The Large Uterus Classification System: a prospective observational study.

OBJECTIVE: To investigate the Large Uterus Classification System (LUCS) ability to predict surgical outcomes and complications in total laparoscopic hysterectomies (TLHs) for large uteri. DESIGN: Prospective observational study. SETTING: Two referral centres. POPULATION OR SAMPLE: Three hundred and ninety-two women who underwent TLH for a large uterus (uterine fundus at or over the transverse umbilical line). METHODS: Between 2004 and 2019, the intraoperative LUCS was estimated in all patients. The LUCS considers the uterine and adnexal vascular pedicles displacement. Type 1 is without vascular pedicles displacement. Type 2 has the cephalad displacement of adnexal vascular pedicles. The uterine vessels displacement regardless of adnexal pedicles defines Type 3. MAIN OUTCOME MEASURES: Patients' characteristics with perioperative outcomes were prospectively collected and compared between the three types of large uteri. RESULTS: Two hundred and fifty-one (64%), 82 (20.9%) and 59 (15.1%) women had Type 1, Type 2 and Type 3 uteri, respectively. Women with Type 1 uteri had a lower uterine weight, shorter operative time, less blood loss and lower complication rates than women with Types 2 and 3. The conversion rate to laparotomy in Type 1 was similar to that in Type 2 (odds ratio [OR] 0.98; 95% CI 0.32-3.56) but lower than Type 3 (OR 0.35; 95% CI 0.14-0.97); in Type 2 it was lower than Type 3, although without the conventional statistical significance (OR 0.36; 95% CI 0.13-1.13; P = 0.07). Multivariable analysis showed that the uterine Type (1 versus 2-3) was independently associated with the total complications rate (OR 2.00; 95% CI 1.09-3.68; P = 0.02). CONCLUSIONS: The LUCS appears associated with surgical outcomes and complications, potentially stratifying the surgical risk and guiding the surgical technique in TLHs for large uteri. TWEETABLE ABSTRACT: The Large Uterus Classification System may predict outcomes in total laparoscopic hysterectomy of large uteri.

Uterine adenomyosis: pathogenesis, diagnostics, symptomatology and treatment.

OBJECTIVE: To summarize the current knowledge about pathogenesis, diagnostics, symptomatology and the treatment of adenomysis. DESIGN: Review article. SETTING: The Centre of Assisted Reproduction, ISCARE I.V.F., Prague. METHODS: Analysis of literature and current studies. RESULTS: This article reviews etiology, diagnostics and classification of adenomyosis, medical and surgical management options and the fertility implication of adenomyosis. CONCLUSION: Uterine adenomyosis is characterized by the presence of endometrial glands in myometrium and usually manifests by pelvic pain, abnormal uterine bleeding or infertility. Although adenomyosis and endometriosis share a number of features, they are considered to be two different entities. Recent improvements of imaging techniques such as transvaginal ultrasound and magnetic resonance imaging have affected the detection of adenomyosis. Adenomyosis has a negative impact on IVF results.

Route of hysterectomy: a retrospective, cohort study in English NHS Hospitals from 2011 to 2017.

