soussis and endometriosis

Discovery promises early diagnosis of endometriosis

Discovery promises early diagnosis of endometriosis

By I.Soussis, MD, MSc, FRCOG, Fertility Specialist

 

Scientists from the Feinstein Institute for Medical Research announced an experimental, rapid and non-invasive way to diagnose endometriosis, which may lead to earlier and more effective treatments for this disorder that affects approximately 176 million women globally.

The scientists found that a particular feature of cells found in menstrual blood suggests that a patient has endometriosis, according to findings published in Molecular Medicine.

The simple test uses menstrual blood and takes only a few days to report. This is a dramatic improvement over current diagnostic methods that rely on laparoscopy, which patients try to avoid, delaying diagnosis typically five to 10 years from the onset of symptoms.

Endometriosis is a chronic condition in which the endometrium grows outside the uterus, typically in the abdominal cavity or on internal organs. Patients often experience significant pain and discomfort during their period or intercourse.  Endometriosis may also lead to infertility or hysterectomy.

Researchers at the Feinstein Institute established the Research Out-Smarts Endometriosis (ROSE) program to study the genetic basis of endometriosis and what is occurring at the cellular level in this disease. As part of ROSE, healthy women and others with endometriosis, provide peripheral and menstrual blood samples which are stored in a biobank so that they can be analysed in current and future research studies.

The recently-published study focused on the role of stromal fibroblasts, a type of stem cell found in menstrual blood, and the immune system. Professors Christine N.Metz, PhD and Peter K.Gregersen, MD, along with Laura A. Warren, an MD-PhD student at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell have led this research effort.

“The cause of endometriosis is not known. One theory is retrograde menstruation, which is where menstrual blood containing uterine tissue is transported into the abdominal cavity instead of out of the body. Almost all women experience retrograde menstruation, but we’re unsure why in some women this endometrial tissue latches on to the abdominal wall and internal organs and grows causing endometriosis,” said Dr. Metz. “In this study, we found that the stem cells in the menstrual blood of women with endometriosis are very different from those of healthy women and we are learning from these differences to develop a novel non-invasive diagnostic test.”

Metz and her colleagues observed that the menstrual blood of endometriosis patients contained a significantly smaller number of uterine natural killer (uNK) cells compared with healthy participants. In addition to this decrease, they observed that endometriosis patients’ stem cells showed impaired decidualization, a process that prepares the uterus for embryo implantation.

“Instead of having to undergo surgery to accurately diagnose endometriosis, these findings will enable us to develop a rapid test for endometriosis based on menstrual blood, which can be easily collected. This will allow medical professionals to know if someone is at risk of developing endometriosis and start treatment sooner, and it will help them monitor patients’ responses to treatment,” said Dr. Gregersen. “Endometriosis is a chronic, complex condition and improved understanding of this disease through studying menstrual blood is likely to drive personalization of new therapies.”

 

You can read the data published in Molecular Medicine, here:

https://molmed.biomedcentral.com/articles/10.1186/s10020-018-0009-6.

Source: https://www.feinsteininstitute.org/2018/03/feinstein-institute-discovery-promises-improved-diagnosis-understanding-endometriosis/

Image credit: http://healthizmo.com/endometriosis-what-you-need-to-know

Breast feeding linked to lower risk of endometriosis

Breast feeding linked to lower risk of endometriosis

 

BY I. SOUSSIS MD

FERTILITY SPECIALIST

A new study, which followed more than 72 thousand women for more than 20 years, has found that breast feeding is linked to a lower risk of being diagnosed with endometriosis.

Researchers found that among the 72,394 women who had one or more pregnancies (that lasted at least 6 months) there were 3,296 laparoscopically confirmed cases of endometriosis. Compared with women who nursed for less than a month per pregnancy, those who nursed for a year or more had a 32% reduced risk of endometriosis. For each additional three months of breast feeding, the risk was reduced by 8%.

The association between the risk reduction and breast feeding may be mediated at least in part by amenorrhea, according to the researchers who analyzed data from Nurses’ Health Study II (NHS II).

The study, led by Brigham and Women’s Hospital (BWH) in Boston, MA, and published in the British Medical Journal. It is the largest study to date on the link between breast feeding and the risk of endometriosis.

A 40% reduced risk of endometriosis was seen in women who breastfed for ≥ 36 months during their reproductive lives versus women who never breastfed.

