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Study Question: What are the pain characteristics among women, with no prior endometriosis diagnosis, undergoing laparoscopy or laparotomy regardless of clinical indication?, Summary Answer: Women with surgically visualized endometriosis reported the highest chronic/cyclic pain and significantly greater dyspareunia, dysmenorrhea, and dyschezia compared with women with other gynecologic pathology (including uterine fibroids, pelvic adhesions, benign ovarian cysts, neoplasms and congenital Müllerian anomalies) or a normal pelvis., What Is Known Already: Prior research has shown that various treatments for pain associated with endometriosis can be effective, making identification of specific pain characteristics in relation to endometriosis necessary for informing disease diagnosis and management., Study Design, Size, Duration: The study population for these analyses includes the ENDO Study (2007-2009) operative cohort: 473 women, ages 18-44 years, who underwent a diagnostic and/or therapeutic laparoscopy or laparotomy at one of 14 surgical centers located in Salt Lake City, UT or San Francisco, CA. Women with a history of surgically confirmed endometriosis were excluded., Participants/materials, Setting and Methods: Endometriosis was defined as surgically visualized disease; staging was based on revised American Society for Reproductive Medicine (rASRM) criteria. All women completed a computer-assisted personal interview at baseline specifying 17 types of pain (rating severity via 11-point visual analog scale) and identifying any of 35 perineal and 60 full-body front and 60 full-body back sites for which they experienced pain in the last 6 months., Main Results and the Role of Chance: There was a high prevalence (≥30%) of chronic and cyclic pelvic pain reported by the entire study cohort regardless of post-operative diagnosis. However, women with a post-operative endometriosis diagnosis, compared with women diagnosed with other gynecologic disorders or a normal pelvis, reported more cyclic pelvic pain (49.5% versus 31.0% and 33.1%, P < 0.001). Additionally, women with endometriosis compared with women with a normal pelvis experienced more chronic pain (44.2 versus 30.2%, P = 0.04). Deep pain with intercourse, cramping with periods, and pain with bowel elimination were much more likely reported in women with versus without endometriosis (all P < 0.002). A higher percentage of women diagnosed with endometriosis compared with women with a normal pelvis reported vaginal (22.6 versus 10.3%, P < 0.01), right labial (18.4 versus 8.1%, P < 0.05) and left labial pain (15.3 versus 3.7%, P < 0.01) along with pain in the right/left hypogastric and umbilical abdominopelvic regions (P < 0.05 for all). Among women with endometriosis, no clear and consistent patterns emerged regarding pain characteristics and endometriosis staging or anatomic location., Limitations, Reasons for Caution: Interpretation of our findings requires caution given that we were limited in our assessment of pain characteristics by endometriosis staging and anatomic location due to the majority of women having minimal (stage I) disease (56%) and lesions in peritoneum-only location (51%). Significance tests for pain topology related to gynecologic pathology were not corrected for multiple comparisons., Wider Implications of the Findings: Results of our research suggest that while women with endometriosis appear to have higher pelvic pain, particularly dyspareunia, dysmenorrhea, dyschezia and pain in the vaginal and abdominopelvic area than women with other gynecologic disorders or a normal pelvis, pelvic pain is commonly reported among women undergoing laparoscopy, even among women with no identified gynecologic pathology. Future research should explore causes of pelvic pain among women who seek out gynecologic care but with no apparent gynecologic pathology. Given our and other's research showing little correlation between pelvic pain and rASRM staging among women with endometriosis, further development and use of a classification system that can better predict outcomes for endometriosis patients with pelvic pain for both surgical and nonsurgical treatment is needed., Study Funding/competing Interests: Supported by the Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development (contracts NO1-DK-6-3428, NO1-DK-6-3427, and 10001406-02). The authors have no potential competing interests., (© The Author 2015. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: We questioned whether a laparoscopy should be performed after a normal hysterosalpingography before starting intrauterine inseminations (IUI) in order to detect further pelvic pathology and whether a postponed procedure after six unsuccessful cycles of IUI yields a higher number of abnormal findings., Methods: In a randomized controlled trial, the accuracy of a standard laparoscopy prior to IUI was compared with a laparoscopy performed after six unsuccessful cycles of IUI. The major end-point was the number of diagnostic laparoscopies revealing pelvic pathology with consequence for further treatment such as laparoscopic surgical intervention, IVF or secondary surgery. Patients were couples with medical grounds for IUI such as idiopathic subfertility, mild male infertility and cervical hostility., Results: Seventy-seven patients were randomized into the diagnostic laparoscopy first (DLSF) group and the same number was randomized into the IUI first (IUIF) group. The laparoscopy was performed on 64 patients in the DLSF group, 10 patients withdrew their consent from participation and three patients (3%) became pregnant prior to laparoscopy. In the IUIF group, 23 patients remained for laparoscopy because pregnancy did not occur after six cycles of IUI. From the original 77 randomized patients, 38 patients became pregnant and 16 patients dropped out. Abnormal findings during laparoscopy with therapeutic consequences were the same in both groups: in the DLSF group, 31 cases (48%) versus 13 cases (56%) in the IUIF group, P = 0.63; odds ratio (OR) = 1.4; 95% confidence interval (CI): 0.5-3.6. The ongoing pregnancy rate in the DLSF group was 34 out of 77 patients (44%) versus 38 out of 77 patients (49%) in the IUIF group (P = 0.63; OR = 1.2; 95% CI: 0.7-2.3)., Conclusions: Laparoscopy performed after six cycles of unsuccessful IUI did not detect more abnormalities with clinical consequences compared with those performed prior to IUI treatment. Our data suggest that the impact of the detection and the laparoscopic treatment of observed pelvic pathology prior to IUI seems negligible in terms of IUI outcome. Therefore, we seriously question the value of routinely performing a diagnostic and/or therapeutic laparoscopy prior to IUI treatment. Further prospective studies could be performed to determine the effect of laparoscopic interventions on the success rate of IUI treatment in order to rule out completely the laparoscopy from the diagnostic route prior to IUI.