OBJECTIVE: To assess variation in the route of hysterectomy over 7 years and to assess regional variation in practice. DESIGN: Retrospective cohort study. SETTING: English NHS Hospitals 2011-2017. POPULATION: 230 876 patients having a hysterectomy for six diagnostic categories (endometrial cancer, endometriosis and pain, menstrual disorders, fibroids, benign adnexal masses, and 'other') identified from Hospital Episode Statistics. METHODS: The proportion of hysterectomies carried out by each route was calculated for each year overall and for each primary diagnosis by year. Comparisons between 2011 and 2017 were via chi-square test. Rank correlation coefficients were calculated to assess trends over the study period. Analysis of regional variation in practice was restricted to 2017. A multivariable logistic regression was performed to obtain crude and adjusted odds of having a minimal access hysterectomy. MAIN OUTCOME MEASURES: The proportion of abdominal, vaginal, laparoscopic, and failed laparoscopic procedures for each primary diagnosis by study year. Odds of a minimal access hysterectomy in 2017. RESULTS: The proportion of hysterectomies performed laparoscopically increased from 20.2% in 2011 to 47.2% in 2017, as did the proportion of failed laparoscopic procedures; 1.7% in 2011 to 2.8% in 2017. The proportion of abdominal hysterectomies decreased from 70.4% in 2011 to 46.5% in 2017. There was a smaller decrease in vaginal procedures from 7.8% in 2011 to 3.5% in 2017. Regional variation in the route of hysterectomy was demonstrated in 2017, which persisted when adjusted for confounding factors. CONCLUSIONS: The proportion of laparoscopic procedures has increased, and it was the commonest route of hysterectomy for this cohort in 2017. There were significant regional differences in route of hysterectomy in 2017. TWEETABLE ABSTRACT: Increasing laparoscopic hysterectomy and decreasing abdominal hysterectomy rates from 2011 to 2017 with regional variation in practice.

Symptoms and classification of uterine adenomyosis, including the place of hysteroscopy in diagnosis.

Where histology used the presence of glands and/or stroma in the myometrium as pathognomonic for adenomyosis, imaging uses the appearance of the myometrium, the presence of striations, related to the presence of endometrial tissue within the myometrium, the presence of intramyometrial cystic structures and the size and asymmetry of the uterus to identify adenomyosis. Preliminary reports show a good correlation between the features detected by imaging and the histological findings. Symptoms associated with adenomyosis are abnormal uterine bleeding, pelvic pain (dysmenorrhea, chronic pelvic pain, dyspareunia), and impaired reproduction. However a high incidence of existing comorbidity like fibroids and endometriosis makes it difficult to attribute a specific pathognomonic symptom to adenomyosis. Heterogeneity in the reported pregnancy rates after assisted reproduction is due to the use of different ovarian stimulation protocols and absence of a correct description of the adenomyotic pathology. Current efforts to classify the disease contributed a lot in elucidated the potential characteristics that a classification system should be relied on. The need for a comprehensive, user friendly, and clear categorization of adenomyosis including the pattern, location, histological variants, and the myometrial zone seems to be an urgent need. With the uterus as a possible unifying link between adenomyosis and endometriosis, exploration of the uterus should not only be restricted to the hysteroscopic exploration of the uterine cavity but in a fusion with ultrasound.

Hydrometrocolpos etiology and management: past beckons the present.

Hydrometrocolpos is a rare condition in which the uterus and the vagina are grossly distended with a retained fluid other than pus or blood. It may present during the neonatal period or later at puberty. Most cases reported earlier were stillbirths and were diagnosed only on autopsy. Antenatal diagnosis is now possible with the advent of ultrasound. An early diagnosis and speedy management is the key to survival. Many previous case reports have focused on the varied clinical presentations, multiple causes, associated syndromes and/or the radiological diagnosis of this condition. However, management options for different types of hydrometrocolpos have not yet been concisely discussed. We have reviewed the literature and tried to summarize the management options applicable to most case scenarios of hydrometrocolpos.

Outcomes and Postoperative Complications After Hysterectomies Performed for Benign Compared With Malignant Indications.

