{"paper_id":"15ee8bfb-5cac-45bb-b422-7fb7dc3b4d09","body_text":"Citation: Sayeeda Pervin, Nasrin Sultana, Bakhtiar Ahmed, Zinat Ara Ferdousi, Mst. Nargish Khanam, Zobaida Sultana \nSusan, Mst. Mafruha Haque  (2025). Comparative Analysis of Maternal Complications in Gestational and Pre -gestational \nDiabetic Pregnancies. Sch Int J Obstet Gynec, 8(5): 173-179. \n \n         173 \n \n \n \nScholars International Journal of Obstetrics and Gynecology \nAbbreviated Key Title: Sch Int J Obstet Gynec \nISSN 2616-8235 (Print) |ISSN 2617-3492 (Online) \nScholars Middle East Publishers, Dubai, United Arab Emirates \nJournal homepage: https://saudijournals.com  \n \n Original Research Article \n \nAssociation of Sociodemographic and Clinical Factors with Severity of \nEndometriosis Based on Laparoscopic Evaluation in Infertile Women \nDr. Sayeeda Pervin1*, Dr. Nasrin Sultana1, Dr. Bakhtiar Ahmed2, Dr. Zinat Ara Ferdousi1, Dr. Mst. Nargish Khanam3, Dr. \nZobaida Sultana Susan4, Dr. Mst. Mafruha Haque5 \n \n1Assistant Professor, Department of Obstetrics and Gynaecology, Dhaka Medical College, Dhaka, Bangladesh \n2Assistant Professor and Resident Surgeon, Department of Surgery, BIRDEM General Hospital, Dhaka, Bangladesh \n3Junior Consultant, Department of Obstetrics and Gynaecology, Dhaka Medical College Hospital, Dhaka, Bangladesh \n4Consultant, Department of Obstetrics and Gynaecology, Shaheed Suhrawardy Medical College and Hospital, Dhaka, Bangladesh \n5Junior Consultant, Department of Obstetrics and Gynaecology, Dhaka Medical College Hospital, Dhaka, Bangladesh  \n \nDOI: https://doi.org/10.36348/sijog.2025.v08i05.006     | Received: 13.04.2025 | Accepted: 19.05.2025 | Published: 23.05.2025 \n \n*Corresponding author: Dr. Sayeeda Pervin \nAssistant Professor, Department of Obstetrics and Gynaecology, Dhaka Medical College, Dhaka, Bangladesh \n \nAbstract  \n \nBackground: Endometriosis is a chronic inflammatory condition affecting women of reproductive age, with a notably \nhigher prevalence in those experiencing infertility. Given this association, the study aimed to assess how socio -\ndemographic and clinical factors relate to the severity of endometriosis based on laparoscopic findings in infertile women. \nAim of the study : The aim of the study was to evaluate the association between socio -demographic and clinical factors \nwith the severity of endometriosis based on laparoscopic evaluation in infertile women.  Methods: This cross-sectional \nstudy was conducted in the Department of Obstetrics and Gynaecology at CARE, BIRDEM General Hospital, Dhaka (July \n2013-June 2015) involving 127 infertile women. Data were collected regarding sociodemographic characteristics and \nclinical factors using a structure d data collection sheet. BMI was calculated from weight and height and included in the \ndata collection sheet. Laparoscopic diagnosis and staging used the Revised American Fertility Society criteria. Data \nanalysis employed SPSS 20 (descriptive statistics, t -tests, chi-square tests). Results: In a study of 127 infertile women, \nStage I endometriosis was most common, with Stage IV less frequent. Older age was linked to Stage I (p=0.016), and \nupper-class women had a higher prevalence (p=0.003). Lower BMI was associated with Stage IV (p=0.043). Severe stages, \nespecially Stage IV, were significantly linked to dysmenorrhoea, menorrhagia, dyspareunia, and chronic pelvic pain.  \nConclusion: Socioeconomic background, age, BMI, and symptom profiles may serve as valuable indicators of \nendometriosis severity in infertile women undergoing laparoscopic evaluation. \nKeywords: Socio-Demographic Factors, Clinical Correlates, Endometriosis Severity . \nCopyright © 2025 The Author(s): This is an open -access article distributed under the terms of the Creative Commons Attribution 4.0 International \nLicense (CC BY-NC 4.0) which permits unrestricted use, distribution, and reproduction in any medium for non -commercial use provided the original \nauthor and source are credited. \n \nINTRODUCTION \nEndometriosis is a long-standing inflammatory \ncondition predominantly seen in women of reproductive \nage, defined by the growth of endometrial-like tissue in \nlocations outside the uterus [1, 2]. This ectopic tissue can \nbe found on the ovaries, fallopian tubes, and the \nperitoneal lining of the pelvis, leading to symptoms such \nas dysmenorrhea, dyspareunia, pelvic pain, and \ninfertility [ 3-5]. The condition can severely affect the \nquality of life for those affected, with an estimated \nprevalence of 6-10% in the general population, and even \nhigher rates observed in women experiencing infertility \n[6]. Several factors have been associated with  an \nincreased risk of developing endometriosis, including \nearly onset of menstruation, heavy menstrual flow, a lean \nbody type, and a family history of the disease [7]. \nHowever, the exact etiology remains uncertain [8], with \nvarious hypotheses proposing mec hanisms such as \nmetaplastic transformation or the spread of endometrial \ntissue through hematogenous or lymphatic pathways. T \n \nThe prevalence of endometriosis among \nwomen with infertility is significantly higher than in the \ngeneral population, with estimates ranging from 30% to \n50% [9 -11]. Numerous studies have shown that \n\n\n \n \nSayeeda Pervin et al; Sch Int J Obstet Gynec, May. 2025; 8(5): 173-179 \n© 2025 | Published by Scholars Middle East Publishers, Dubai, United Arab Emirates                                                                                       174 \n  \n \nendometriosis is commonly found in women suffering \nfrom chronic pelvic pain, with its prevalence varying \nbased on the diagnostic methods employed. Laparoscopy \nremains the gold standard for diagnosis, as it enables \ndirect visualization of endometrial lesion s, nodules, or \ncysts [12]. However, the prevalence and severity of \nendometriosis in infertile women can differ \nconsiderably, with some estimates suggesting that \ninfertile women are 6 -21 times more likely to have \nendometriosis compared to their fertile coun terparts \n[13,14]. Factors such as pelvic anatomical distortions, \nendocrine and ovulatory disturbances, and immune \nsystem alterations are thought to contribute to infertility \nin women with endometriosis [15]. Interestingly, certain \nstudies indicate that end ometriosis may be equally \nprevalent in both fertile and infertile women, raising \nquestions about whether the condition is the primary \ncause of infertility. \n \nEndometriosis is a well -established cause of \ninfertility, but the mechanisms through which it affects \nfertility are complex and multifactorial. Factors such as \ntubal obstruction, impaired ovulation, failure of sperm \nmigration, and altered immune responses all contribute \nto the subfertility seen in women with the condition [16]. \nDiagnosing endometriosis is often difficult due to its \nsymptoms overlapping with those of other disorders, \nleading to frequent underdiagnosis. While imaging \ntechniques like ultrasound and MRI can provide valuable \ninformation, laparoscopy remains the gold standard for \nconfirming the diagnosis and assessing the extent of the \ndisease. Treatment options may include medical or \nsurgical interventions, with laparoscopic surgery \noffering benefits such as minimal tissue damage, faster \nrecovery, and potentially better fertility outcomes. \nDespite advances in diagnostic and treatment methods, \nendometriosis continues to pose significant challenges in \nclinical