Background: A new technique called transvaginal hydrolaparoscopy (THL) was recently developed for the exploration of the tubo-ovarian structures in infertile patients without obvious pelvic pathology. This study was performed to investigate the usefulness of THL to evaluate Chlamydia trachomatis tubal infertility., Methods: Forty-one women with primary and secondary infertility participated in this study. Fourteen had past C. trachomatis infection. In 38 (92.7%) of the 41, access to the pouch of Douglas was obtained. In total, 71 (93.4%) out of 76 adnexa were clearly visualized. Thirty-seven patients were analysed and compared their tubal passages and peritubal adhesions using both hysterosalpingography (HSG) and THL. Twenty-four tubes from 14 patients with past C. trachomatis infection and 44 tubes from 23 patients without a history of C. trachomatis infection were compared., Results: For the diagnosis of the tubal passage, there were no significant differences in the discrepancy rates between HSG and THL, in patients with and without past C. trachomatis infection. In 14 (58.3%) of the 24 tubes from patients with past C. trachomatis infection and in eight (18.2%) of the 44 tubes from patients without infection, peritubal adhesion was diagnosed only by THL. There was a significant difference in the discrepancy rates of the diagnosis of peritubal adhesion between HSG and THL in the two groups (P = 0.0007 )., Conclusions: These results suggest that C. trachomatis infection is highly associated with peritubal adhesion which is difficult to diagnose by HSG. Therefore, in C. trachomatis antibody-positive patients, exclusion of tubal pathology by THL or standard laparoscopy should be carried out to consider appropriate treatments. Although THL is not a substitute for laparoscopy, it can be proposed as a first line procedure in the early stages of the infertility investigation.

