The predictive value of Endometriosis
Fertility Index(EFI) in Chinese women
with endometriosis-associated infertility
treated by laparoscopy
Xianghui Zhang, Wei Huang Dept. Obs/Gyn
West China Second University, Sichuan University, China [email protected]
Background
Endometriosis afflict 35~50% women of reproductive age
by the related infertility, chronic pelvic pain and other
physical problems.
Giudice LC, Kao LC. Lancet 2004.
Infertility
Chronic Pain
Background
Although a definitive mechanism to the causal links
between endometriosis and infertility is still far away from
us.
It is clear that the fecundity does rebound in some degree
after medical management.
Bulletti C. J Assist Reproduct Geneti 2010.
De Ziegler D. Lancet 2010.
Background
Laparoscopic surgery is a widely used mean to deal with
endometriosis-associated infertility both for mild-moderate
and severe patients.
Raffi F. Eur J Obstet Gynecol Reprod Biol 2014. Marcoux S. New Eng J Med 1997. Somigliana E. Placenta 2011.
Background
While pregnancy outcome after laparoscopy was not
consistent with the most widely used staging system of
endometriosis, namely revised American Fertility Society
(rAFS) score.
.
Zeng C. Gynecol Obstet Invest 2014. Vercellini P. Hum 2006
Background
Adamson developed the endometriosis fertility index (EFI ) in
2010, a scoring system consist of historical factors at the time
of surgery, adnexal function after the intervention of surgery
and assessment of endometriosis that was derived from r-
AFS .
Adamson GD. Fertil Steril 2010.
Endometriosis Fertility Index(EFI) Historical factors Surgical factors
Points Description Points Description
2 If age is ≤35 years 3 If LF score = 7–8 (high score)
1 If age is 36–39 years 2 If LF score = 4–6 (moderate score)
0 If age is ≥40 years 0 If LF score = 1–3 (low score)
2 If years infertile is ≤3 1 If AFS endometriosis lesion score <16
0 If years infertile is >3 0 If AFS endometriosis lesion score ≥16
1 If there is a history of prior pregnancy
1 If AFS total score <71
0 If there is no history of prior pregnancy
0 If AFS total score ≥71
Background
With the aim to demonstrate the predictive value of EFI
for natural conception after surgery, this retrospective
study was made in Chinese women with endometriosis
associated infertility.
Methods
The study reviewed infertile women diagnosed of
endometriosis-associated infertility that underwent
laparoscopic treatment from January 2008 to December
2012.
Inclusion criteria
• Diagnosis is based on visual typical-lesions under laparoscopy;
• Infertility after more than one year of unprotected intercourse;
• Male partners with normal semen analysis.
Methods
Exclusion criteria
• Ovulation disorders (e.g. PCOS, hyperprolactinemia );
• Genital tract malformations;
• Uterine diseases(e.g. adenomyosis, Intrauterine adhesion);
• Severe systemic disease.
Follow –up
! outpatient visit, telephone or letter was conducted to
follow-up postoperative outcomes.
! The duration of follow-up was 12~68 months.
Statistical analysis
! Relevant EFI score and pregnant outcomes were
analyzed by using the SPSS statistical software 21.0.
! The χ2-test and Kaplan-Meier survival analysis were
used for the comparison of cumulative pregnant rate in
different time.
Results
! A total of 1325 women were eligible for the study.
! 46 patients were excluded because of pregnancy by IVF-ET.
! 228 women were lost to follow up, lost rate was 17.83%.
! 1051 of remaining 1279 patients were successfully followed-
up
Clinical characteristics of 1051 endometriosis associated infertile women
Age at operation (yr ) 29.81±4.30 (20~46) BMI 20.34±2.57(13.67~33.73) Duration of infertility(yr) 3.04±2.64(1~18) Type of Infertility primary infertility (%) 561(53.38%) secondary infertility(%) 490(46.62%) r-AFS classification stage I (%) 349(33.21%) stage II (%) 266(25.31%) stage IV (%) 248(23.59%) stage V (%) 188(17.89%)
EFI n(%) 10 121(11.51%
) 9 261(24.83%
) 8 228(21.69%
) 7 194(18.45%
) 6 120(11.41%
) 5 67(6.37%) 4 40(3.8%) 3 13(1.23%) 2 7(0.67%) 1 0
Results
! 505 (48.05%, 505/1051) patients became pregnant naturally
! 13 cases ongoing pregnancies (8 over 12-week pregnancy)
! 60 (5.71%) women suffered from spontaneous abortion or
termination gestation as fetal anomaly.