OBJECTIVE: To compare complications and outcomes after hysterectomy for benign compared with malignant indications in the United States. METHODS: Women who underwent hysterectomy in the United States for either benign or malignant indications from January 2008 to December 2012 were retrospectively identified using the National Surgical Quality Improvement Program database. Patients were excluded if the procedure was not performed for primary gynecologic indications. Appropriate procedures were identified using Current Procedural Terminology and International Classification of Diseases, 9th Revision codes. Univariate and multivariable models for complication risk were estimated using logistic regression. RESULTS: We identified 59,525 eligible patients, with 49,331 (82.9%) hysterectomies performed for benign and 10,194 (17.1%) for malignant indications. All complications, including wound complications (2.5% benign compared with 5.5% malignant, P<.001), venous thromboembolism (0.33% compared with 1.7%, P<.001), urinary tract infection (2.7% compared with 3.2%, P=.009), sepsis (0.53% compared with 1.9%, P<.001), blood transfusion (2.6% compared with 11.5%, P<.001), death (0.02% compared with 0.10%, P<.001), unplanned readmission (1.8% compared with 4.5%, P<.001), and returns to the operating room (0.91% compared with 1.4%, P<.001), were significantly more common for malignant hysterectomies. The overall rate of complications for benign cases was 7.9% compared with a rate of 19.4% for malignant hysterectomy. The median operating time for laparoscopy in benign cases was significantly longer than for open or vaginal hysterectomy procedures (127 minutes compared with 105 or 94 minutes, respectively; P<.001). The median operating time in malignant cases was significantly longer than for benign cases (P<.001). CONCLUSION: Hysterectomies performed for gynecologic malignancies are associated with a more than twofold higher complication rate compared with those performed for benign conditions. Minimally invasive surgery is associated with a decreased complication rate compared with open surgery. These data can be used for patient counseling and surgical planning, determining physician and hospital costs of care, and considered when assigning value-based reimbursement.

Hysterectomy trends for benign indications over a 15-year period in an academic teaching center in Poland: a retrospective cohort study.

OBJECTIVES: The aim of the study was to evaluate changes in the operative trends for various types of hysterectomy due to benign indications, between 2001 and 2015, at the 2nd Department of Gynecology, Medical University of Lublin, as compared to the National Health Service (NHS) registry in Poland. MATERIAL AND METHODS: A retrospective cohort study was conducted. Data from the Internal Hospital Discharge Registry and Pathological Results Registry have been compared to the NHS database, which has been available nationwide since 2009. RESULTS: The study group included 5629 women who underwent hysterectomy due to benign indications. During the study period, the following number of procedures were performed: total abdominal hysterectomy - 344 (6.11%), total abdominal hysterectomy with bilateral salpingo-oophorectomy - 1760 (31.27%), total vaginal hysterectomy - 563 (10.00%), subtotal abdominal hysterectomy - 2536 (45.05%), and laparoscopically-assisted subtotal hysterectomy (LASH) - 426 (7.57%). The abdominal route, with the preference for subtotal abdominal hysterectomy, was the main approach to hysterectomy. Symptomatic fibroids were the most common indication for the procedure. Comparison of data collected over the last five years revealed a significant difference in the approach to hysterectomy in favor of subtotal abdominal hysterectomy (SAH) and LASH. CONCLUSIONS: Less invasive techniques of hysterectomy (LASH, SAH), which are the preferred choice at the 2nd Department of Gynecology (Lublin), are safe and effective options of treating benign conditions. We are of the opinion that these ap-proaches should be offered to patients instead of more radical techniques. Proper training of physicians may influence the decision-making process in favor of minimally invasive techniques.

Comparison of the ESHRE-ESGE and ASRM classifications of Müllerian duct anomalies in everyday practice.

