Background: The Endometriosis Fertility Index is a post-operative score which, on the basis of anamnestic data (historical factors) and the anatomical picture assessed at the end of surgery (surgical factors), estimates the probability of spontaneous conception 36 months after surgery. The possibility of assessing EFI during transvaginal ultrasound, rather than surgery, has recently been opened up, but there is still no conclusive data Aim of the study: the primary aim of the presented study is to verify whether the EFI score calculated at ultrasound can represent an accurate estimate of the classical EFI, which has already been extensively validated, thus assessing the concordance between the two scores. The secondary objective is to identify EFI score classes for which surgery could be avoided as non-resolving and unnecessary. Materials and methods: Patients aged 18-49 years, diagnosed with symptomatic endometriosis in search of pregnancy, referred to the "Endometriosis and Chronic Pelvic Pain" Outpatient Clinic of the UOC of Gynaecology and Obstetrics of the AOUPD were included. The EFI score was calculated at three different times for each patient: during the second level ultrasound, during the diagnostic laparoscopy and at the end of surgery. The concordance, both by absolute values and by clinical EFI class, between the two pre-operative EFIs, ultrasound (A) and laparoscopic (B) (primary outcome), was then compared. The concordance, both by absolute values and by EFI clinical class, between the ultrasound and post-operative EFI and between the laparoscopic and post-operative EFI was then assessed (secondary outcome). Results: comparing ultrasound and laparoscopic EFI, the concordance is good (Cohen's K = 0.74 for absolute values and 0.72 for clinical classes). Regarding the individual parameters LFS, AFS endo and AFS tot, the results obtained in the two pre-operative EFIs did not differ significantly (p value of 0.465 for LFS, 0.589 for AFS endo and 0.310 for AFS tot). The numerical concordance between the pre-operative EFI and the post-operative EFI was modest (EFI A vs C: K = 0.32; EFI B vs C: K = 0.29). The concordance tends to increase when clinical classes are considered instead of absolute values (EFI A vs C: K = 0.55; EFI B vs C: K = 0.51). In patients with low ultrasound EFI, 66.7% progressed to intermediate clinical class post-operatively. In the patients with an intermediate ultrasound EFI, 53.8% switched to high clinical class. Finally, of the patients with a high ultrasound EFI, 95% remained in the high clinical class. Conclusions: the present study confirms that the ultrasound can be a useful and sensitive tool for assessing EFI and, therefore, the likelihood of spontaneous pregnancy in relation to the state of pelvic anatomy impairment. Surgery is associated with fertility benefit predominantly in the high and intermediate clinical classes, and the course of clinical management of infertile patients with endometriosis must certainly be personalised according to the clinical picture and wishes of each patient, and according to factors such as age, ovarian reserve, personal desire. The EFI proves to be a fundamental pre-operative tool for identifying the best alternatives for each patient: options range from starting a PMA pathway, to operative laparoscopy, to spontaneous pregnancy attempts.
Background: l'Endometriosis Fertility Index è un punteggio post-operatorio che, sulla base di dati anamnestici (fattori storici) e del quadro anatomico valutato al termine dell'intervento (fattori chirurgici), stima la probabilità di concepimento spontaneo a 36 mesi dall'intervento chirurgico. Si è recentemente aperta la possibilità di valutare l’EFI in sede di ecografia transvaginale, anziché in sede di intervento chirurgico, ma non esistono ancora dati certi sulla sua affidabilità rispetto all’EFI classico, già ampiamente validato. Scopo dello studio: l’obiettivo primario dello studio presentato è verificare se il punteggio EFI calcolato in sede di ecografia può rappresentare una stima accurata dell’EFI classico, già ampiamente validato, valutando quindi la concordanza tra i due punteggi. L’obiettivo secondario è identificare classi di punteggio EFI per cui l’intervento chirurgico potrebbe essere evitato, in quanto non risolutivo e non necessario. Materiali e metodi: sono state incluse pazienti di età compresa tra i 18 e i 49 anni, con diagnosi di endometriosi sintomatica in cerca di una gravidanza, afferite all’Ambulatorio “Endometriosi e Dolore pelvico cronico” della UOC di Ginecologia e Ostetricia dell’AOUPD. Il punteggio EFI è stato calcolato in tre momenti differenti per ciascuna paziente: durante l’ecografia di secondo livello, durante la laparoscopia diagnostica e al termine dell’intervento chirurgico. È stata successivamente confrontata la concordanza, sia per valori assoluti sia per classe clinica EFI, tra i due EFI pre-operatori, ecografico (A) e laparoscopico (B) (outcome primario). È stata poi valutata la concordanza, sia per valori assoluti sia per classe clinica EFI, tra EFI ecografico e post-operatorio e tra EFI laparoscopico e post-operatorio (outcome secondario). Risultati: confrontando EFI ecografico e laparoscopico, la concordanza è risultata essere buona (K= 0.74 per valori assoluti e K=0.72 per le classi cliniche). Per