Incidence of endometriosis was 453 per 100,000 person-years in the women who breastfed for less than a month versus 184 per 100,000 person-years for those who reported a lifetime total ≥ 36 months. Every additional 3 months of total breastfeeding per pregnancy was associated with an 8% lower risk of endometriosis. A 14% lower risk of endometriosis was seen for every additional 3 months of exclusive breastfeeding.

The protective association with breast feeding was strongest among women who had given birth within the last 5 years. Postpartum amenorrhea partially influenced the association with breastfeeding (34% total breast feeding and endometriosis and 57% for exclusive breast feeding and endometriosis).

Endometriosis is a chronic, incurable gynecologic disorder that affects girls and women. The disorder arises when tissue that is similar to the lining of the uterus (endometrium) is found attached to other areas in the body, generally in the pelvic cavity. As a result, most women with endometriosis experience “chronic pelvic pain, painful periods, and pain during intercourse.

 

How successful is egg donation in women with endometriosis?

By I.Soussis MD

Egg donation is a fantastic tool in our hands, that allows us to explore how endometriosis affects the results of IVF.

Its action is through the endometrium or through the quality of the oocytes and subsequently through the quality of the produced embryos?

In trying to answer the question two different approaches have been taken:

1. The eggs of the same donor were shared by two recipients. One recipient is healthy and the other suffers from endometriosis. Data was prospectively collected and the pregnancy rates between the two groups compared.

2. Retrospective studies with oocyte donation cycles, in which a recipient became pregnant and the other not. The data was analyzed according  to the cause of infertility. We also examined the origin of the eggs and compared the pregnancy rates between recipients, receiving ova from donors with endometriosis or without endometriosis.

Diaz et al 2000, from the Valencia Infertility Institute IVI IVF studied 58 recipients. Of these 25 were suffering from severe endometriosis stage III and IV. The remaining 33 recipient did not suffer from endometriosis. Both groups of women followed the same preparation of the endometrium, prior to embryo transfer. The number of fertilized eggs, of transferred embryos, the pregnancy rates and abortion rates were similar in both groups. So severe endometriosis does not affect pregnancy rates when the eggs come from healthy donors.

Similar results were reported from 444 egg donation cycles in 222 recipients from Bodri et al 2007.

Simon et al. 1994 again from I.V.I IVF retrospectively examined 178 embryo transfers into 141 recipients. Significantly lower pregnancy rates were found in women who received oocytes from donors with endometriosis.

To further investigate the influence of endometriosis on the endometrium or the egg, the same group of scientists in Spain, organized a prospective study Pelicer et al 1994.

Patients were divided into three groups. A: 44 donors without endometriosis who gave eggs to healthy recipients, B: 14 donors with endometriosis who gave eggs to healthy recipients, and C: 16 donors without endometriosis donated to recipients with endometriosis.

Significantly lower embryo implantation rates were observed in group B 6.8% versus 20.1% A and 20.8% C.

Significantly lower rates of pregnancy were observed in group B 28.6% vs. 61.4% A and 60% C.

Budak et al 2007 studied retrospectively> 10,000 oocyte donation cycles over a period of 10 years. They confirmed that pregnancy rates in recipients with endometriosis were identical to those women without endometriosis.

In agreement with the mentioned studies, analysis of the results of egg donation  in our IVF Unit in Athens, IVF & Genetics, showed that the recipients with endometriosis have excellent pregnancy rates of 60%.

Conclusions:

1. Pregnancy rates after oocyte donation in recipients with endometriosis are excellent, when the eggs originate from donor without endometriosis and they can reach 61.4%.

2. Pregnancy rates after oocyte donation are lower than expected, even in healthy recipients, when the eggs originate from donors with endometriosis.

3. Endometriosis affects the quality of the eggs.

 

 

 

How successful is intrauterine insemination in women with endometriosis?

By I. Soussis MD

How successful is intrauterine insemination in infertile women with endometriosis?

Tummon et al. 1997 enrolled 103 infertile couples with endometriosis stage I and II in a prospective randomized  study. Of those patients 53 underwent superovulation treatment with gonadotrophins and intrauterine insemination (127 cycles) and  the remaining 50 were the control group and were just observed for 184 cycles. The birth rate in the treatment group were 5-6 higher than the controls.

Cumulative pregnancy rate. Women with IUI and superovulation versus no treatment

Cumulative pregnancy rate.
Women with IUI and superovulation versus no treatment

In another study, initially randomized, Nulsen et al. 1993, compared superovulation with gonadotrophins and intrauterine insemination with insemination without superovulation.

