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Alson S, Henic E, Jokubkiene L, Sladkevicius P. Endometriosis diagnosed by ultrasound is associated with lower live birth rates in women undergoing their first in vitro fertilization/intracytoplasmic sperm injection treatment. Fertil Steril 2024; 121:832-841. [PMID: 38246403 DOI: 10.1016/j.fertnstert.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/09/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024]
Abstract
OBJECTIVE To study the cumulative live birth rate (CLBR) after the first in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment in women with or without deep-infiltrating endometriosis (DIE) and/or endometrioma diagnosed by transvaginal ultrasonography (TVUS), using the International Deep Endometriosis Analysis (IDEA) group definitions. DESIGN Prospective observational cohort study at a university hospital. PATIENTS(S) In total, 1,040 women with subfertility aged 25 to ≤39 years were undergoing their first IVF/ICSI treatment between January 2019 and October 2022. Of these, 234 (22.5%; 95% confidence interval [CI], 20.0-25.0) women were diagnosed with DIE and/or endometrioma at systematic TVUS before starting their treatment. INTERVENTION(S) All women underwent their first IVF or ICSI treatment. Fresh and/or frozen embryos from the first cycle were used until pregnancy was achieved or no embryos remained. MAIN OUTCOME MEASURE(S) Cumulative live birth rate after the first IVF/ICSI cycle in women with or without DIE and/or endometrioma. RESULT(S) The CLBR after the first IVF/ICSI treatment in the total cohort of women was 426/1,040 (41.0%; 95% CI, 38.0-44.0). Women with DIE and/or endometrioma had a lower CLBR (78/234, 33.3%; 95% CI, 27.3-39.4) than women without the disease (348/806, 43.2%; 95% CI, 39.8-46.6). The crude relative risk (RR) for cumulative live birth for women with DIE and/or endometrioma was 0.77; 95% CI, 0.63-0.94, and after adjustments were made for age, body mass index, s-antimüllerian hormone, stimulation protocol, and day for embryo transfer, the adjusted RR was 0.63; 95% CI, 0.48-0.82. There was no difference in the number of retrieved mature oocytes, fertilization rate, or good quality embryos between the 2 groups. CONCLUSION The presence of DIE and/or endometrioma diagnosed by TVUS lowers the chance of live birth in women undergoing their first IVF/ICSI treatment.
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Affiliation(s)
- Sara Alson
- Obstetric, Gynecological and Prenatal Ultrasound research, Department of Clinical Sciences, Malmö, Lund University, Sweden; Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden; Reproductive Medicine Center, Skåne University Hospital, Malmö, Sweden.
| | - Emir Henic
- Reproductive Medicine Center, Skåne University Hospital, Malmö, Sweden; Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Ligita Jokubkiene
- Obstetric, Gynecological and Prenatal Ultrasound research, Department of Clinical Sciences, Malmö, Lund University, Sweden; Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
| | - Povilas Sladkevicius
- Obstetric, Gynecological and Prenatal Ultrasound research, Department of Clinical Sciences, Malmö, Lund University, Sweden; Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
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Singh SS, Allaire C, Al-Nourhji O, Bougie O, Bridge-Cook P, Duigenan S, Kroft J, Lemyre M, Leonardi M, Leyland N, Maheux-Lacroix S, Wessels J, Wahl K, Yong PJ. Guideline No. 449: Diagnosis and Impact of Endometriosis - A Canadian Guideline. J Obstet Gynaecol Can 2024; 46:102450. [PMID: 38555044 DOI: 10.1016/j.jogc.2024.102450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