STUDY QUESTION: Does the European Society of Human Reproduction and Embryology-European Society for Gynaecological Endoscopy (ESHRE-ESGE) classification of female genital tract malformations significantly increase the frequency of septate uterus diagnosis relative to the American Society for Reproductive Medicine (ASRM) classification? SUMMARY ANSWER: Use of the ESHRE-ESGE classification, compared with the ASRM classification, significantly increased the frequency of septate uterus recognition. WHAT IS KNOWN ALREADY: The ESHRE-ESGE criteria were supposed to eliminate the subjective diagnoses of septate uterus by the ASRM criteria and replace the complementary absolute morphometric criteria. However, the clinical value of the ESHRE-ESGE classification in daily practice is difficult to appreciate. The application of the ESHRE-ESGE criteria has resulted in a significantly increased recognition of residual septum after hysteroscopic metroplasty, with a possible risk of overdiagnosis of septate uterus and problems for its management. STUDY DESIGN, SIZE, AND DURATION: A prospective observational study was performed with 261 women consecutively enrolled between June and September 2013. PARTICIPANTS/MATERIALS, SETTING, AND METHODS: Non-pregnant women of reproductive age presented for evaluation to a private medical center. A gynecological examination and 3D ultrasonography were performed to assess the anatomy of the uterus, cervix and vagina. Congenital anomalies were diagnosed using the ASRM classification with additional morphometric criteria as well as with the ESHRE-ESGE classification. We compared the frequency and concordance of diagnoses of septate uterus and all congenital malformations of the uterus according to both classifications. The morphological characteristics of septate uterus recognized by both criteria were compared. MAIN RESULTS AND ROLE OF CHANCE: Of the 261 patients enrolled in this study, septate uterus was diagnosed in 44 (16.9%) and 16 (6.1%) patients using the ESGE-ESHRE and ASRM criteria, respectively [relative risk (RR)ESHRE-ESGE:ASRM 2.74; 95% confidence interval (CI), 1.6-4.72; P < 0.01]. At least one congenital anomaly were diagnosed in 58 (22.2%) and 43 (16.5%) patients using the ESHRE-ESGE and ASRM classifications (RRESHRE-ESGE:ASRM, 1.35; 95% CI, 0.95-1.92, P = 0.1), respectively. The two criteria had moderate strength of agreement in the diagnosis of septate uterus (κ = 0.45, P < 0.01). There was good agreement in differentiation between anomaly and norm between the two assessment criteria (κ = 0.79, P < 0.01). The percentages of all congenital malformations and results of the differentiation between the anomaly and norm were obtained after excluding the confounding original ESHRE-ESGE criterion of dysmorphic uterus (internal indentation <50% uterine wall thickness). The morphology of septa identified by the ESHRE-ESGE [length of internal fundal indentation (mm): median 10.7; lower-upper quartile, 8.1-20] significantly differed (P < 0.01) from that identified by the ASRM criteria [length of internal fundal indentation (mm): median, 21.1; lower-upper quartile, 18.8-33.1]. Internal fundal indentation in 16 out of 44 (36.4%) cases was <1 cm in the septate uterus by ESHRE-ESGE and met the criteria for normal uterus by ASRM. LIMITATIONS AND REASONS FOR CAUTION: The study participants were women who visited a diagnostic and treatment center specialized in uterine congenital malformations for a medical assessment, not from the general public. WIDER IMPLICATIONS OF THE FINDINGS: Septate uterus diagnosis by ESHRE-ESGE was quantitatively dominated by morphological states corresponding to arcuate uterus or cases that were not diagnosed as congenital malformations by ASRM. Relative overdiagnosis of septate uterus by ESHRE-ESGE in these cases may lead to unnecessary overtreatment without the expected benefits. The ESHRE-ESGE classification criteria should be redefined due to confusions in the methodology. Until the criteria are revised, septate uterus should not be diagnosed using this classification system and it should not be used as an eligibility criterion for hysteroscopic metroplasty. STUDY FUNDING/COMPETING INTERESTS: This work was supported by Jagiellonian University (grant no. K/ZDS/003821). The authors have no competing interests to declare.

The effect of endometriosis on in vitro fertilisation outcome: a systematic review and meta-analysis.

BACKGROUND: Endometriosis is found in 0.5-5% of fertile women and 25-40% of infertile women. It is known that endometriosis is associated with infertility, but there is uncertainty whether women with endometriosis have adverse pregnancy outcomes in in vitro fertilisation (IVF) treatment. OBJECTIVES: To explore the association between endometriosis and IVF outcome. SEARCH STRATEGY: Searches were conducted on MEDLINE, EMBASE, Cochrane Library and Web of Science (inception, December 2012) in all languages, together with reference lists of retrieved papers. SELECTION CRITERIA: Studies comparing IVF outcome in women with endometriosis with women without endometriosis. Patients were classified by stage of endometriosis. The outcomes were fertilisation, implantation, clinical pregnancy and live birth rates. Study selection was conducted independently by two reviewers. The Newcastle-Ottawa Quality Assessment Scale was used for quality assessment. DATA COLLECTION AND ANALYSIS: Data extraction was conducted independently by two reviewers. Relative risks from individual studies were meta-analysed. MAIN RESULTS: Twenty-seven observational studies were included, comprising 8984 women. Meta-analysis of these studies showed that fertilisation rates were reduced in stage I/II of endometriosis (relative risk [RR] = 0.93, 95% confidence interval [95% CI] 0.87-0.99, P = 0.03). There was a decrease in the implantation rate (RR = 0.79, 95% CI 0.67-0.93, P = 0.006) and clinical pregnancy rate (RR = 0.79, 95% CI 0.69-0.91, P = 0.0008) in women with stage III/IV endometriosis undergoing IVF treatment. CONCLUSION: The presence of severe endometriosis (stage III/IV) is associated with poor implantation and clinical pregnancy rates in women undergoing IVF treatment.