To assess the efficiency of transvaginal ultrasonography (TVUS) in the screening of pelvic pathologies in the initial workup of infertile women, we carried out a prospective comparison of sonographic diagnosis with laparoscopic and pathological findings. Between February 1994 and April 1995, 133 premenopausal non-pregnant women underwent TVUS on the day before laparoscopy. The efficiency of TVUS in detecting pelvic pathologies was 90.2% with a sensitivity of 86.2%, a specificity of 97.8% and positive and negative predictive values of 98.6 and 78.8% respectively. If the six false-negative cases with a histological diagnosis of minimal endometriosis were defined as 'normal pelvis', sensitivity and specificity could be corrected to 92.5 and 98.6% respectively. Endometriomas were diagnosed by TVUS with an efficiency of 96.4%, with a sensitivity and a specificity of 90 and 96.7 % and with positive and negative predictive values of 75 and 99.1% respectively. The sensitivity of vaginal sonographic characterization of pelvic adhesions was 61.1% with a specificity and positive predictive value of 98.2 and 84.6%. The negative predictive value of TVUS was 94.1%. These data suggest that it is not possible to characterize pelvic adhesions, especially filmy adhesions, with acceptable accuracy. However, in the initial workup of infertile women, if the patient is young, if both hysterosalpingography and TVUS are negative, laparoscopy could be postponed. In couples with severe male factor infertility and for whom in-vitro fertilization or intracytoplasmic sperm injection is the treatment of choice, laparoscopy might be avoided where the TVUS is negative.

This study was designed to evaluate the routine use of rigid salpingoscopy during diagnostic laparoscopy for infertility, and to relate the morphologic image of the endosalpinx with pregnancy outcome. A total of 158 consecutive patients (232 Fallopian tubes) undergoing a diagnostic laparoscopy for infertility were studied. Salpingoscopy was performed at the time of diagnostic laparoscopy for infertility. The intraluminal image was classified using a simplified classification (class I-V). The relationship between this classification and the cumulative pregnancy rates was calculated using life table analysis. Patients with a normal salpingoscopy (class I and II) had a 71% cumulative pregnancy rate. In the intermediate group (class III) the cumulative pregnancy rate was 34%. No intrauterine pregnancies were observed in the group with severe intratubal pathology (class IV and V). Of the 107 slapingoscopies of patients with endometriosis 105 (98%) were class I or II. However, among patients with pelvic adhesions, only 42% were normal. Nine out of 50 abnormal salpingoscopies were found when no tubal factor was suspected during laparoscopy, without any pelvic adhesions. These results suggest that salpingoscopy is an important tool for detecting mucosal abnormalities, and for eventually referring patients for assisted reproductive technology. Salpingoscopy is usually normal in patients with endometriosis, but in patients with non-endometriotic pelvic adhesions it is not.

The objective of this study was to investigate intra-observer as well as inter-observer variability in the assessment of laparoscopic scoring of adhesive disease. Patients with suspected pelvic adhesions underwent a laparoscopic examination and surgical correction, using a standardized adhesion scoring system for severity as well as for extent of the adhesive process. An active agent or placebo was placed in the peritoneal cavity to discourage reformation of adhesions on a double-blind basis. A second laparoscopy was performed in 6-10 weeks and patients were re-scored. The videotapes were viewed and re-scored by the operator and four other gynaecological surgeons on two occasions, 3 months apart. Both adhesion severity and extent scores were lower following laparoscopic intervention. Reliability coefficients as defined by intra-class correlations were large indicating good reliability (0.778 and 0.758 for severity and extent respectively). Intra-observer (replication) variability was 12% of the total versus 19% for inter-observer variability of adhesion severity. These values were 15.4 and 22.3% of the total respectively, for adhesion extent. Individual observers tended to up-grade severity and minimize extent of adhesions when comparing the second with the first videotape views. The surgeon recorded greater adhesion score differences between the two procedures than the other observers. Though two physicians consistently had higher scores than two others, the intra-observer and interobserver variabilities were acceptable. Consultant review of high quality videotaped laparoscopic procedures is a valid method of independent assessment of operative findings.