OBJECTIVE To provide a contemporary approach to the understanding of the impact and methods for the diagnosis of endometriosis in Canada. TARGET POPULATION Individuals, families, communities, health care providers, and health care administrators who are affected by, care for patients with, or manage delivery of services for endometriosis. OPTIONS The diagnosis of endometriosis is facilitated by a detailed history, examination, and imaging tests with providers who are experienced in endometriosis care. Surgical evaluation with pathology confirms a diagnosis of endometriosis; however, it is not required for those whose diagnosis was confirmed with imaging. OUTCOMES There is a need to address earlier recognition of endometriosis to facilitate timely access to care and support. Education directed at the public, affected individuals and families, health care providers, and health care administrators are essential to reduce delays in diagnosis and treatment. BENEFITS, HARMS, AND COSTS Increased awareness and education about the impact and approach to diagnosis may support timely access to care for patients and families affected by endometriosis. Earlier and appropriate care may support a reduced health care system burden; however, improved clinical evaluation may require initial investments. EVIDENCE Each section was reviewed with a unique search strategy representative of the evidence available in the literature related to the area of focus. The literature searches for each section of this guideline are listed in Appendix A and include information from published systematic reviews described in the text. VALIDATION METHODS The recommendations were developed following two rounds of review by a national expert panel through an iterative 2-year consensus process. Further details on the process are shared in Appendix B. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix C (Table C1 for definitions and Table C2 for interpretations of strong and conditional recommendations). INTENDED AUDIENCE This guideline is intended to support health care providers and policymakers involved in the care of those impacted by endometriosis and the systems required to support them. TWEETABLE ABSTRACT Endometriosis impact and diagnosis updated guidelines for Canadian health care providers and policymakers. SUMMARY STATEMENTS RECOMMENDATIONS.
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Singh SS, Allaire C, Al-Nourhji O, Bougie O, Bridge-Cook P, Duigenan S, Kroft J, Lemyre M, Leonardi M, Leyland N, Maheux-Lacroix S, Wessels J, Wahl K, Yong PJ. Directive clinique n o 449 : Directive canadienne sur le diagnostic et les impacts de l'endométriose. J Obstet Gynaecol Can 2024; 46:102451. [PMID: 38555045 DOI: 10.1016/j.jogc.2024.102451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
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Avery JC, Deslandes A, Freger SM, Leonardi M, Lo G, Carneiro G, Condous G, Hull ML. Noninvasive diagnostic imaging for endometriosis part 1: a systematic review of recent developments in ultrasound, combination imaging, and artificial intelligence. Fertil Steril 2024; 121:164-188. [PMID: 38101562 DOI: 10.1016/j.fertnstert.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023]
Abstract
Endometriosis affects 1 in 9 women and those assigned female at birth. However, it takes 6.4 years to diagnose using the conventional standard of laparoscopy. Noninvasive imaging enables a timelier diagnosis, reducing diagnostic delay as well as the risk and expense of surgery. This review updates the exponentially increasing literature exploring the diagnostic value of endometriosis specialist transvaginal ultrasound (eTVUS), combinations of eTVUS and specialist magnetic resonance imaging, and artificial intelligence. Concentrating on literature that emerged after the publication of the IDEA consensus in 2016, we identified 6192 publications and reviewed 49 studies focused on diagnosing endometriosis using emerging imaging techniques. The diagnostic performance of eTVUS continues to improve but there are still limitations. eTVUS reliably detects ovarian endometriomas, shows high specificity for deep endometriosis and should be considered diagnostic. However, a negative scan cannot preclude endometriosis as eTVUS shows moderate sensitivity scores for deep endometriosis, with the sonographic evaluation of superficial endometriosis still in its infancy. The fast-growing area of artificial intelligence in endometriosis detection is still evolving, but shows great promise, particularly in the area of combined multimodal techniques. We finalize our commentary by exploring the implications of practice change for surgeons, sonographers, radiologists, and fertility specialists. Direct benefits for endometriosis patients include reduced diagnostic delay, better access to targeted therapeutics, higher quality operative procedures, and improved fertility treatment plans.