practice and patient care, primarily du e to the \nvariability in symptoms and the complexity of its \nmanagement. \n \nDespite the well -established association \nbetween endometriosis and infertility, limited data exist \non how socio-demographic and clinical factors correlate \nwith disease severity as confirmed by laparoscopy. \nUnderstanding these associations could enhance early \nrecognition and individualized management strategies in \ninfertile women. Therefore, the purpose of this study was \nto assess the association between socio - demographic \nand clinical factors with the severity of endometriosis in \ninfertile women as determined by laparoscopic \nexamination. \n \nObjective \n• The aim of the study was to evaluate the \nassociation between socio -demographic and \nclinical factors with the severity of \nendometriosis based on laparoscopic evaluation \nin infertile women. \n \nMETHODOLOGY & MATERIALS \nThis cross -sectional descriptive study was \nconducted at the Center for Assisted Reproduction \n(CARE), Department of Obstetrics and Gynaecology, \nBIRDEM General Hospital, Dhaka, Bangladesh, from \nJuly 2013 to June 2015. A total of 127 consecutive \ninfertile women who underwent diagnostic laparoscopy \nbetween January 2014 and December 2014 were \nincluded, selected based on specific inclusion criteria. \n \nInclusion Criteria: \n• Female patients with infertility (both primary \nand secondary) selected for diagnostic \nlaparoscopy for the evaluation of infertility at \nCARE, BIRDEM General Hospital \n• Age between 20 and 40 years \n \nExclusion Criteria: \n• Infertility due to male factor \n• Patients with medical disorders such as severe \nheart disease contraindicating anesthesia \n• Infertility caused by chromosomal disorders or \nprimary amenorrhea \n \nData were collected using a structured data \ncollection form that included demographic, \nanthropometric, and clinical variables. After obtaining \ninformed consent and explaining the study objectives, a \ndetailed medical history and thorough clinical \nexaminations were performed for each patient. \nDiagnostic laparoscopy was conducted, and findings \nwere documented systematically. Endometriosis was \ndiagnosed primarily through visual inspection during \nlaparoscopy and classified according to the Revised \nAmerican Ferti lity Society (rAFS) staging system into \nfour categories: minimal (Stage I), mild (Stage II), \nmoderate (Stage III), and severe (Stage IV). \nCharacteristic laparoscopic findings included powder -\nburn lesions, red flame -like areas, yellow -brown \npatches, and cho colate cysts. Body mass index (BMI) \nwas calculated as weight in kilograms. Socioeconomic \nstatus was assessed based on monthly household income \nand grouped as low, middle, or upper income. All \ncollected data were entered, cleaned, and analyzed using \nSPSS version 20. Descriptive statistics were expressed \nas mean, standard deviation, and proportions, while \ninferential statistics including t-tests and chi-square tests \nwere employed to determine associations, with a p-value \nof <0.05 considered statistically sign ificant. Ethical \napproval was obtained from the Ethical Review \nCommittee of BADAS, and confidentiality and \nvoluntary participation were ensured throughout the \nstudy. \n \n \n \n\n \n \nSayeeda Pervin et al; Sch Int J Obstet Gynec, May. 2025; 8(5): 173-179 \n© 2025 | Published by Scholars Middle East Publishers, Dubai, United Arab Emirates                                                                                       175 \n  \n \nRESULTS \n \n \nFigure 1: Age Distribution of the Study Population (N=127) \n \nThe majority of the study participants were in \nthe 26–30 years age group (58 women, 45.7%), followed \nby 39 women (30.7%) aged 31 –35 years. A total of 23 \nparticipants (18.1%) were aged 21 –25 years, while only \n7 women (5.5%) were in the 36–40 years age group. The \nmean age was 29.31 ± 4.08 years. \n \n \nFigure 2: Socioeconomic Status of the Study Population (N=127) \n \nAmong the 127 infertile women studied, the \nmajority belonged to the middle socioeconomic class (74 \nwomen, 58.3%), followed by 38 women (29.9%) in the \nupper class and 15 women (11.8%) in the lower \nsocioeconomic group. \n \nTable 1: Distribution of the study population according to severity of endometriosis on laparoscopy (N = 24)  \nStage of Endometriosis Frequency (n) Percentage (%) \nStage I (Minimal) 9 7.1% \nStage II (Mild) 4 3.1% \nStage III (Moderate) 4 3.1% \nStage IV (Severe) 7 5.5% \n \n\n\n \n \nSayeeda Pervin et al; Sch Int J Obstet Gynec, May. 2025; 8(5): 173-179 \n© 2025 | Published by Scholars Middle East Publishers, Dubai, United Arab Emirates                                                                                       176 \n  \n \nTable 1 shows the laparoscopic staging of \nendometriosis among the study population. Stage I \n(minimal) was observed in 9 participants (7.1%), Stage \nIV (severe) in 7 (5.5%), and both Stage II (mild) and \nStage III (moderate) in 4 participants each (3.1%). \n \nTable 2: Association of Age of the Respondents with Different Stages of Endometriosis  \nStage of Endometriosis Endometriosis Mean Age (Years) Standard Deviation p-value \nStage I (Minimal) Yes 32.44 3.712 0.016 \nNo 29.08 4.026 \nStage II (Mild) Yes 28 4.243 0.571 \nNo 29.36 4.089 \nStage III (Moderate) Yes 30 4.397 0.735 \nNo 29.29 4.091 \nStage IV (Severe) Yes 31.43 5.255 0.165 \nNo 29.19 3.999 \n \nTable 2 summarizes the association between the \nage of the respondents and the laparoscopic stages of \nendometriosis. In cases of minimal (Stage I) \nendometriosis, the mean age at presentation was 32.44 ± \n3.71 years, compared to 29.08 ± 4.03 years in those \nwithout Stage I disease, showing a statistically \nsignificant difference (p = 0.016). However, for Stage II, \nIII, and IV endometriosis, no significant differences in \nmean age were observed between those with and without \nthe respective stages (p > 0.05). \n \nTable 3: Association of Endometriosis with Different Socioeconomic Conditions  \nEndometriosis Upper Class Middle Class Lower Class p-value \nYes 58.3% 33.3% 8.3% 0.003 \nNo 23.3% 64.1% 12.6% \n \nTable 3 shows that the majority (58.3%) of \nrespondents with endometriosis belonged to the upper \nsocioeconomic class, while only 23.3% of those without \nendometriosis were from this group. In contrast, a higher \npercentage of respondents without endometriosis  \n(64.1%) were from the middle class. This difference was \nstatistically significant (p = 0.003), indicating a potential \nassociation between higher socioeconomic status and the \npresence of endometriosis. \n \nTable 4: Association of BMI with Severity of Endometriosis on Laparoscopy  \nStage of Endometriosis Endometriosis Mean BMI Standard Deviation p-value \nStage I (Minimal) Yes 25.56 5.81 0.439 \nNo 26.93 5.06 \nStage II (Mild) Yes 27.6 5.67 0.769 \nNo 26.81 5.11 \nStage III (Moderate) Yes 24.5 1.91 0.345 \nNo 26.91 5.16 \nStage IV (Severe) Yes 23.05 3.17 0.043 \nNo 27.05 5.12 \n \nTable 4 summarizes the association between \nbody mass index (BMI) and stages of endometriosis via \ndiagnostic laparoscopy. Respondents with stage I \nendometriosis had a mean BMI of 25.56, while those in \nstage II had a mean BMI of 27.60, and stage III \nrespondents had a mean BMI of 24.50. No statistically \nsignificant association was found between BMI and \nthese stages. However, in stage IV (severe \nendometriosis), those with endometriosis had a \nsignificantly lower mean BMI of 23.05 