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Endometriosis is a chronic disease that affects around 10% of reproductive age women worldwide and a common cause of infertility. One of its manifestations is ovarian endometriomas, which are present in 17-44% of endometriosis patients. Endometriomas can impair fertility by mechanical stretching and local inflammation, promoting oxidative stress in the surrounding ovarian cortex that could lead to apoptosis and necrosis of early follicles. The removal of endometriomas may improve spontaneous pregnancy rates, as already demonstrated by some studies. To reduce endometriomas recurrence, it is advised to perform cystectomy followed by hormonal suppression. However, this approach is unfeasible in patients desiring pregnancy. At the same time, cystectomy poses a threat to ovarian reserve and, therefore, to controlled ovarian stimulation. Women who have endometriomas surgically removed are at risk to have diminished response to ovarian stimulation if in vitro fertilization is needed in the future.

Objective: To evaluate serum and peritoneal concentrations of amyloid protein A in women with endometriosis and to compare them with those of women without endometriosis., Study Design: A prospective study evaluated 76 women suspected of having pelvic endometriosis. Fifty-seven women (group A) were confirmed by videolaparoscopy and had their serum and peritoneal amyloid A concentrations measured by ELISA. The average levels from group A were compared to those obtained in group B. Group B was composed of 13 women without endometriosis, submitted to elective laparoscopy for tubal ligation., Results: Peritoneal amyloid A concentrations in group A (310.3 +/- 97.8 ng/mL) were higher than those of group B (53.4 +/- 58.2 ng/mL); p = 0.0. However, serum concentrations in groups A (14.01 +/- 32.3 ng/mL) and B (9.5 +/- 15.9 ng/mL) did not differ significantly; p = 0.35., Conclusion: The peritoneal amyloid A protein concentration in pelvic endometriosis was higher when compared to normal controls, corroborating the inflammatory nature of the disease. This finding suggests that the procedure of evaluating the peritoneal amyloid A concentration in endometriosis merits further investigation.

Background: Endometriosis is a multifactorial gynecological disease characterized by the presence of functional endometrium-like tissue in ectopic sites. Several studies have focused on elucidating the immunological, endocrine, environmental and genetic factors involved in endometriosis. However, its pathogenesis is still unclear., Methods: High-resolution comparative genomic hybridization was applied to screen for genomic imbalances in laser microdissected stromal and epithelial cells from 20 endometriotic lesions and three samples of eutopic endometrium derived from eight patients. The expression of seven stemness-related markers (CD9, CD13, CD24, CD34, CD133, CD117/c-Kit and Oct-4) in endometrial tissue samples was evaluated by immunohistochemistry., Results: Samples of eutopic endometrium showed normal genomic profiles. In ectopic tissues, an average of 68 genomic imbalances was detected per sample. DNA losses were more frequently detected and involved mainly 3p, 5q, 7p, 9p, 11q, 16q, 18q and 19q. Many of the genomic imbalances detected were common to endometriotic stroma and epithelia and also among different endometriotic sites from the same patient. These findings suggested a clonal origin of the endometriotic cells and the putative involvement of stem cells. Positive immunostaining for CD9, CD34, c-Kit and Oct-4 markers was detected in isolated epithelial and/or stromal cells in eutopic and ectopic endometrium in the majority of cases., Conclusions: The presence of shared genomic alterations in stromal and epithelial cells from different anatomical sites of the same patient and the expression of stemness-related markers suggested that endometriosis arises as a clonal proliferation with the putative involvement of stem cells.

In patients with endometriosis of the appendix, other sites are use to be affected by the disease, mainly bladder, rectosigmoid and retrocervical endometriosis. When these characteristics are present or if patients have more than three sites affected by endometriosis, the surgeon should evaluate the appendix carefully., (Copyright (c) 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe clinical and epidemiological aspects of patients with pelvic endometriosis who underwent laparoscopy at our service., Methods: Retrospective study of 892 post-laparoscopy patients with histologically confirmed diagnosis of endometriosis., Results: Mean age was 33.2 ± 6.3 years, and 78.7% of patients were Caucasian. We found that 76.9% of women in the sample had a higher education. Most (56.5%) patients were nulliparous, and 62.2% reported dysmenorrhea as the chief complaint. Chronic pelvic pain was the most prevalent symptom, followed by deep dyspareunia, reported by 56.8% and 54.7% of patients respectively. Infertility was reported by 39.8% of the 892 patients in the sample., Conclusion: Endometriosis is most often diagnosed in the fourth decade of life. Patients with this condition present with multiple complaints, and must always undergo thorough questioning to properly guide diagnosis and monitor treatment results.