The success rate was 5.7 times higher in the superovulation group.

Werbrouck et al. 2006, studied infertile women with endometriosis, who were treated with gonadotrophins and intrauterine insemination within six months from their laparoscopy. They reported pregnancy rates similar to those with unexplained infertility (20% vs 20,5%).

ESHRE Guidelines 2015:

1. Superovulation with gonadotrophins and intrauterine insemination in infertile women with endometriosis stage I and II increases the birth rate compared with conservative management (observation).

2. Superovulation with gonadotrophins and intrauterine insemination in infertile women with endometriosis stage I and II increases the birth rate compared with intrauterine insemination alone.

3. Superovulation with gonadotrophins and intrauterine insemination in infertile women with endometriosis, within six months of laparoscopy, is equally effective as in those with unexplained infertility.

Good Practice Point (opinion of the ESHRE specialists). IVF treatment is advised if there is tubal factor, sperm problems or other treatment have failed.

Antral follical count as a predictor of ovarian responsiveness in women with endometriosis or with a history of surgery for endometriosis

A vaginal ultrasound scan showing an ovary with an endometrioma. no other small follicles can be seen

A vaginal ultrasound scan showing an ovary with an endometrioma. no other small follicles can be seen

By I.Soussis MD

Antral follicle count AFC, has proven to be one of the most reliable predictors of ovarian response to the drug stimulation during IVF treatment. It refers to the number of small follicles counted at the ovary prior to starting the stimulation.

In 2015 Benaglia et al. researched AFC as a predictor in 83 women undergoing IVF due to endometriosis. These women had undergone surgery in the past for the removal of endometriosis(chocolate cyst) or had a cyst during their IVF attempt.

The ovaries were divided into four groups:

1-Ovaries without previous surgery and without endometriomas(42)

2-Ovaries without previous surgery, with endometriomas(46)

3-Ovaries with previous surgery without endometriomas(55)

4-Ovaries with previous surgery, with endometriomas(23)

The ovaries with surgery(78) and those with endometriomas(69) were analyzed statistically. The AFC was also investigated to see if it could predict poor ovarian stimulation (2 or less oocytes per stimulation) as well as hyperstimulation(7 or more oocytes per stimulation).

It was found that this predictor was prognostically useful, not only in ovaries with endometriomas but also in those without endometriomas and in those that had undergone surgery for endometriomas.

The most useful predictors of ovarian response and IVF success is the combination of the woman’s age, the antral follicle count and the levels of the hormones FSH and AMH.

Fertil Steril. 2015 Apr 29. pii: S0015-0282(15)00218-6. doi: 10.1016/j.fertnstert.2015.03.013. [Epub ahead of print]

Antral follicle count as a predictor of ovarian responsiveness in women with endometriomas or with a history of surgery for endometriomas.

Benaglia L1, Candotti G2, Busnelli A3, Paffoni A2, Vercellini P3, Somigliana E3.

Endometriosis Fertility Index(EFI). A new reliable and validated predictive index for natural conception in women with endometriosis

By I.Soussis  MD

Scientists have expressed their disappointment over the decades, regarding the lack of correlation between the staging of endometriosis and the severity of the clinical symptoms, a woman experiences. In this regard women with severe endometriosis have no pain whatsoever, where as those with slight endometriosis can suffer from severe period pain. The same also applies regarding endometriosis and infertility.

There are a lot of good reasons for having an effective staging protocol of any illness/disorder, especially so of endometriosis. This way, scientists would all speak the same language, the diagnosis would be more reliable, comparing treatments would be easier and the progress of research would be quicker, all of which would greatly benefit the patient.

Adamson and Pesta from the USA  introduced a new diagnostic index in 2010, that is able to predict better the chances of natural conception in women with surgically diagnosed and histologically proven endometriosis.

This endometriosis Fertility Index(EFI) was developed by retrospectively analyzing the data of 579 infertile women with endometriosis, who had undergone laparoscopic staging of the disease. The ovaries, fallopian tubes and fimbria were graded by the surgeon, according to their estimated functional ability. Furthermore, the age of the patient, the duration of infertility in years and the obstetric history were taken into consideration, when creating this new EFI.