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Affiliation(s)
- Jodie C Avery
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.
| | - Alison Deslandes
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Shay M Freger
- Department of Obstetrics and Gynecology McMaster University, Hamilton, ON, Canada
| | - Mathew Leonardi
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Department of Obstetrics and Gynecology McMaster University, Hamilton, ON, Canada
| | - Glen Lo
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| | - Gustavo Carneiro
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Centre for Vision, Speech and Signal Processing (CVSSP), School of Computer Science and Electronic Engineering, University of Surrey, Guildford, United Kingdom
| | - G Condous
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Gynaecology Department, Omni Ultrasound and Gynaecological Care, Sydney, New South Wales, Australia
| | - Mary Louise Hull
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Gynaecology Department, Embrace Fertility, Adelaide, South Australia, Australia
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Avery JC, Knox S, Deslandes A, Leonardi M, Lo G, Wang H, Zhang Y, Holdsworth-Carson SJ, Thi Nguyen TT, Condous GS, Carneiro G, Hull ML. Noninvasive diagnostic imaging for endometriosis part 2: a systematic review of recent developments in magnetic resonance imaging, nuclear medicine and computed tomography. Fertil Steril 2024; 121:189-211. [PMID: 38110143 DOI: 10.1016/j.fertnstert.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 12/20/2023]
Abstract
Endometriosis affects 1 in 9 women, taking 6.4 years to diagnose using conventional laparoscopy. Non-invasive imaging enables timelier diagnosis, reducing diagnostic delay, risk and expense of surgery. This review updates literature exploring the diagnostic value of specialist endometriosis magnetic resonance imaging (eMRI), nuclear medicine (NM) and computed tomography (CT). Searching after the 2016 IDEA consensus, 6192 publications were identified, with 27 studies focused on imaging for endometriosis. eMRI was the subject of 14 papers, NM and CT, 11, and artificial intelligence (AI) utilizing eMRI, 2. eMRI papers describe diagnostic accuracy for endometriosis, methodologies, and innovations. Advantages of eMRI include its: ability to diagnose endometriosis in those unable to tolerate transvaginal endometriosis ultrasound (eTVUS); a panoramic pelvic view, easy translation to surgical fields; identification of hyperintense iron in endometriotic lesions; and ability to identify super-pelvic lesions. Sequence standardization means eMRI is less operator-dependent than eTVUS, but higher costs limit its role to a secondary diagnostic modality. eMRI for deep and ovarian endometriosis has sensitivities of 91-93.5% and specificities of 86-87.5% making it reliable for surgical mapping and diagnosis. Superficial lesions too small for detection in larger capture sequences, means a negative eMRI doesn't exclude endometriosis. Combined with thin sequence capture and improved reader expertise, eMRI is poised for rapid adoption into clinical practice. NM labeling is diagnostically limited in absence of suitable unique marker for endometrial-like tissue. CT studies expose the reproductively aged to radiation. AI diagnostic tools, combining independent eMRI and eTVUS endometriosis markers, may result in powerful capability. Broader eMRI use, will optimize standards and protocols. Reporting systems correlating to surgical anatomy will facilitate interdisciplinary preoperative dialogues. eMRI endometriosis diagnosis should reduce repeat surgeries with mental and physical health benefits for patients. There is potential for early eMRI diagnoses to prevent chronic pain syndromes and protect fertility outcomes.
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Affiliation(s)
- Jodie C Avery
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.