Müllerian anomalies and recurrent miscarriage.

PURPOSE OF REVIEW: To review the prevalence of congenital uterine anomalies and pregnancy outcomes in patients with these anomalies. RECENT FINDINGS: Women with a history of recurrent miscarriage have been estimated to have a 3.2-10.4% likelihood of having a major uterine anomaly except arcuate uterus. Hysterosalpingography and/or 2D ultrasound can be used as the initial screening tools. The American Fertility Society classification of Müllerian anomalies is the most commonly utilized standardized classification. However, there is still no international consensus to distinguish between septate and bicornuate uteri. A total of 35.1-65.9% of patients with bicornuate or septate uteri give live births after correctional surgery. In regard to the live birth rate in the absence of surgery, it has been reported that 33.3-59.5% of patients with such anomalies had a successful first pregnancy after the examination, as compared to 71.7% of individuals with normal uteri (P=0.084), with no significant difference in the cumulative live birth rate (78.0 and 85.5%, respectively) between the two groups. SUMMARY: Randomized controlled trials comparing the pregnancy outcomes between cases treated and not treated by surgery among patients with a history of recurrent miscarriage are needed because it is not established whether surgery could improve live birth rate.

The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies.

STUDY QUESTION: What classification system is more suitable for the accurate, clear, simple and related to the clinical management categorization of female genital anomalies? SUMMARY ANSWER: The new ESHRE/ESGE classification system of female genital anomalies is presented. WHAT IS KNOWN ALREADY: Congenital malformations of the female genital tract are common miscellaneous deviations from normal anatomy with health and reproductive consequences. Until now, three systems have been proposed for their categorization but all of them are associated with serious limitations. STUDY DESIGN, SIZE AND DURATION: The European Society of Human Reproduction and Embryology (ESHRE) and the European Society for Gynaecological Endoscopy (ESGE) have established a common Working Group, under the name CONUTA (CONgenital UTerine Anomalies), with the goal of developing a new updated classification system. A scientific committee (SC) has been appointed to run the project, looking also for consensus within the scientists working in the field. PARTICIPANTS/MATERIALS, SETTING, METHODS: The new system is designed and developed based on (i) scientific research through critical review of current proposals and preparation of an initial proposal for discussion between the experts, (ii) consensus measurement among the experts through the use of the DELPHI procedure and (iii) consensus development by the SC, taking into account the results of the DELPHI procedure and the comments of the experts. Almost 90 participants took part in the process of development of the ESHRE/ESGE classification system, contributing with their structured answers and comments. MAIN RESULTS AND THE ROLE OF CHANCE: The ESHRE/ESGE classification system is based on anatomy. Anomalies are classified into the following main classes, expressing uterine anatomical deviations deriving from the same embryological origin: U0, normal uterus; U1, dysmorphic uterus; U2, septate uterus; U3, bicorporeal uterus; U4, hemi-uterus; U5, aplastic uterus; U6, for still unclassified cases. Main classes have been divided into sub-classes expressing anatomical varieties with clinical significance. Cervical and vaginal anomalies are classified independently into sub-classes having clinical significance. LIMITATIONS, REASONS FOR CAUTION: The ESHRE/ESGE classification of female genital anomalies seems to fulfill the expectations and the needs of the experts in the field, but its clinical value needs to be proved in everyday practice. WIDER IMPLICATIONS OF THE FINDINGS: The ESHRE/ESGE classification system of female genital anomalies could be used as a starting point for the development of guidelines for their diagnosis and treatment. STUDY FUNDING/COMPETING INTEREST(S): None.