Scientists studied prospectively the index in the next 222 women. They reported remarkably good correlation, of the predictive value of the index, for the chance of natural conception and pregnancy  and the clinical results for all stages of endometriosis. Especially women with an EFI score of 9-10, had the highest chance of natural conception. The percentage of pregnancies was 55% in the first year and 74% three years following the laparoscopy. In contrast, only 10% of women with a low EFI score of 0-3, became pregnant.

Adamson stated: “The EFI is a proven simple, reliable clinical tool, that predicts the chances of natural conception in women with endometriosis. It reassures women who have a good prognosis and avoids wasting time in those with a poor prognosis”.

The reliability of the EFI has been reassessed in various studies and different populations.

Wong et al. from China reported on 2013 that the use of the EFI helped to predict better the chances of natural conception, in 199 women with endometriosis, than the older staging system from the American Fertility Society rAFS.

Garaveglia et al. analyzed the reliability of the EFI in 104 Italian women with endometriosis in 2015. The index proved to be a reliable prognostic tool.

Tomasetti et al. studied 233 European women with endometriosis in Belgium in 2013. They found a statistically significant relationship between the EFI and the time it took for a woman to conceive naturally.

Boujenah et al. showed in 2015 in France, that the EFI could reliably predict the natural conception of women with endometriosis. When laparoscopic treatment was used in conjunction with IVF, the percentage of pregnancies within 18 months was 78.8%.

All women undergoing laparoscopy and treatment of endometriosis, should ask their doctor to calculate their EFI.

This way they will posses a reliable tool, to help them decide in an unbiased manner, if they can attempt to conceive naturally or if they should turn to IVF, without wasting any precious time.

this form can be used to calculate EFI. the last chart shows the expected pregnancy rate according to the EFI score. G. David Adamson and J Pasta. Fertil Steril 2010;94:1609-15

this form can be used to calculate EFI. the last chart shows the expected pregnancy rate according to the EFI score. G. David Adamson and J Pasta. Fertil Steril 2010;94:1609-15

 

 

Men living with endometriosis: insights and experiences of male partners, living with women with endometriosis

Image courtesy of holohololand at FreeDigitalPhotos.net

Image courtesy of holohololand at FreeDigitalPhotos.net

By I.Soussis MD

Hudson et al. from the UK, presented an interesting study at the latest ESHRE conference, held in Lisbon Portugal in June 2015.

The main question was: How do partners of women with endometriosis perceive the disorder and how do they help their wives/partners to deal with their symptoms and to seek medical help?

Endometriosis is a chronic gynaecological condition(disorder), affecting 5-15% of women, during their reproductive age.  The symptoms include painful menstruation, painful intercourse, tiredness, chronic pelvic pain and heavy periods.  Furthermore, 40% of visits to  fertility clinics are due to endometriosis.

Many studies show the negative effect endometriosis has on social and marital relations, as well as the help that the male partner provides.  However, most of these studies focus on the women’s experiences.

In this study “Endopart UK”, 22 heterosexual couples were interviewed.  The inclusion criteria were, a laparoscopic diagnosis of endometriosis and the cohabitation of the couple.  Both men and women were interviewed separately.

It was found that the impact endometriosis had on the daily lives of the men and on their feelings was impressive.

Every long term disorder affects the healthy partner, but endometriosis more than any other, because it affects the reproduction and sex life of the couple.

The partners took an active role during doctor’s appointments and helped their female partners to choose the right treatment. Their support during the implementation of the treatment was significant.

In the future, the treatment should not just focus on the woman, but should take into account the effect that endometriosis and its treatment have on the quality of the couple’s life and also that of the male partner.

ESHRE 2015, O-080: Men living with endometriosis:perceptions and experiences of male partners of women with the condition. N. Hudson, L.Culley, H. Mitchell, C.Law, E. Denny, N. Raine-Fenning

Natural conception in women with deep infiltrating endometriosis

By I.Soussis MD

How high is the percentage of natural conception and pregnancy in women with untreated colorectal endometriosis?

Erasmo et al. from Genova, Italy attempted to answer this question. Their study was presented at the ESHRE annual conference in Lisbon in 2015.

The study involved 55 patients with colorectal endometriosis, attempting to get pregnant, between 2009 and 2014.  Their partners all had normal sperm count.  All patients with a bowel stenosis (narrowing) greater than 60% and those who had undergone surgery for endometriosis, were excluded from the study.

 

Results:

The average age of patients was 33 years.  Natural conception happened in 17 patients(30.9%).  The average time to conception was nine months(2-32).