| | - Steven Knox
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Benson Radiology, Adelaide, Australia
| | - Alison Deslandes
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Mathew Leonardi
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Department of Obstetrics and Gynecology McMaster University, Hamilton, Canada
| | - Glen Lo
- Curtin University Medical School Perth, Australia
| | - Hu Wang
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Australian Institute for Machine Learning, University of Adelaide, Australia
| | - Yuan Zhang
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Australian Institute for Machine Learning, University of Adelaide, Australia
| | - Sarah Jane Holdsworth-Carson
- Julia Argyrou Endometriosis Centre, Epworth HealthCare, Richmond, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Australia
| | - Tran Tuyet Thi Nguyen
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Embrace Fertility, Adelaide, Australia
| | - George Stanley Condous
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Omni Ultrasound and Gynaecological Care, Sydney Australia, (j)Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Australia
| | - Gustavo Carneiro
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; University of Surrey, Guildford, United Kingdom
| | - Mary Louise Hull
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Embrace Fertility, Adelaide, Australia
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Bourdon M, Maignien C, Giraudet G, Estrade JP, Indersie E, Solignac C, Arbo E, Roman H, Chapron C, Santulli P. Investigating the medical journey of endometriosis-affected women: Results from a cross-sectional web-based survey (EndoVie) on 1,557 French women. J Gynecol Obstet Hum Reprod 2024; 53:102708. [PMID: 38097043 DOI: 10.1016/j.jogoh.2023.102708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE To investigate the medical journey and the quality of life of French endometriosis-affected women, from the onset of the symptoms to the therapeutic management. STUDY DESIGN Between January 15th 2020 and February 3rd 2020, a prospective cross-sectional web-based survey was conducted among women diagnosed with endometriosis. The questionnaire included 52 questions distributed in five sections (screening, sociodemographic characteristics, impacts on quality of life, SF36 questionnaire, management of endometriosis and proposals for care improvement). RESULTS One thousand five hundred fifty-seven endometriosis-affected women aged of 42±12.8 years answered the questionnaire. On average, 7 years elapsed between the first symptoms (at 23.8 ± 10.2 years) and the diagnosis (31.0 ± 8.9 years). The mean number of symptoms was 4.6 ± 2.3, with 82 % of women experiencing pain scores between 7 and 10/10. Following diagnosis, 66 % women received a medical treatment, mostly hormonal treatments (45 %), with a significant decrease in pain intensity (VAS scores after treatment = 4.9 ± 2.7, p < 0.001). Most women (62 %) had already been operated, among whom 22 % by laparotomy. Finally, patients reported numerous impacts on their daily lives, particularly on the sexual, psychological, and physical fields. The overall mean score of quality of life was 4.3 ± 2.6 /10. CONCLUSION This large prospective web-based survey underlines that the journey of women with endometriosis is long and difficult until diagnosis and efficient treatment. It emphasizes the urgent need to reduce the diagnostic delay and thereby the burden of endometriosis on women's lives. Moreover, the creation of referral multidisciplinary centers appears to be crucial to improve the management of the disease.
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Affiliation(s)
- Mathilde Bourdon
- Université de Paris-Cité, Faculté de Santé, Faculté de Médecine Paris Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paris Centre, Centre Hospitalier Universitaire Cochin, Service de Gynécologie-Obstétrique II et de Médecine de la Reproduction, Paris, France; Université de Paris, Department of Infection, Immunity, Inflammation, INSERM U1016, Institut Cochin, Paris, France
| | - Chloé Maignien
- Université de Paris-Cité, Faculté de Santé, Faculté de Médecine Paris Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paris Centre, Centre Hospitalier Universitaire Cochin, Service de Gynécologie-Obstétrique II et de Médecine de la Reproduction, Paris, France
| | | | - Jean-Philippe Estrade
- Department of Gynecological Surgery, Hôpital Privé de Provence, Aix-en-Provence, France
| | - Emilie Indersie
- French Association for Endometriosis EndoFrance, Gaillac, France
| | | | | | - Horace Roman
- Endometriosis Center, Clinique Tivoli-Ducos, IFEMEndo, Bordeaux, France
| | - Charles Chapron
- Université de Paris-Cité, Faculté de Santé, Faculté de Médecine Paris Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paris Centre, Centre Hospitalier Universitaire Cochin, Service de Gynécologie-Obstétrique II et de Médecine de la Reproduction, Paris, France
| | - Pietro Santulli
- Université de Paris-Cité, Faculté de Santé, Faculté de Médecine Paris Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paris Centre, Centre Hospitalier Universitaire Cochin, Service de Gynécologie-Obstétrique II et de Médecine de la Reproduction, Paris, France; Université de Paris, Department of Infection, Immunity, Inflammation, INSERM U1016, Institut Cochin, Paris, France.