Background: Successful surgical treatment of deep bowel endometriosis depends on obtaining detailed information about the lesions, prior to the procedure. The objective of this study was to determine the capability of transvaginal ultrasonography with bowel preparation (TVUS-BP) to predict the presence of one or more rectosigmoid nodules and the deepest bowel layer affected by the disease., Methods: A prospective study of 194 patients with clinical and TVUS-BP suspected deep endometriosis submitted to videolaparoscopy. Image data were compared with surgical and histological results., Results: With respect to bowel nodule detection and presence of at least two rectosigmoid lesions, TVUS-BP had a sensitivity of 97 and 81%, specificity 100 and 99%, positive predictive value (PPV) 100 and 93% and negative predictive value (NPV) 98 and 96%, respectively. Regarding diagnosis of infiltration of the submucosal/mucosal layer, TVUS-BP had a sensitivity of 83%, specificity 94%, PPV 77%, NPV 96%., Conclusions: These findings show that TVUS-BP is an adequate exam for evaluating the presence of one or more rectosigmoid nodules and the deepest layer affected in deep infiltrating bowel endometriosis, confirming the importance of this technique for defining the most appropriate surgical strategy to be implemented.

Objective: To verify whether bladder and ureter endometriosis had the same clinical features and disease behavior., Design: Case-control study., Setting: Multidisciplinary group in Sao Paulo, Brazil., Patient(s): A total of 690 patients were submitted to laparoscopy with histologically diagnosis of endometriosis between July 1999 and December 2006. Twelve of these patients had lesions affecting the ureter and 26 had lesions affecting the bladder. A control group consisted of 652 patients in whom endometriosis was not affecting either the ureter or the bladder., Intervention(s): None., Main Outcome Measure(s): Clinical and surgical features of patients with ureteral or bladder endometriosis., Result(s): No patients with ureteral endometriosis had lesions affecting the bladder. Compared with the control group, patients with ureteral endometriosis had more advanced disease (Stages III and IV) according to the American Society of Reproductive Medicine (ASRM) staging classification (100% vs. 65.5%); they also had more retrocervical (83.3% vs. 21.6%) and rectum-sigmoid lesions (91.7% vs. 17.9%). Compared with the control group, more patients with bladder endometriosis had cyclic dysuria and/or hematuria (34.6% vs. 9.8%), more advanced stages of the disease (88.4% vs. 65.5%), and an association with endometriosis of the rectum-sigmoid (65.3% vs. 17.9%)., Conclusion(s): Ureter endometriosis is not associated with the bladder disease; however, it is associated with advanced ASRM stages and with retrocervical and rectum-sigmoid lesions.

Deeply infiltrating endometriosis is the clinical form of the disease that is generally associated with conditions of more intense pain and may require more complex surgical management, consequently resulting in greater risks to the patient. In recent years, various investigators have confirmed the usefulness of methods such as magnetic resonance imaging (MRI), transrectal ultrasound and transvaginal ultrasound (TVUS) for the diagnosis of deep endometriotic lesions. The objectives of the present study are to describe the method used to perform TVUS for the detection of deeply infiltrating endometriosis, and to discuss the clinical benefits that the data obtained may offer clinicians providing care for patients suspected of having this type of endometriosis.

Objective: To evaluate interleukin (IL)-12 and IL-18 levels in the serum and peritoneal fluid of women with and without endometriosis., Design: Cross-sectional survey., Setting: University hospital., Patients: Interleukin-12 and IL-18 levels were compared in 105 patients submitted to laparoscopy because of symptoms suggestive of endometriosis (pain and/or infertility). The disease was confirmed in 72 patients (study group), while in 33 patients findings were not compatible with endometriosis (control group). INTEVENTION(S): Blood sample and peritoneal fluid were obtained from patients during videolaparoscopy., Main Outcome Measure(s): The levels of IL-12 and IL-18 in peripheral blood and peritoneal fluid were determined and compared with the stage and site of the disease and histologic classification., Result(s): IL-12 levels measured in peritoneal fluid were higher in patients with endometriosis compared with the control group. A significant increase in IL-12 levels was found when the more advanced stages of the disease were compared with the initial stages. No statistically significant differences were found in IL-18 levels, either in serum or in peritoneal fluid samples., Conclusion(s): Patients with severe endometriosis have higher IL-12 levels irrespective of IL-18 levels, suggesting that in this disease an alternative pathway is involved in induction of the Th1 immune response.