Twelve patients conceived with IUI or IVF(21.8%) over an average of 21 months (2-54).  After the first pregnancy, 3 out of 7 patients conceived naturally the second time.

The total percentage of pregnancies was 52.7% (29/55 women) with an average follow up of 21.5 months (2-54).

 

Conclusion:

At least half of women (50%) with deep infiltrating endometriosis can spontaneously conceive following IUI or IVF without having to undergo surgery for the removal of endometriosis.

P-324,ESHRE 2015. Fertility in patients with untreated colorectal endometriosis.

I. Erasmo, F. Sozzi, A Racca, U. Leone Roberti Maggiore, P. L. Venturini, V. Remogida, S. Ferrero

University of Genoa

Spontaneous Miscarriage In Women With Endometriosis

Image courtesy of imagerymajestic at FreeDigitalPhotos.net

Image courtesy of imagerymajestic at FreeDigitalPhotos.net

By I.Soussis MD

If women suffering with endometriosis have a higher risk of adverse pregnancy outcome in early pregnancy, such as spontaneous miscarriage or ectopic pregnancy, was not well documented up to now.

A study from Japan compared 49 pregnant women with endometriosis to 59 without the disease. They found that the incidence of spontaneous miscarriage was not  statistically significant different among the two groups. (18,4% in women with and 18,6% in women without endometriosis). Obviously in this study the numbers are small and its statistical power is rather weak.

Aris  studied the impact of endometriosis  on adverse pregnancy outcome in the Eastern Townships of Canada, over a 12 year period. The pregnancies studied were 31068 and of those 784 were in women with endometriosis (2,5%). In 183/784 pregnancies in women with endometriosis, an adverse outcome was recorded (23,3%). The risk of spontaneous miscarriage in women with endometriosis was statistically significant higher than the general population. The risk of miscarriage was almost twice than in women without endometriosis (1,89).

Saraswat et al. presented in Lisbon at the annual meeting of ESHRE 2015, an extremely interesting linkage analysis of the Scottish national registry. They studied 14655 women discharged from all Scottish national hospitals over a period of 30 years (1981-2010). They compared the pregnancy outcome in  5375 women with surgically confirmed endometriosis to 8280 women without endometriosis, who were pregnant at the same period. The chance of adverse pregnancy outcome in the first trimester was significantly higher in women with endometriosis. More specific the risk of spontaneous miscarriage was 1,7  and the risk of ectopic pregnancy was 2,7 times higher, than in women without endometriosis.

The statistical power of the last two studies is extremely strong. Indeed Saraswat et al. studied the whole population of Scotland over a long period of time.

Conclusions: The presence of endometriosis increases the risk of spontaneous miscarriage and ectopic pregnancy. Women with endometriosis should be followed closely in the first trimester of pregnancy. They should also be informed of the increased chances of adverse pregnancy outcome.

Eur J Obstet Gynecol Reprod Biol. 2014 Jan;172:36-9. doi: 10.1016/j.ejogrb.2013.10.024. Epub 2013 Oct 31. Endometriosis and pregnancy outcome: are pregnancies complicated by endometriosis a high-risk group? Mekaru K1, Masamoto H2, Sugiyama H2, Asato K2, Heshiki C2, Kinjyo T2, Aoki Y2.

Gynecol Endocrinol. 2014 Jan;30(1):34-7. Doi:10.3109/09513590.2013.848425. Epub 2013 Oct 17.  A 12 year cohort study of adverse pregnancy outcome in Eastern Townships of Canada: impact of endometriosis. Aris A.

ESHRE 2015, O-122. Reproductive and pregnancy outcomes in women with endometriosis: a Scottish national record linkage study L.Saraswat, D.Ayansina, S.Bhattacharya, D.Miligkos, A.Horne, K. Cooper, S. Bhattacharya.

Ενδομητρίωση και Αποβολές Κυήσεως

Image courtesy of imagerymajestic at FreeDigitalPhotos.net

Image courtesy of imagerymajestic at FreeDigitalPhotos.net

Άρθρο του Ι.Σούση

Το κατά πόσον γυναίκες με ενδομητρίωση αντιμετωπίζουν μεγαλύτερη πιθανότητα αποβολής κατά το πρώτο τρίμηνο της εγκυμοσύνης, λόγω της ενδομητρίωσης, δεν ήταν καλά τεκμηριωμένο μέχρι πρόσφατα.