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Gete DG, Doust J, Mortlock S, Montgomery G, Mishra GD. Associations between endometriosis and common symptoms: findings from the Australian Longitudinal Study on Women's Health. Am J Obstet Gynecol 2023; 229:536.e1-536.e20. [PMID: 37499990 DOI: 10.1016/j.ajog.2023.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/28/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Endometriosis has been linked to higher rates of a variety of symptoms; however, the findings from longitudinal studies are scarce and inconsistent. OBJECTIVE This study aimed to examine the association between endometriosis and common symptoms in a prospective cohort study. STUDY DESIGN This study included 7606 women born from 1973 to 1978 using data from the Australian Longitudinal Study on Women's Health that were collected every 3 years from 2009 to 2018. We identified women with endometriosis based on self-reported incidence from each survey and linked administrative health data. At each survey, women also completed a checklist on the presence of 24 symptoms. Generalized estimating equations for multinomial responses were used for analyses. RESULTS Women with endometriosis had significantly more menstrual symptoms than those without endometriosis with an adjusted odds ratio (95% confidence interval) of 3.61 (3.11-4.19) for severe period pain, 2.40 (2.10-2.74) for heavy menstrual bleeding, 1.76 (1.52-2.03) for irregular bleeding, and 1.52 (1.32-1.76) for premenstrual tension. They also had higher odds of mental health problems with adjusted odds ratios of 1.67 (1.39-2.01) for depression and 1.59 (1.24-2.03) for anxiety and higher odds of allergies and nonspecific symptoms with adjusted odds of 1.62 (1.40-1.89) for allergies or hay fever or sinusitis, 1.79 (1.56-2.05) for severe tiredness, 1.56 (1.35-1.81) for sleep difficulty, and 1.77 (1.37-2.18) for palpitations. There was also a strong association with other forms of pain with an adjusted odds ratio of 1.76 (1.53-2.04) for backpain, 1.50 (1.29-1.74) for headaches or migraines, and 1.65 (1.41-1.93) for stiff or painful joints. Women with endometriosis also had increased odds of developing bowel and urinary symptoms with an adjusted odds ratio (95% confidence interval) of 1.67 (1.35-2.08) for constipation, 1.46 (1.12-1.90) for hemorrhoids or piles, 1.25 (1.03-1.52) for indigestion or heartburn, 2.80 (1.71-4.58) for urine burn or stings, and 1.37 (1.03-1.82) for vaginal discharge or irritation. The association between each symptom and endometriosis was similar whether endometriosis was surgically confirmed or clinically suspected. No association was found between endometriosis and the risk for skin problems, leaking urine, or breathing difficulty. CONCLUSION This study suggests that women with endometriosis are more likely to report not only menstrual symptoms but are also at an increased risk for mental health problems, other pain symptoms, bowel and urinary symptoms, and nonspecific symptoms, such as severe tiredness and difficulty sleeping.
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Affiliation(s)
- Dereje G Gete
- Australian Woman and Girls' Health Research Centre, School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jenny Doust
- Australian Woman and Girls' Health Research Centre, School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Sally Mortlock
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia
| | - Grant Montgomery
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia
| | - Gita D Mishra
- Australian Woman and Girls' Health Research Centre, School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
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Tuominen A, Saavalainen L, Niinimäki M, Gissler M, But A, Härkki P, Heikinheimo O. First live birth before surgical verification of endometriosis-a nationwide register study of 18 324 women. Hum Reprod 2023:dead120. [PMID: 37403272 PMCID: PMC10391315 DOI: 10.1093/humrep/dead120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/22/2023] [Indexed: 07/06/2023] Open
Abstract
