectomy remains a clinical challenge in the long-term management of endometriosis. The Empressin Injection Technique (EIT), which involves the use of a vasopressin analog during surgery, may reduce recurrence by improving the completeness of cyst removal. This study aimed to evaluate the impact of the EIT on recurrence rates compared to standard cystectomy without Empressin. Methods: We conducted a retrospective case–control study of 263 patients who underwent laparoscopic cystectomy for unilateral or bilateral endometriomas between 2014 and 2024 at a tertiary endometriosis referral center. The patients were divided into two groups: EIT (n = 110) and control (n = 153). In the EIT group, 10 mL of diluted Empressin (1 mL in 100 mL NaCl 0.9%) was injected at the cyst capsule–ovarian cortex interface prior to stripping. Demographic and clinical variables were analyzed using descriptive statistics (chi-square test and the Mann–Whitney t-test) and logistic regression to identify factors associated with recurrence between the two groups. Results: No significant differences were found between the groups regarding age, BMI, #ENZIAN O score, or r-ASRM stage. No intraoperative or postoperative complications were reported. Recurrence was significantly lower in the EIT group (5.5%) compared to the control group (19.6%) (p = 0.001; OR 0.2, 95% CI: 0.08–0.55). Hormonal therapy was administered postoperatively in 69.1% of EIT patients and 62.5% of controls. Pregnancy rates were comparable between the groups. Repeat surgery for recurrence was required only in the control group (4.2%, p = 0.004). Conclusions: Use of Empressin during laparoscopic cystectomy significantly reduces endometrioma recurrence without adverse effects, particularly when combined with postoperative hormonal therapy. Full article

Background: Endometriosis is a chronic, estrogen-dependent inflammatory disease affecting up to 10% of women of reproductive age. It substantially impacts quality of life (QoL) through pelvic pain, infertility, and psychological distress. Increasing attention has been directed toward patient-reported outcomes and validated QoL instruments, which are essential for understanding the burden of disease and guiding individualized management. Materials and Methods: We performed a narrative review of the literature published in the last five years in PubMed, Scopus, Web of Science, and Cochrane Library, focusing on validated QoL instruments, fertility indices, and clinical outcomes after minimally invasive surgery (MIS) for deep infiltrating endometriosis (DIE). Discussions: The most widely used QoL instruments are the Endometriosis Health Profile-30 (EHP-30), Short Form-36 (SF-36), and EQ-5D, each providing multidimensional evaluation across physical, psychological, and social domains. Fertility-related prognosis is assessed with the Endometriosis Fertility Index (EFI), while staging of disease severity relies on rASRM and #ENZIAN classifications. Evidence from comparative and cohort studies suggests that both laparoscopic and robotic MIS can improve QoL and reproductive outcomes; however, the magnitude of benefit varies across studies, patient phenotypes, and follow-up periods. Conclusions: MIS is an increasingly used therapeutic option for DIE, with growing evidence of improvement in pain and QoL, but current data remain heterogeneous and do not uniformly support superiority over other approaches. Routine incorporation of validated QoL instruments and fertility indices into both clinical practice and research is essential to better stratify patients, support shared decision-making, and optimize long-term outcomes. Full article

Aim: The aim of the study was to synthesize validated patient-reported outcome measures (PROMs) for assessing health-related quality of life (HRQoL) in women with endometriosis and to outline their clinical implications. Methods: We conducted a narrative review of English-language literature indexed in PubMed, Scopus, Web of Science, and Cochrane Library, covering the period 2014–2024, with earlier seminal studies included where relevant. We focused on validated PROMs for QoL but also considered standardized tools such as the Endometriosis Fertility Index (EFI), rASRM, and #Enzian classifications, given their role in clinical interpretation and counseling. Findings: Generic instruments (SF-36, WHOQOL-BREF, EQ-5D), disease-specific tools (EHP-30, EHP-5), and fertility-related questionnaires (FertiQoL, FPI) have demonstrated validity and responsiveness; however, these are inconsistently applied in practice. Knowledge gaps remain regarding routine implementation, timing, and frequency of assessment, and integration with clinical staging or fertility indices (e.g., EFI). Global frameworks such as the WERF EPHect platform facilitate standardized clinical and surgical data capture, though their use is primarily in research rather than routine care. Conclusions: We recommend combining a disease-specific PROM (EHP-30/EHP-5) with a generic instrument (SF-36 or EQ-5D) and adding FertiQoL when fertility is relevant. PROMs should be collected longitudinally (baseline, post-intervention, follow-up) and interpreted alongside clinical context, including pain phenotype, surgical staging (#Enzian/rASRM), and fertility goals. Embedding PROMs into multidisciplinary pathways enables shared decision-making, individualized treatment planning, and improved comparability of patient-centered outcomes. Full article