Μια μελέτη από την Ιαπωνία συνέκρινε 49 έγκυες με ενδομητρίωση, με 59 έγκυες που δεν έπασχαν από τη νόσο. Δεν βρήκαν στατιστικά σημαντικές διαφορές στην συχνότητα αποβολών ανάμεσα στις δύο ομάδες (18,4% σε γυναίκες με ενδομητρίωση και 18,6% σε γυναίκες χωρίς). Βέβαια ο αριθμός των γυναικών ήταν μικρός και η στατιστική δύναμη της μελέτης ασθενής.

Ο Aris μελέτησε την επίδραση της ενδομητρίωσης στα ποσοστά αυτόματων αποβολών και τις επιπλοκές της εγκυμοσύνης, για μία περίοδο 12 ετών, στις Ανατολικές περιοχές του Καναδά. Από τις 31068 εγκυμοσύνες, οι 784 ήταν σε γυναίκες με ενδομητρίωση (2,5%). Σε 183/784 κυήσεις παρουσιάστηκαν επιπλοκές (23,3%). Ο κίνδυνος αυτόματης αποβολής σε γυναίκες με ενδομητρίωση ήταν στατιστικά σημαντικά υψηλότερος. Οι γυναίκες με ενδομητρίωση είχαν σχεδόν διπλάσιο κίνδυνο αυτόματης αποβολής από τον γενικό πληθυσμό (χ1,89).

Η Saraswat και οι συνεργάτες της παρουσίασαν στη Λισαβώνα τον Ιούνιο του 2015 στο ετήσιο συνέδριο της Ευρωπαϊκής Εταιρείας Ανθρώπινης Αναπαραγωγής (ESHRE 2015), μία μελέτη από τα Εθνικά Αρχεία της Σκωτίας. Πιο συγκεκριμένα μελέτησαν 14655 γυναίκες που παρακολουθήθηκαν για 30 χρόνια (1981-2010) από όλα τα νοσοκομεία της Σκωτίας. Συνέκριναν την κατάληξη της εγκυμοσύνης σε 5375 γυναίκες με χειρουργικά επιβεβαιωμένη ενδομητρίωση και 8280 γυναίκες χωρίς ενδομητρίωση, που κυοφορούσαν κατά την ίδια χρονική περίοδο. Η πιθανότητα επιπλοκών της εγκυμοσύνης κατά το πρώτο τρίμηνο ήταν στατιστικά σημαντικά αυξημένη σε γυναίκες με ενδομητρίωση. Η πιθανότητα αυτόματης αποβολής ήταν 1,7 φορές υψηλότερη και εξωμητρίου κύησης 2,7 φορές υψηλότερη σε σχέση με γυναίκες που δεν είχαν ενδομητρίωση. Η στατιστική δύναμη των δύο τελευταίων μελετών είναι εξαιρετικά ισχυρή. Ιδιέταιρα η μελέτη της Saraswat αφορά τον συνολικό πληθυσμό της Σκωτίας για μία μακρά χρονική περίοδο.

Συμπέρασμα: Η παρουσία της ενδομητρίωσης αυξάνει την πιθανότητα αυτόματης αποβολής και εξωμητρίου κυήσεως. Γυναίκες με ενδομητρίωση πρέπει να παρακολουθούνται στενά κατά το πρώτο τρίμηνο της κυήσης και να είναι ενήμερες για την αυξημένη πιθανότητα αυτόματης αποβολής και εξωμητρίου κύησης.

Eur J Obstet Gynecol Reprod Biol. 2014 Jan;172:36-9. doi: 10.1016/j.ejogrb.2013.10.024. Epub 2013 Oct 31. Endometriosis and pregnancy outcome: are pregnancies complicated by endometriosis a high-risk group? Mekaru K1, Masamoto H2, Sugiyama H2, Asato K2, Heshiki C2, Kinjyo T2, Aoki Y2.

Gynecol Endocrinol. 2014 Jan;30(1):34-7. Doi:10.3109/09513590.2013.848425. Epub 2013 Oct 17.  A 12 year cohort study of adverse pregnancy outcome in Eastern Townships of Canada: impact of endometriosis. Aris A.

ESHRE 2015, O-122. Reproductive and pregnancy outcomes in women with endometriosis: a Scottish national record linkage study L.Saraswat, D.Ayansina, S.Bhattacharya, D.Miligkos, A.Horne, K. Cooper, S. Bhattacharya.

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