! 20 (1.9%) patients experienced ectopic pregnancy.
! The live birth rate was 38.53% (405/1051)
Results
Estimated cumulative PRs(pregnant rates) at different time by r-AFS staging
The PRs among diffeent r-AFS staging (I-IV) was no significant difference (52.15% I , 47.37% II, 47.58% III, 42.02% IV; P=0.161)
r"AFS& & Cumulative&PRs,&%&(n/total&n)&12months& & & & & & & & & & & & & & & & 24months& & & & & & & & & & & & & & & & 36months& & & & & & & & & & & & & >40months& &
&
&&
&
45.56%(159/349)& & & & & & & & 50.14%(175/349)& & & & & & & & & & & 51.58%(180/349)& & & & & 52.15%(182/349)&37.59%(100/266)& & & & & & & & 43.23%(115/266)& & & & & & & & & & & 46.62%(124/266)& & & & & 47.37%(126/266)&22.18%(55/248)& & & & & & & & & 42.34%(105/248)& & & & & & & & & & & 47.18%(117/248)& & & & & 47.58%(118/248)&28.19%(53/188)& & & & & & & & & 40.96%(77/188)& & & & & & & & & & & & 42.02%(79/188)& & & & & & 42.02%(79/188)&&
!
Results
Estimated cumulative PRs(pregnant rates) at different time by EFI score.
EFI$ Cumulative$PRs,$%$(n/total$n)$12months$ $ $ $ $ $ $ $ $ $ $ $ $ $ 24months$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 36months$ $ $ $ $ $ $ $ $ $ $ $ $ >40months$ $
0~2$3$4$5$6$7$8$9$10$
14.29%(1/7)$ $ $ $ $ $ $ $ $ $ 14.29%(1/7)$ $ $ $ $ $ $ $ $ $ $ $ $ 14.29%(1/7)$ $ $ $ $ $ $ $ $ $ $ 14.29%(1/7)$7.69%(1/13)$ $ $ $ $ $ $ $ $ $ 7.69%(1/13)$ $ $ $ $ $ $ $ $ $ $ $ $ 7.69%(1/13)$ $ $ $ $ $ $ $ $ $ $ 7.69%(1/13)$12.50%(5/40)$ $ $ $ $ $ $ $ $ 17.50%(7/40)$ $ $ $ $ $ $ $ $ $ $ $ 20.00%(8/40)$ $ $ $ $ $ $ $ $ $ 22.50%(9/40)$11.94%(8/67)$ $ $ $ $ $ $ $ $ 14.93%(10/67)$ $ $ $ $ $ $ $ $ $ $ 20.90%(14/67)$ $ $ $ $ $ $ $ $ 20.90%(14/67)$25.00%(30/120)$ $ $ $ $ $ 30.00%(36/120)$ $ $ $ $ $ $ $ $ $ 32.50%(39/120)$ $ $ $ $ $ $ $ 33.33%(40/120)$26.80%(52/194)$ $ $ $ $ $ 41.75%(81/194)$ $ $ $ $ $ $ $ $ $ 43.81%(85/194)$ $ $ $ $ $ $ $ 44.85%(87/194)$39.04%(89/228)$ $ $ $ $ $ 50.44%(115/228)$ $ $ $ $ $ $ $ $ 52.63%(120/228)$ $ $ $ $ $ $ 53.07%(121/228)$41.38%(108/261)$ $ $ $ $ 52.11%(136/261)$ $ $ $ $ $ $ $ $ 54.79%(143/261)$ $ $ $ $ $ $ 54.79%(143/261)$60.33%(73/121)$ $ $ $ $ $ 70.25%(85/121)$ $ $ $ $ $ $ $ $ $ 73.55%(89/121)$ $ $ $ $ $ $ $ $ 73.55%(89/121)$
!