Four subtypes of adenomyosis assessed by magnetic resonance imaging and their specification.

OBJECTIVE: The aim of the present study was to differentiate and specify the subtypes of adenomyosis. STUDY DESIGN: Surgically treated adenomyosis (n = 152) was subcategorized retrospectively into 4 subtypes on the basis of magnetic resonance imaging geography. Subtype I (n = 59) consisted of adenomyosis that occurs in the uterine inner layer without affecting the outer structures. Subtype II (n = 51) consisted of adenomyosis that occurs in the uterine outer layer without affecting the inner structures. Subtype III (n = 22) consisted of adenomyosis that occurs solitarily without relationship to structural components. Adenomyosis that did not satisfy these criteria composed subtype IV (n = 20). Stepwise logistic regression analysis was used for specification of the subtypes. RESULTS: Subtypes I-III were suggested as a product of direct endometrial invasion, endometriotic invasion from the outside, and de novo metaplasia, respectively. Subtype IV was a heterogeneous mixture of far advanced disease. CONCLUSION: Adenomyosis appears to consist of 3 distinct subtypes of different causes and an additional subtype of indeterminate cause.

The relevance of post-cesarean adhesions.

With an increasing number of cesareans and repeat cesarean deliveries, clinicians have started to realize the importance of adhesions after cesarean delivery. Adhesions develop more frequently and with increasing severity with each repeat cesarean, and are associated with increasing maternal morbidity especially bladder injury and increased delivery time. It appears that adhesion formation could be reduced with closure of the peritoneum, double-layer closure of the uterine incision, and the use of adhesion barrier. In many reports of adhesion formation after cesarean delivery, authors have used different methods to evaluate adhesions. We encourage clinicians to adopt a newly published site-specific classification of adhesions after caesarean delivery.

Comparison of revised American Fertility Society and ENZIAN staging: a critical evaluation of classifications of endometriosis on the basis of our patient population.

OBJECTIVE: To develop a classification that takes deep infiltrating endometriosis into account, the ENZIAN score was introduced. The ENZIAN classification supplements the revised American Fertility Society (AFS) score with regard to the description of deep infiltrating endometriosis, retroperitoneal structures, and other organs. The null hypothesis was that classifying a lesion by the revised AFS as well as the ENZIAN system is not meaningful, because the two systems express different locations. DESIGN: Retrospective. SETTING: Hospital admissions. PATIENT(S): Two hundred nineteen women admitted for endometriosis. INTERVENTION(S): Surgical interventions. MAIN OUTCOME MEASURE(S): Classification of the severity of endometriosis according to the revised AFS and the ENZIAN classification, focusing on the distribution pattern in deep infiltrating endometriosis, and the identification of duplicate classifications of the same lesions in the revised AFS as well as the ENZIAN systems. RESULT(S): Deep infiltrating endometriosis was diagnosed in 160 of 219 patients (73%). These patients had 236 lesions of deep infiltrating endometriosis, which were classified by ENZIAN as follows: compartment a (vertical): 26%; compartment b (horizontal): 41%; compartment c (dorsal): 24%; uterine adenomyosis: 4%; bladder disease: 2%; ureter disease: 1%; and bowel disease: 2%. The severity of deep infiltrating endometriosis according to ENZIAN (grades 1 = mild to 4 = severe) was as follows: grade 1: 45%; grade 2: 26%; grade 3: 19%; grade 4: 10%. Fifty-eight patients were classified according to ENZIAN although they did not fulfill the criteria of deep infiltrating endometriosis and had previously been classified according to the revised AFS classification. Adaptation of the ENZIAN score would reduce the diagnoses of deep infiltrating endometriosis by 36% (95% confidence interval [CI] 29%-44%). CONCLUSION(S): The ENZIAN score is a helpful aid to describe deep infiltrating endometriosis, but needs to be adapted.