Endometriosis, a prevalent gynecological condition affecting 10–15% of reproductive-age women, involves the growth of endometrial-like tissue outside the uterine cavity. This chronic inflammatory disease can significantly impact fertility by disrupting ovulation, tubal transport, and implantation. Clinical manifestations vary widely, ranging from asymptomatic cases to severe pelvic pain, dysmenorrhea, and dyspareunia. Accurate diagnosis remains challenging, often requiring a combination of patient history, clinical examination, and imaging studies. This paper will discuss the clinical approach to endometriosis during a first-line gynecological appointment, focusing on patient history, including detailed assessment of menstrual, pelvic, and bowel symptoms, and clinical examination; thorough gynecological examination, including abdominal and pelvic palpation, speculum examination, and bimanual examination; imaging evaluation (particularly of the role of ultrasound in identifying and characterizing endometriotic lesions, including the use of the #ENZIAN classification for deep infiltrating endometriosis and evaluation of fertility impact); and discussion of the Endometriosis Fertility Index (EFI) as a tool for assessing fertility potential. This comprehensive approach aims to guide clinicians in identifying and managing endometriosis effectively, improving patient outcomes and optimizing fertility management strategies. Methods: A literature search for suitable articles published from January 1974 to 2024 in the English language was performed using PubMed. Results: Endometriosis is associated with infertility rates ranging from 20% to 68%, with mechanisms including pelvic adhesions, chronic inflammation, and immune dysregulation. The revised American Society for Reproductive Medicine (rASRM) classification and #ENZIAN classification were identified as essential tools for staging and characterizing the disease. Transvaginal ultrasound (TVS) demonstrated high diagnostic accuracy for deep infiltrating endometriosis, with a sensitivity of up to 96% and specificity of 99%. EFI emerged as a valuable predictor of natural conception post-surgery. Additionally, the review underscores the frequent co-occurrence of adenomyosis in women with endometriosis, which may further compromise fertility. Despite advancements in imaging techniques and classification systems, the variability in symptom presentation and disease progression continues to challenge early diagnosis and effective management. Conclusions: Endometriosis is a prevalent gynecological condition affecting women of reproductive age and is associated with infertility. This paper describes the diagnostic approach to endometriosis during a first-line gynecological appointment, focusing on clinical history, physical examination, and the role of imaging, particularly ultrasound, in identifying and characterizing endometriosis lesions. The adoption of standardized classification systems such as #ENZIAN and EFI enhances disease staging and fertility prognosis, allowing for tailored treatment strategies. Despite improvements in non-invasive diagnostic methods, challenges persist in correlating symptom severity with disease extent, necessitating continued research into biomarkers and novel imaging techniques. Additionally, the frequent coexistence of adenomyosis further complicates fertility outcomes, underscoring the need for comprehensive management strategies. Further research is needed to enhance early detection strategies and optimize fertility preservation techniques for affected women. Full article

Background/Objectives: Chronic inflammation plays a critical role in pelvic pain among endometriosis patients. This study examines the association between inflammatory markers—specifically the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR)—and pelvic pain in endometriosis. Methods: We conducted a retrospective analysis of endometriosis patients, assessing NLR and PLR levels in those with and without pelvic pain. Diagnostic utility was evaluated using ROC curves, and logistic regression determined associations between these markers, pain presence, and endometriosis severity. Results: Patients with pelvic pain had significantly higher median levels of both NLR and PLR (p < 0.05). NLR demonstrated moderate diagnostic accuracy with an AUC of 0.63, sensitivity of 59%, and specificity of 71% at a cut-off of 1.85. PLR, with a cut-off of 139.77, showed an AUC of 0.60, with a specificity of 82% and sensitivity of 40%, indicating better utility for excluding pain. Logistic regression analysis revealed that NLR > 1.85 was significantly associated with pelvic pain (OR = 3.06, 95% CI: 1.45–6.49, p = 0.003), as was PLR > 139.77 (OR = 2.84, 95% CI: 1.18–6.82, p = 0.02). Advanced rASRM stages (III and IV) also correlated with elevated NLR and PLR values. Conclusions: Elevated NLR and PLR are associated with pelvic pain and advanced stages of endometriosis, suggesting these ratios are potential markers for assessing inflammation and disease severity. Further studies should explore combining NLR and PLR with other biomarkers to improve diagnostic accuracy in endometriosis. Full article