STUDY QUESTION Do women with endometriosis have lower first live birth rate before surgical diagnosis than women without verified endometriosis? SUMMARY ANSWER Compared to reference women, the incidence of first live birth was lower in women prior to surgical verification of endometriosis irrespective of the type of endometriosis. WHAT IS KNOWN ALREADY Endometriosis is associated with pain and reduced fertility. The mechanism of infertility is partly explained by anatomical, endocrinological, and immunological changes. Over the past decades, the treatment of both endometriosis and infertility has evolved. Knowledge of fertility far before surgical diagnosis of endometriosis in large cohorts and of different types of endometriosis has been lacking. The diagnostic delay of endometriosis is long, 6-7 years. STUDY DESIGN, SIZE, DURATION Retrospective population-based cohort study focused on the time period before the surgical verification of endometriosis. All women with surgical verification of endometriosis in 1998-2012 were identified from the Finnish Hospital Discharge Register and the reference cohort from the Central Population Register. Data on deliveries, gynecological care, and sociodemographic factors before the surgical diagnosis were gathered from Finnish national registers maintained by the Finnish Institute for Health and Welfare, the Digital and Population Data Services Agency, and Statistics Finland. PARTICIPANTS/MATERIALS, SETTING, METHODS All women aged 15-49 years at the time of surgical verification of endometriosis (ICD-10: N80.1-N80.9) in Finland during 1998-2012 were identified (n = 21 620). Of them, we excluded women born in 1980-1999 due to the proximity of the surgical diagnosis (n = 3286) and women left without reference (n = 10) for the final endometriosis cohort of 18 324 women. From the final cohort, we selected sub-cohorts of women with isolated diagnosis of ovarian (n = 6384), peritoneal (n = 5789), and deep (n = 1267) endometriosis. Reference women were matched by age and residence and lacked registered clinical or surgical diagnosis of endometriosis (n = 35 793). The follow-up started at the age of 15 years and ended at the first birth, sterilization, bilateral oophorectomy, hysterectomy, or until the surgical diagnosis of endometriosis or corresponding index day-whichever came first. Incidence rate (IR) and the incidence rate ratio (IRR) of first live birth before the surgical verification of endometriosis with corresponding CIs were calculated. In addition, we reported the fertility rate of parous women (the number of all children divided by the number of parous women in the cohort) until the surgical verification of endometriosis. The trends in first births were analysed according to the women's birth cohort, type of endometriosis, and age. MAIN RESULTS AND THE ROLE OF CHANCE Surgical diagnosis of endometriosis was set at the median age of 35.0 years (IQR 30.0-41.4). Altogether 7363 women (40.2%) with endometriosis and 23 718 (66.3%) women without endometriosis delivered a live born infant before the index day (surgery). The IRs of the first live birth per 100 person-years were 2.64 (95% CI 2.58-2.70) in the endometriosis cohort and 5.21 (95% CI 5.15-5.28) in the reference cohort. Between the endometriosis sub-cohorts, the IRs were similar. The IRR of the first live birth was 0.51 (95% CI 0.49-0.52) between the endometriosis and reference cohorts. Fertility rate per parous woman before the surgical diagnosis was 1.93 (SD 1.00) and 2.16 (SD 1.15) in the endometriosis and reference cohorts (P < 0.01). The median age at the first live birth was 25.5 (IQR 22.3-28.9) and 25.5 (IQR 22.3-28.6) years (P = 0.01), respectively. Between the endometriosis sub-cohorts, women in the ovarian sub-cohort were the oldest at the time of surgical diagnosis with the median age of 37.2 years (IQR 31.4-43.3), (P < 0.001). Altogether 44.1% (2814) of the women with ovarian, 39.4% (2282) with peritoneal, and 40.8% (517) with deep endometriosis delivered a live born infant before the diagnosis. IRRs between the endometriosis sub-cohorts did not differ. Fertility rate per parous woman was lowest, 1.88 (SD 0.95), in the ovarian sub-cohort compared to 1.98 (SD 1.07) in the peritoneal and 2.04 (SD 0.96) in deep endometriosis (P < 0.001). Women with ovarian endometriosis were oldest at first live birth compared to women in other sub-cohorts with a median age of 25.8 years (IQR 22.6-29.1) (P < 0.001). Cumulative distributions of first live birth were presented according to age at first live birth and birth cohorts of the participants. LIMITATIONS, REASONS FOR CAUTION The increasing age at first live birth, increasing practice of clinical diagnostics, conservative treatment of endometriosis, a possible effect of coexisting adenomyosis, and use of artificial reproductive treatments should be considered when assessing the results. In addition, the study is limited due to possible confounding effects of socioeconomic factors, such as level of education. It should be noted that, in this study, we assessed parity only during the years preceding the surgical verification of endometriosis. WIDER IMPLICATIONS OF THE FINDINGS The need for early diagnosis and relevant treatment of endometriosis appears clear given the impairment of fertility prior to its surgical verification. STUDY FUNDING/COMPETING INTEREST(S) The study was funded by the Hospital District of Helsinki and Uusimaa and by Finska Läkaresällskapet. The authors report no conflicts of interest. All authors have completed the ICMJE Disclosure form. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- A Tuominen