Study Objective: To estimate the relationship between the depth of lesions of rectal endometriosis and the percentage of the circumference of the bowel segment affected by the disease., Design: A prospective pathologic analysis of 45 surgical specimens of bowel endometriosis obtained by laparoscopic segmental resection of the rectosigmoid (Canadian Task Force classification II-1)., Setting: Tertiary referral hospital., Patients: forty-five patients were submitted to a segmental resection of the rectum due to endometriosis between July 2004 and September 2006., Interventions: Morphometric aspects of endometriotic lesions were analyzed, such as size and thickness of the lesion, deepest layer of bowel affected by lesion, and percentage of circumference of bowel affected by endometriosis., Measurements and Main Results: Results showed that in lesions that reached the submucous layer of the bowel, the circumference affected was 31.6% greater than in lesions that reached only the outer muscular layer, whereas in lesions that reached the mucous layer, the circumference affected was 52.5% greater than in those that reached the outer muscular layer of the bowel. In addition, 89.3% of lesions with an affected circumference greater than 40% were those affecting the submucous or mucous layers of the bowel. These results suggest that when a lesion reaches these 2 deepest layers of the rectosigmoid, risk increases that the circumference affected will be greater than 40% (relative risk = 1.5; 95% CI: 1.0-2.3; p = .03)., Conclusion: In endometriotic lesions affecting the rectosigmoid beyond the inner muscular layer of the bowel wall, more than 40% of the circumference of the rectosigmoid is affected by the disease, confirming the recommendation of segmental resection of the bowel for this form of the disease.

Background: Deeply infiltrating endometriosis affecting the retrocervical region and the rectosigmoid generally requires surgical treatment. Clinical examination, transvaginal ultrasonography (TVUS) and pelvic magnetic resonance imaging (MRI) are useful in the preoperative diagnosis of the involvement of these sites. The objective of this study was to evaluate the capacity of digital vaginal examination, TVUS and MRI to diagnose rectosigmoid and retrocervical involvement., Methods: A total of 104 patients with clinically suspected endometriosis were submitted to clinical examination, pelvic MRI and TVUS until 3 months prior to videolaparoscopy and the findings of these methods were matched with histopathological confirmation of endometriosis., Results: Endometriosis was histologically confirmed in 98 of 104 (94.2%) patients. With respect to the rectosigmoid and retrocervical sites, respectively, digital vaginal examination had a sensitivity of 72 and 68%, specificity of 54 and 46%, positive predictive value (PPV) of 63 and 45%, negative predictive value (NPV) of 64 and 69% and accuracy of 63 and 55%. For TVUS, sensitivity was 98 and 95%, specificity 100 and 98%, PPV 100 and 98%, NPV 98 and 97% and accuracy 99 and 97%. MRI had a sensitivity of 83 and 76%, specificity of 98 and 68%, PPV of 98 and 61%, NPV of 85 and 81% and accuracy of 90 and 71%., Conclusions: TVUS had better sensitivity, specificity, PPV, NPV and accuracy in cases of deep retrocervical and rectosigmoid endometriosis when compared with MRI and digital vaginal examination, confirming that it is an important preoperative examination for the definition of surgical strategies.

Objectives: To investigate whether there is an association between vascular endothelial growth factor (VEGF) levels in serum and peritoneal fluid, and the presence of pelvic endometriosis and its clinical symptoms., Methods: Blood and peritoneal fluid sample levels of VEGF were measured in 46 women undergoing laparoscopy: 32 with suspected endometriosis and 14 with confirmed endometriosis. Data were analyzed according to phase of the menstrual cycle, symptoms, disease stage, and disease site., Results: There were no significant associations between serum and peritoneal fluid levels of VEGF and the presence of endometriosis, even when controlling for the menstrual phase. However, among the women with confirmed endometriosis, there was a significant increase (P=0.002) in the mean peritoneal VEGF level in those in the late secretory phase compared with those in the proliferative and early secretory phases., Conclusions: Measuring VEGF levels in symptomatic patients is not helpful to differentiate those with endometriosis from those with a different condition. However, in the late secretory and menstrual phases, mean VEGF levels were higher in women with confirmed endometriosis than in those suspected of having the disease.