Objectives: To determine the association between ovarian endometriomas and stage of endometriosis. Methods: A total of 222 women aged 18–55 years old, who underwent minimally invasive surgery between January 2016 and December 2021 for treatment of endometriosis were included in the study. Patients underwent laparoscopic and/or robotic treatment of endometriosis by a single surgeon (FRN) and were staged using the ASRM revised classification of endometriosis. Pre-operative imaging studies, and operative and pathology reports were reviewed for the presence of endometriomas and the final stage of endometriosis. Using univariate analyses for categorical variables and the two-sample t-test or Mann–Whitney test for continuous data, association between endometriomas, stage of endometriosis, type of endometrioma, and other patient parameters such as age, gravidity, parity, laterality of endometriomas, prior medical treatment, and indication for surgery was analyzed. Results: Of the 222 patients included in the study, 86 patients had endometrioma(s) and were found to have stage III–IV disease. All 36 patients with bilateral endometriomas and 70% of patients with unilateral endometriomas had stage IV disease. Conclusions: The presence of ovarian endometrioma(s) indicates a higher stage of disease, correlating most often with stage IV endometriosis. Understanding the association between endometriomas and anticipated stage of disease can aid in appropriate pre-operative planning and patient counseling. Full article

Background and Objectives: Oral contraceptives (OCs) are usually used to treat endometriosis; however, the evidence is inconsistent about whether OC use in the past, when given to asymptomatic women, is protective against the development of future disease. We aimed to assess the relationship between the use of OCs and the likelihood of discovering endometriosis, considering the length of time under OCs during their fertile age. Materials and Methods: This was a monocentric retrospective cohort study in a tertiary-care University Hospital (Department of Human Reproduction, Division of Gynaecology and Obstetrics, University Medical Centre Ljubljana, Slovenia) carried out from January 2012 to December 2022. Reproductive-aged women scheduled for laparoscopic surgery for primary infertility and subsequent histopathological diagnosis of endometriosis were compared to women without an endometriosis diagnosis. They were classified based on the ratio of years of OC use to fertile years in four subgroups: never, <25%, between 25 and 50%, and >50. Results: In total, 1923 women (390 with and 1533 without endometriosis) were included. Previous OC use was higher in those with endometriosis than controls (72.31% vs. 58.64%; p = 0.001). Overall, previous OC usage was not related to histopathological diagnosis of endometriosis (aOR 1.06 [95% CI 0.87–1.29]). Women who used OCs for less than 25% of their fertile age had reduced risk of rASRM stage III endometriosis (aOR 0.50 [95% CI 0.26–0.95]; p = 0.036) or superficial implants (aOR 0.88 [95% CI 0.58–0.95]; p = 0.040). No significant results were retrieved for other rASRM stages. Using OCs for <25%, between 25 and 50%, or >50% of fertile age did not increase the risk of developing superficial endometriosis, endometriomas, or DIE. Conclusions: When OCs are used at least once, histological diagnoses of endometriosis are not increased. A protective effect of OCs when used for less than 25% of fertile age on superficial implants may be present. Prospective research is needed to corroborate the findings due to constraints related to the study’s limitations. Full article

Both endometriosis and ovarian dermoid cysts are benign conditions characterized by the presence of well-differentiated tissues in ectopic locations. The presence and surgical excision of these entities can potentially impact ovarian reserves, contributing to reduced chances of future pregnancy. The objective of our study is to investigate the bidirectional association between endometriosis and ovarian dermoid cysts, as well as to analyze the clinical characteristics of patients diagnosed with both conditions. A retrospective cohort study was conducted, including women who underwent laparoscopy and received histological diagnoses of endometriosis and/or dermoid cysts between 2011 and 2019 at the Cantonal Hospital of Schaffhausen. We identified 985 women with endometriosis and 83 women with ovarian dermoid cysts. Among these groups, 22 women presented with both endometriosis and ovarian dermoid cysts. The majority of the above patients had endometriosis stage rASRM I-II (72.7%), with peritoneal endometriosis being the most common phenotype of endometriosis (77.2%). Out of the 14 patients with a desire for future pregnancy, the majority (11/14, 78.5%) had an EFI score of 7–8. The prevalence of bilateral ovarian dermoid cysts was higher in women with both ovarian dermoid cysts and endometriosis in comparison to women with ovarian dermoid cysts without endometriosis (18% vs. 6.5%). Our study revealed that 26.5% of women with ovarian dermoid cysts also had endometriosis, a notably higher prevalence than observed in the general population. Clinicians should be aware of this co-existence, and preoperative counseling should be an integral part of the care plan for affected individuals, where the potential risks and the available options for fertility preservation should be discussed in detail. Full article