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Obstetrics and Gynecology, Hyvinkää Hospital, Hyvinkää, Finland
| | - L Saavalainen
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - M Niinimäki
- Department of Obstetrics and Gynecology, Oulu University Hospital, Wellbeing Services County of North Ostrobothnia, Oulu, Finland
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
- Medical Research Center Oulu (MRC Oulu), University of Oulu, Oulu University Hospital, Wellbeing Services County of North Ostobothnia, Oulu, Finland
| | - M Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Academic Primary Health Care Center, Stockholm, Sweden
| | - A But
- Department of Biostatistics, University of Helsinki, Helsinki, Finland
| | - P Härkki
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - O Heikinheimo
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Homer HA. Effects of endometriosis on in vitro fertilisation - Myth or reality? Aust N Z J Obstet Gynaecol 2023; 63:3-5. [PMID: 36788708 DOI: 10.1111/ajo.13643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 02/16/2023]
Affiliation(s)
- Hayden Anthony Homer
- Christopher Chen Oocyte Biology Research Laboratory, UQ Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Queensland Fertility Group, Brisbane, Queensland, Australia
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Affiliation(s)
- Louie Ye
- The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne and the Royal Women's Hospital, Victoria, Australia
| | - Lucy H R Whitaker
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Rebecca L Mawson
- The Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
| | - Martha Hickey
- The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne and the Royal Women's Hospital, Victoria, Australia
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Alson S, Jokubkiene L, Henic E, Sladkevicius P. Prevalence of endometrioma and deep infiltrating endometriosis at transvaginal ultrasound examination of subfertile women undergoing assisted reproductive treatment. Fertil Steril 2022; 118:915-923. [PMID: 36175206 DOI: 10.1016/j.fertnstert.2022.07.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 07/26/2022] [Accepted: 07/28/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To estimate the prevalence of endometrioma and deep infiltrating endometriosis (DIE), assessed by systematic transvaginal ultrasound examination, in women with subfertility accepted for their first assisted reproductive treatment and to describe the prevalence of endometriotic lesions in different anatomical locations of the pelvis. DESIGN Cross-sectional study. SETTING Reproductive Medicine Center, Department of Obstetrics and Gynecology, University hospital. PATIENT(S) A total of 1,191 women with subfertility aged 25-39 years accepted for their first assisted reproductive treatment between December 2018 and May 2021. INTERVENTION(S) All women underwent a systematic transvaginal ultrasound examination. The endometriotic lesions visible on ultrasound examination were described according to the International Deep Endometriosis Analysis group consensus opinion for systematic approach to assess endometriotic lesions. MAIN OUTCOME MEASURE(S) Prevalence of endometrioma and DIE in women with subfertility and prevalence of endometriotic lesions in various anatomical locations of the pelvis. RESULT(S) Endometriosis prevalence was 21.8%, with endometriotic lesions found in 260 of the 1,191 women. Overall, 125 (10.5%) women had endometrioma and 205 (17.2%) women had DIE. Of these 260 women, 197 (75.8% of women with endometriosis) did not have any previous knowledge about having endometriosis. The most common location for endometriotic lesions was the uterosacral ligaments, with lesions found in 151 (12.7%) of all women. The second most common location was the ovaries containing endometrioma, found in 125 (10.5%) women. Most women had 1 (n = 121, 10.2%) or 2 (n = 82, 6.9%) endometriotic lesions. CONCLUSION(S) The prevalence of endometrioma and DIE in women with subfertility, diagnosed by systematic transvaginal ultrasound examination, was 21.8%. Of these, three-fourth of women had no knowledge about the presence of disease.