Fertility in women with minimal endometriosis compared with normal women was assessed by means of a donor insemination program in unstimulated cycles.

OBJECTIVE: The purpose of this study was to compare the pregnancy rate in an artificial insemination donor program in women with minimal endometriosis and in women without endometriosis. STUDY DESIGN: A prospective double-blinded study was conducted in women with azoospermic partners. RESULTS: The per-cycle pregnancy rate was 8.6% (9/104 women) in the minimal endometriosis group vs 13.3% (26/196 women) in the control group. The per-woman pregnancy rate was 37.5% (9/24 women) in the minimal endometriosis group and 51.0% (26/51 women) in the control group. CONCLUSION: Pregnancy rates were statistically similar in normal women and in women with minimal endometriosis.

Smoking habits of 411 women with histologically proven endometriosis and 567 unaffected women.

Smoking habits did not influence either the risk of any form of endometriosis (superficial peritoneal endometriosis, ovarian endometriomas, and deep infiltrating endometriosis) and did not correlate with the revised American Fertility Society stages or scores.

Proteomic analysis of serum yields six candidate proteins that are differentially regulated in a subset of women with endometriosis.

OBJECTIVE: To identify potential novel biomarkers that differ between subjects with and without endometriosis and that might aid in developing a noninvasive, serum-based diagnostic test. DESIGN: Case-control evaluation of a diagnostic test. SETTING: University medical center. PATIENT(S): Consenting women of reproductive age undergoing laparoscopy for indications of pain, infertility, elective tubal ligation, tubal reanastomosis, or other benign indication. INTERVENTION(S): Diagnostic laparoscopy and peripheral venipuncture. MAIN OUTCOME MEASURE(S): Concentrations of low-molecular-weight proteins in serum; surgical staging of endometriosis. RESULT(S): Six proteins were found that were differentially expressed between those with and without disease and that had good diagnostic properties. Taken together in a two-step diagnostic algorithm, we were able to diagnose 55% of subjects, with 99% accuracy as to the status of disease. Further combining this algorithm with that derived by our previous study of serum putative markers (monocyte chemoattractant protein-1, migration inhibitory factor, leptin, and CA-125) improved our diagnostic capability to 73% of subjects, with 94% overall accuracy. CONCLUSION(S): This study is the critical first step in the identification of potential novel biomarkers of endometriosis. Future identification of the proteins and further validation in a second population is needed before applying these findings in clinical practice.

Evaluation of high-sensitivity C-reactive protein in comparison with C-reactive protein as biochemical serum markers in women with endometriosis.

OBJECTIVE: To compare high-sensitivity C-reactive protein (hs-CRP) with CRP as a soluble serum marker for the diagnosis of women with endometriosis. DESIGN: Prospective nonrandomized controlled trial (Canadian Task Force classification II-1). SETTING: University hospital. PATIENT(S): Eighty-two women were laparoscopically evaluated. No endometriosis was diagnosed in 34 women (the non-E group). Endometriosis was confirmed by histology in 48 women (the E group). Eighty-two women did not undergo laparoscopic evaluation (the unknown-E group). Afterward, the women were staged according to the revised American Society for Reproductive Medicine criteria (r-ASRM). INTERVENTION(S): CRP and hs-CRP were measured initially before laparoscopy. MAIN OUTCOME MEASURE(S): The hs-CRP and CRP levels and the correlation of those parameters with the stage of the disease. RESULT(S): There was a trend toward higher CRP levels and higher hs-CRP levels in the E group, while the lowest levels of both markers were found in the non-E group. There was a significantly lower hs-CRP level in the non-E group in comparison with the CRP level in this group. No differences between the different stages of the disease were found with either marker. CONCLUSION(S): Measurement of the two markers did not appear to be advantageous for the diagnosis of endometriosis independent of the stage of the disease. Nevertheless, a very low hs-CRP level might serve as a marker for an absence of endometriosis.