This study aims to evaluate the role of endometriosis family history on the clinical manifestation and fertility performance of primary and recurrent endometriosis. In total, 312 primary and 323 recurrent endometrioma patients with a histological diagnosis were included in this study. Family history was significantly correlated with recurrent endometriosis (adjusted OR: 3.52, 95% CI: 1.09–9.46, p = 0.008). Patients with a family history showed a significantly higher proportion of recurrent endometriosis (75.76% vs. 49.50%), higher rASRM scores, higher incidence of severe dysmenorrhea, and severe pelvic pain than the sporadic cases. Recurrent endometrioma showed statistical increase in rASRM scores, percentage of rASRM Stage IV, dysmenorrhea, dyschezia, those undergoing semi-radical surgery or unilateral oophorosalpingectomy, postoperative medical treatment, e with a positive family history, while a decrease in the incidence of asymptomatic phenomena and those undergoing ovarian cystectomy compared to those with primary endometriosis. The naturally conceived pregnancy rate was higher in primary endometriosis compared to recurrent endometriosis. Compared to recurrent endometriosis with a negative family history, recurrent endometriosis with a positive family history had a higher incidence of severe dysmenorrhea, chronic pelvic pain, a higher spontaneous abortion rate, and a lower natural pregnancy rate. Primary endometriosis with a family history presented a higher incidence of severe dysmenorrhea than those without a family history. In conclusion, endometriosis patients with a positive family history presented a higher pain severity and lower conception probability compared to the sporadic cases. Recurrent endometriosis showed further-exacerbated clinical manifestations, more pronounced familial tendency, and lower pregnancy rates than primary endometriosis. Full article

Background: The early diagnosis of endometriosis in adolescents is not developed. Objective: We aim to conduct clinical, imaging, laparoscopic and histological analyses of peritoneal endometriosis (PE) in adolescents in order to improve early diagnosis. Methods: In total, 134 girls (from menarche to 17 years old) were included in a case–control study: 90 with laparoscopically (LS) confirmed PE, 44 healthy controls underwent full examination and LS was analyzed in the PE group. Results: Patients with PE were characterized with heredity for endometriosis, persistent dysmenorrhea, decreased daily activity, gastrointestinal symptoms, higher LH, estradiol, prolactin and Ca-125 (<0.05 for each). Ultrasound detected PE in 3.3% and MRI in 78.9%. The most essential MRI signs are as follows: hypointense foci, the heterogeneity of the pelvic tissue (paraovarian, parametrial and rectouterine pouch) and sacro-uterine ligaments lesions (<0.05 for each). Adolescents with PE mostly exhibit initial rASRM stages. Red implants correlated with the rASRM score, and sheer implants correlated with pain (VAS score) (<0.05). In 32.2%, foci consisted of fibrous, adipose and muscle tissue; black lesions were more likely to be histologically verified (0.001). Conclusion: Adolescents exhibit mostly initial PE stages, which are associated with greater pain. Persistent dysmenorrhea and detected MRI parameters predict the laparoscopic confirmation of initial PE in adolescents in 84.3% (OR 15.4; <0.01), justifying the early surgical diagnostics and shortening the time delay and suffering of the young patients. Full article

Endometriosis is a common gynaecological disease, causing symptoms such as pelvic pain and infertility. Accurate diagnosis and assessment are often challenging. Transvaginal ultrasound (TVS), along with magnetic resonance imaging (MRI), are the most common imaging modalities. In this narrative review, we present the evidence behind the role of TVS in the diagnosis and assessment of endometriosis. We recognize three forms of endometriosis: Ovarian endometriomas (OMAs) can be adequately assessed by transvaginal ultrasound. Superficial peritoneal endometriosis (SUP) is challenging to diagnose by either imaging modality. TVS, in the hands of appropriately trained clinicians, appears to be non-inferior to MRI in the diagnosis and assessment of deep infiltrating endometriosis (DIE). The IDEA consensus standardized the terminology and offered a structured approach in the assessment of endometriosis by ultrasound. TVS can be used in the non-invasive staging of endometriosis using the available classification systems (rASRM, #ENZIAN). Given its satisfactory overall diagnostic accuracy, wide availability, and low cost, it should be considered as the first-line imaging modality in the diagnosis and assessment of endometriosis. Modifications to the original ultrasound technique can be employed on a case-by-case basis. Improved training and future advances in ultrasound technology are likely to further increase its diagnostic performance. Full article