quanto riguarda i singoli parametri LFS, AFS endo e AFS tot, i risultati ottenuti nei due EFI pre-operatori non differiscono significativamente (p value pari a 0.465 per il LFS, 0.589 per l’AFS endo e 0.310 per l’AFS tot). La concordanza numerica tra gli EFI pre-operatori e l’EFI post-operatorio risulta essere modesta (EFI A vs C: Kappa pari a 0.32; EFI B vs C: Kappa pari a 0.29), con una tendenza ad aumentare quando si considerano le classi cliniche invece dei valori assoluti (EFI A vs C: Kappa pari a 0.55; EFI B vs C: Kappa pari a 0.51). Nelle pazienti con EFI ecografico basso, il 66.7% è passato a classe clinica intermedia inseguito all’intervento. Nelle pazienti con EFI ecografico intermedio, il 53.8% è passato a classe clinica alta. Infine, delle pazienti con EFI ecografico alto, il 95% si è mantenuto nella classe clinica alta. Conclusioni: Il presente studio conferma che l’ecografia può rappresentare un utile e sensibile strumento per valutare l’EFI e, dunque, la probabilità di gravidanza spontanea in relazione allo stato di compromissione dell’anatomia pelvica. L’intervento chirurgico si associa a beneficio in termini di fertilità prevalentemente per le classi cliniche alta e intermedia, e il percorso di gestione clinica di pazienti infertili con endometriosi deve essere senz’altro personalizzato in base al quadro clinico e ai desideri di ciascuna paziente, ed in base a fattori quali età, riserva ovarica, desiderio personale. L’EFI si conferma uno strumento pre-operatorio fondamentale per identificare le alternative migliori percorribili per ciascuna paziente: le opzioni spaziano dall’avviamento di un percorso di PMA, alla laparoscopia operativa, a tentativi di gravidanza spontanea.
Endometriosis Fertility Index: da modello post-operatorio predittivo di gravidanza a modello pre-operatorio. Ruolo dell'ecografia pelvica.
MASSIMI, CHIARA
2023/2024
Abstract
Background: The Endometriosis Fertility Index is a post-operative score which, on the basis of anamnestic data (historical factors) and the anatomical picture assessed at the end of surgery (surgical factors), estimates the probability of spontaneous conception 36 months after surgery. The possibility of assessing EFI during transvaginal ultrasound, rather than surgery, has recently been opened up, but there is still no conclusive data Aim of the study: the primary aim of the presented study is to verify whether the EFI score calculated at ultrasound can represent an accurate estimate of the classical EFI, which has already been extensively validated, thus assessing the concordance between the two scores. The secondary objective is to identify EFI score classes for which surgery could be avoided as non-resolving and unnecessary. Materials and methods: Patients aged 18-49 years, diagnosed with symptomatic endometriosis in search of pregnancy, referred to the "Endometriosis and Chronic Pelvic Pain" Outpatient Clinic of the UOC of Gynaecology and Obstetrics of the AOUPD were included. The EFI score was calculated at three different times for each patient: during the second level ultrasound, during the diagnostic laparoscopy and at the end of surgery. The concordance, both by absolute values and by clinical EFI class, between the two pre-operative EFIs, ultrasound (A) and laparoscopic (B) (primary outcome), was then compared. The concordance, both by absolute values and by EFI clinical class, between the ultrasound and post-operative EFI and between the laparoscopic and post-operative EFI was then assessed (secondary outcome). Results: comparing ultrasound and laparoscopic EFI, the concordance is good (Cohen's K = 0.74 for absolute values and 0.72 for clinical classes). Regarding the individual parameters LFS, AFS endo and AFS tot, the results obtained in the two pre-operative EFIs did not differ significantly (p value of 0.465 for LFS, 0.589 for AFS endo and 0.310 for AFS tot). The numerical concordance between the pre-operative EFI and the post-operative EFI was modest (EFI A vs C: K = 0.32; EFI B vs C: K = 0.29). The concordance tends to increase when clinical classes are considered instead of absolute values (EFI A vs C: K = 0.55; EFI B vs C: K = 0.51). In patients with low ultrasound EFI, 66.7% progressed to intermediate clinical class post-operatively. In the patients with an intermediate ultrasound EFI, 53.8% switched to high clinical class. Finally, of the patients with a high ultrasound EFI, 95% remained in the high clinical class. Conclusions: the present study confirms that the ultrasound can be a useful and sensitive tool for assessing EFI and, therefore, the likelihood of spontaneous pregnancy in relation to the state of pelvic anatomy impairment. Surgery is associated with fertility benefit predominantly in the high and intermediate clinical classes, and the course of clinical management of infertile patients with endometriosis must certainly be personalised according to the clinical picture and wishes of each patient, and according to factors such as age, ovarian reserve, personal desire. The EFI proves to be a fundamental pre-operative tool for identifying the best alternatives for each patient: options range from starting a PMA pathway, to operative laparoscopy, to spontaneous pregnancy attempts.| File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.12608/65810