Background: Efforts have been made to correctly characterize the role of the immune response in endometriosis. The objective of this study was to analyse the interaction between Th1 and Th2 immune response patterns and endometriosis by evaluating a panel of cytokines., Methods: Between January 2004 and November 2005, 98 patients, classified into two groups according to the histologically confirmed presence (Group A) or absence of endometriosis (Group B), were evaluated. Interleukins (IL) 2, 4 and 10, tumour necrosis factor-alpha and interferon-gamma (IFN-gamma) were measured by flow cytometry in the peripheral blood and peritoneal fluid of all patients., Results: IFN-gamma and IL-10 levels were significantly higher in the peritoneal fluid of patients with endometriosis compared to those without endometriosis (P < 0.05). There was a significant alteration in the IL-4/IFN-gamma (P < 0.001), IL-4/IL-2 (P = 0.006), IL-10/IFN-gamma (P < 0.001) and the IL-10/IL-2 ratios (P < 0.001) in the peritoneal fluid of patients with endometriosis, with a predominance of IL-4 and IL-10, reflecting a shift towards Th2 immune response despite the increase in IFN-gamma concentrations., Conclusions: Endometriosis is an inflammatory disease involving a possible shift towards Th2 immune response component, as demonstrated by the relative increase in cytokines characteristic of this pattern of immune response.

Objective: To analyze morphologic aspects of bowel endometriosis., Design: Prospective study of 35 consecutive cases of bowel endometriosis., Setting: Multidisciplinary group practice and teaching hospital., Patient(s): Thirty-five patients with bowel endometriosis were assessed between September 2003 and June 2005., Intervention(s): Histologic analysis of 35 tissue samples removed at laparoscopic rectosigmoidectomy., Main Outcome Measure(s): We performed an evaluation of lesion size, number of lesions present in the bowel, intestinal wall layers affected by the endometriotic lesion, circumference of the intestinal loop affected by the endometriotic lesion, and presence of lymph nodes with foci of endometriosis., Result(s): Analysis of the surgical samples revealed lymph nodes in the pericolic adipose tissue of 19 (54%), cases and in 5 of these cases (26.3%), endometriosis had affected the lymph nodes. When the thickness of the endometriotic lesion reached 1.75 cm, lymph nodes of all patients were affected, and all patients in whom more than 80% of the circumference of the intestinal loop was affected by endometriosis presented with positive lymph nodes., Conclusion(s): This study raises doubts about whether this form of the disease can still be considered a clinically benign disease.

Objective: To report the case of a patient submitted to laparoscopic bowel resection in whom histology revealed endometriosis and schistosomiasis., Design: Case report., Setting: Multidisciplinary group practice and teaching hospital., Patient(s): A 31-year-old patient with pelvic pain., Intervention(s): Laparoscopic bowel resection., Main Outcome Measure(s): Laparoscopic treatment of endometriosis affecting the sigmoid., Result(s): Histology performed on tissue removed at surgery revealed epithelioid granulomas with birefringent and partially calcified eggs characteristic of Schistosoma mansoni within an endometriotic lesion affecting the entire width of the sigmoid., Conclusion(s): Endometriosis and schistosomiasis may be present simultaneously in patients with bowel symptoms and pelvic pain.

Objective: To describe the use of mechanical anastomoses in cases of laparoscopically assisted vaginal rectosigmoidectomy for the treatment of rectosigmoid endometriosis., Methods: Pilot study evaluating eight patients with rectosigmoid endometriosis referred for surgical treatment. All patients were submitted to laparoscopically assisted vaginal segmental resection of the rectosigmoid with anastomoses performed using linear and circular staplers., Results: The average length of the surgical procedure was 177.5 min and average duration of hospitalization was 4.13 days. There were no intra-operative complications and integrity of the anastomoses was confirmed in all patients. One patient reported partial improvement of symptoms and 7 patients presented complete clinical remission 12 months following surgery., Conclusion: Laparoscopically assisted vaginal segmental resection of the sigmoid infiltrated by endometriosis is a feasible surgical procedure. The technique combines transvaginal access with mechanical intestinal anastomoses performed using linear and circular staplers, and achieves good results with low morbidity.