This study’s objective was to compare the predictive validity of the three most utilized classification scores for endometriosis, #Enzian, EFI, and rASRM, in achieving a spontaneous pregnancy or pregnancy via assisted reproductive technology (ART) after surgery for endometriosis. The monocentric retrospective study was carried out from January 2012 to December 2021 at the gynaecology department of the cantonal hospital of Fribourg. Patients consulting for infertility and operated on for endometriosis with histological confirmation were included. The predictive value of #Enzian, rASRM, and EFI was evaluated and compared concerning the prediction of fertility after surgery, both spontaneous and ART, during the following 12 months. A total of 58 women (mean age 33.1 ± 4.57 years) were included. Overall, 30 women achieved a pregnancy, seven spontaneously. Among all women who achieved a pregnancy, there was a lower prevalence of rASRM stage III–IV (16.67% vs. 39.29%, p = 0.054). Women achieving a pregnancy had a significantly higher EFI score than others (p < 0.05). No significant differences were observed concerning the #Enzian score. In conclusion, the revised #Enzian score is not correlated with pregnancy achievement; EFI score is the only score significantly associated with the pregnancy outcome in women affected by endometriosis. Full article

Approximately 10% (176 million) of women of reproductive age worldwide suffer from endometriosis, which has a high rate of postoperative recurrence. The objective of this study was to investigate the risk factors of severe endometriosis and establish a preoperative prediction model. A retrospective analysis of a database established between January 2020 and March 2022 including 491 women with a pathology-based endometriosis diagnosis was conducted. Subjects were divided into two groups: the non-severe group (ASRM ≤ 40) and the severe group (ASRM > 40). Age ≥ 40 years, bilateral lesions, pelvic nodules, adenomyosis, APTT, CA125 ≥ 34.5 U/mL, D-dimer ≥ 0.34 mg/L, and maximum cyst diameter ≥ 58 mm were independent correlation factors for severe endometriosis. The logistic regression equation for these factors showed good diagnostic efficiency (AUC = 0.846), which was similar to the model with intraoperative indicators (AUC = 0.865). Patients with severe endometriosis also had a shorter APTT and higher D-dimer and PLT, indicating hypercoagulability. In conclusion, we constructed a simple and feasible formula involving parameters that are preoperatively accessible to predict the severity of endometriosis. This study is of reference value for determining the timing of and alternatives to surgery. At the same time, attention should be paid to the primary prevention of venous thrombosis and cardiovascular metabolic diseases in patients with severe endometriosis. Full article

Endometriosis seems to have a strong negative effect on female fertility. The aim of this study was to assess the rate of tubal occlusion diagnosed via laparoscopic chromopertubation in infertile women with endometriosis and compare the results to infertile women without endometriosis. In this retrospective cohort study, 275 infertile women with endometriosis and 49 infertile women without endometriosis undergoing diagnostic laparoscopy for primary or secondary infertility with chromopertubation at the Medical University of Vienna between January 2012 and December 2020 have been investigated. During the laparoscopic assessment of tubal patency, significantly more fallopian tubes were occluded in the endometriosis group compared to the control group (25.8 versus 15.3%; p = 0.029). Unilateral and bilateral occlusion was found significantly more often in patients with endometriosis (p = 0.021). In the multivariate analysis, only the rASRM stage (the revised classification of endometriosis by the American Society for Reproductive Medicine) showed a significant association with bilateral occlusion (OR 1.400, 95%CI: 1.018–1.926; p = 0.038). Both a higher rASRM stage (OR 2.181, 95%CI: 1.191–3.995; p = 0.012) and secondary infertility (OR 1.514, 95%CI: 1.156–1.983; p = 0.003) were associated with an increased risk for any kind of fallopian tube occlusion. Endometriosis seems to be associated with an increased risk for fallopian tube occlusion. The rate of tubal occlusion increased significantly with the rASRM stage. Full article

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. Full article