A total of 25 women undergoing videolaparoscopy and a dye test to investigate pelvic adhesions and infertility were evaluated to determine whether applying a score system to pelvic adhesions was reproducible, and its place in determining prognosis or management. The surgeon performing the laparoscopies scored each case using the American Fertility Society (AFS) system, gave an estimate of the likely prognosis from microsurgery and recorded a recommended management [surgery or in-vitro fertilization (IVF)]. The video images and histories were independently reviewed by two other surgeons experienced in tubal surgery, who also scored each case and recorded prognosis from surgery and recommended management. Several differences in adhesion scores for each case were noted. Agreement was present between surgeons regarding estimated prognosis for microsurgery and also in recommending management, particularly when prognosis was considered poor and IVF was recommended. Despite some reproducibility, the AFS score system did not predict outcome or management decisions. However, the surgeons' fundamental impression of the state of the pelvis and recommendation for either surgery or IVF were more consistent and reproducible. Any future proposed system for adhesion classification will need to account for, and be predictive of, the decreasing number of patients for whom surgery (rather than IVF) is the preferred management.

The objective of this study is to determine in a group of subfertile women whether patient history can differentiate women with a healthy pelvis from those with endometriosis or adnexal adhesions. In this prospective study, consecutive subfertile women undergoing laparoscopy and tubal hydrotubation for the sole indication of subfertility were evaluated at the teaching hospital fertility unit. They had a minimum of 2 years subfertility. The main outcome measures were: patients' response to a 7-point physical symptom and medical history questionnaire, laparoscopic findings of endometriosis and adnexal adhesions quantified according to the American Fertility Society classification. Of 104 patients, 99 patients were retained in the analysis. Forty per-cent had endometriosis, 19% pelvic adhesions and 40% a normal pelvis. Severe dysmenorrhoea was the only symptom predictive for endometriosis (relative risk 1.7). Severe dysmenorrhoea, a vaginal discharge, past use of a coil and previous laparotomies were all predictive for pelvic adhesions (relative risks 2.1, 3.3, 2.1, 1.9, respectively). The relative risk increased with severity of the disease. Patients with moderate and severe adhesions were 4.2 and 5.3 times more likely to have severe dysmenorrhoea and a vaginal discharge than patients with a normal pelvis. Subfertile women giving a positive response to selected questions about their medical history are at increased risk of endometriosis and pelvic adhesions. Where resources are limited, such a system could be used to plan effective use of available diagnostic facilities.

A total of 324 patients participating in our in-vitro fertilization/embryo transfer (IVF) programme underwent a diagnostic hysteroscopy. Of these, 152 women were referred before their first IVF attempt, because of some hysterosalpingographic suspicion of an intra-uterine abnormality; the other 172 patients had failed to conceive after IVF and transfer of good quality embryos. An intra-uterine pathology (mainly intra-uterine adhesions) was diagnosed in 50% of the patients in each group. Hysterosalpingography, although very sensitive, had low specificity (23%), a false positive rate of 44% and false negative rate of 10%. The main risk factor for intra-uterine pathology was a previous abortion. Conception rates were 22% after surgical treatment and 38% after the diagnostic procedure. We think that hysteroscopy should be performed in every patient failing to conceive after replacement of good quality embryos. It is also recommended whenever a suspicious finding is revealed by hysterosalpingography, before IVF. Routine hysteroscopy before entering an IVF programme should be seriously considered.

Investigation of the tubal factor in infertility is limited to an assessment of anatomical structure and tubal patency. No test of ascendant tubal function is currently available. The migration of radionuclide (99mTc-labelled human albumin microspheres) through the genital tract in 96 infertile women was compared with pelvic findings at laparoscopy and chromopertubation. The radionuclide test correlated with laparoscopy in the diagnosis of patency or blockage in 83 cases (86%). In nine patients, where 'blockage' was diagnosed on the radionuclide test but patency found at laparoscopy, a higher prevalence of pelvic abnormality was found, compared to the 78 patients where both tests demonstrated patency (P less than 0.02). The radionuclide test may facilitate detection of diseased but patent tubes and, as an adjunct to laparoscopy and chromopertubation, may provide useful information about tubal function.