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Affiliation(s)
- Sara Alson
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Lund University, Sweden.
| | - Ligita Jokubkiene
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Emir Henic
- Reproductive Medicine Center, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Povilas Sladkevicius
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Lund University, Sweden
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Fitz VW, Minis E, Petrozza JC. Look (more carefully) before you leap: systematic ultrasounds for endometriosis in patients with subfertility. Fertil Steril 2022; 118:924-925. [PMID: 36184325 DOI: 10.1016/j.fertnstert.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/06/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Victoria W Fitz
- Division of Reproductive Endocrinology and Infertility, Department of OB/GYN, Massachusetts General Hospital, Boston, Massachusetts
| | - Evelyn Minis
- Division of Reproductive Endocrinology and Infertility, Department of OB/GYN, Massachusetts General Hospital, Boston, Massachusetts
| | - John C Petrozza
- Division of Reproductive Endocrinology and Infertility, Department of OB/GYN, Massachusetts General Hospital, Boston, Massachusetts
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13
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Mak J, Leonardi M, Condous G. 'Seeing is believing': arguing for diagnostic laparoscopy as a diagnostic test for endometriosis. Reprod Fertil 2022; 3:C23-C28. [PMID: 35794928 PMCID: PMC9254269 DOI: 10.1530/raf-21-0117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/10/2022] [Indexed: 11/08/2022] Open
Abstract
Endometriosis is a benign disease that can cause pain and infertility in women. Debate exists over how endometriosis should best be diagnosed. On one hand, endometriosis can be diagnosed by directly examining pelvic anatomy via a surgical procedure known as diagnostic laparoscopy. On the other hand, the disease can be diagnosed via non-surgical means such as using medical imaging, the symptoms described by the patient and whether the patient responds to non-surgical therapies such as medication. In this debate article, we argue in favour of diagnostic laparoscopy. We review the safety of the procedure, compare the ability of diagnostic laparoscopy vs medical imaging to detect endometriosis and consider the benefits of formally diagnosing or ruling out the condition.
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Affiliation(s)
- Jason Mak
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, New South Wales, Australia
| | - Mathew Leonardi
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - George Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, New South Wales, Australia
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Makieva S, Sharma K, Serdarogullari M, Uraji J, Ali ZE, Liperis G, Ammar OF, D’Hooghe T, Hull ML, Leonardi M, Vigano’ P, Massarotti C. #ESHREjc report: diagnosing endometriosis loosens the Gordian knot of infertility treatment. Hum Reprod 2022; 37:2219-2223. [DOI: 10.1093/humrep/deac134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Indexed: 12/28/2022] Open
Affiliation(s)
- Sofia Makieva
- Kinderwunschzentrum, Klinik für Reproduktions-Endokrinologie, Universitätsspital Zürich , Zurich, Switzerland
| | - Kashish Sharma
- ART Fertility Clinics LLC , Abu Dhabi, United Arab Emirates
| | - Munevver Serdarogullari
- Department of Histology and Embryology, Faculty of Medicine Cyprus International University , Northern Cyprus via Mersin 10 , Turkey
| | | | - Zoya E Ali
- Research & Development Department, Hertility Health Limited , London, UK
| | - George Liperis
- Westmead Fertility Centre, Institute of Reproductive Medicine, University of Sydney , Westmead, NSW, Australia
| | - Omar F Ammar
- Nuffield Department of Women’s & Reproductive Health, University of Oxford , Oxford, UK
| | - Thomas D’Hooghe
- Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA , Darmstadt, Germany
- Department of Development and Regeneration, Biomedical Sciences, University of Leuven (KU Leuven) , Leuven, Belgium
- Department of Obstetrics and Gynecology, Yale University School of Medicine , New Haven, CT, USA
| | - M Louise Hull
- The Endometriosis Group, Robinson Research Institute, University of Adelaide , Adelaide, South Australia
| | - Mathew Leonardi
- Department of Obstetrics and Gynecology, McMaster University , Hamilton, Canada
| | - Paola Vigano’
- Infertility Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico , Milano, Italy
| | - Claudia Massarotti
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino , Genova, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova , Genova, Italy
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