compared to \n27.05 in those witho ut endometriosis. A statistically \nsignificant association was found between stage IV \n(severe endometriosis) and BMI (p = 0.043), suggesting \nthat patients with severe endometriosis tend to have a \nrelatively lower BMI. \n \nTable 5: Association of Clinical Presentations and Laparoscopic Staging of Endometriosis  \nClinical presentation \nDysmenorrhoea \nStaging of endometriosis Mild Moderate Severe P value \nStage I 2 (6.3%) 2 (5.3%) 4 (22.2%) 0.053 \nStage II 1 (3.1%) 0 (0.0%) 3 (16.7%) 0.004 \n\n \n \nSayeeda Pervin et al; Sch Int J Obstet Gynec, May. 2025; 8(5): 173-179 \n© 2025 | Published by Scholars Middle East Publishers, Dubai, United Arab Emirates                                                                                       177 \n  \n \nStage III 1 (3.1%) 0 (0.0%) 1 (5.6%) 0.556 \nStage IV 0 (0.0%) 4 (10.5%) 3 (16.7%) 0.016 \nTotal 4 (12.5%) 6 (15.8%) 11 (61.2%)   \nMenorrhagia \nStage I 7 (11.7%) 0.057 \nStage II 2 (3.3%) 0.991 \nStage III 2 (3.3%) 0.991 \nStage IV 7 (11.7%) 0.004 \nTotal 18 (30.0%)  - \nDyspareunia \nStage I 8 (32.0%) 0.085 \nStage II 2 (8.0%) 0.121 \nStage III 0 (0.0%)   \nStage IV 4 (16.0%) 0.010 \nTotal 14 (56.0%)  - \nChr. pelvic pain \nStage I 6 (27.3%) 0.000 \nStage II 3 (13.6%) 0.002 \nStage III 1 (4.5%) 0.680 \nStage IV 5 (22.7%) 0.000 \nTotal 15 (68.1%)  - \n \nTable 5 summarizes the association between \nclinical presentations of endometriosis and the severity \nof the condition as assessed through diagnostic \nlaparoscopy. Statistically significant associations were \nfound between moderate to severe dysmenorrhoea and \nboth mild (stage II) and severe (stage IV) endometriosis \n(p = 0.004, 0.016). A significant association was also \nobserved between menorrhagia and dyspareunia with \nstage IV (severe) endometriosis (p = 0.004, 0.010), as \nwell as chronic pelvic pain with stage II (mild) \nendometriosis (p = 0.002). However, no statistical \nassociation was noted between clinical presentations and \nother stages of endometriosis. \n \nDISCUSSION \nEndometriosis is a prevalent gynecological \ncondition that significantly contributes to female \ninfertility. It is characterized by the presence of \nendometrial-like tissue outside the uterine cavity, often \nresulting in chronic pelvic pain and subfertility. \nLaparoscopy continues to be the gold standard for \ndiagnosing and staging endometriosis. The present study \naimed to assess the association between socio -\ndemographic and clinical factors with the severity of \nendometriosis in infertile women, based on laparoscopic \nevaluation. A total of 127 infertile patients were \nincluded, all of whom underwent diagnostic laparoscopy \nat the Center for Assisted Reproduction (CARE), \nBIRDEM General Hospital. \n \nIn the present study, the majority of participants \nwere in the 26–30 years age group (45.7%), followed by \n31–35 years (30.7%), with a mean age of 29.31 ± 4.08 \nyears. These findings are comparable to the observations \nby Chandrika et al. [17] found that 40% of infertile \nwomen were aged between 26 and 30 years, 34% were \nover 30 years, and 26% were between 21 and 25 years, \nwith a mean age of 28.74 ± 3.81 years.  These findings \nsuggest that endometriosis -related infertility is most \nprevalent in women in their late twenties to early thirties, \nemphasizing the importance of timely evaluation and \nmanagement in this age group. \n \nIn this study, the majority belonged to the \nmiddle socioeconomic class (74 women, 58.3%), \nfollowed by 38 women (29.9%) in the upper class and 15 \nwomen (11.8%) in the lower socioeconomic group. This \ndistribution highlights that most participants seeking \ncare at the tertiary center were from middle -income \nbackgrounds. \n \nIn the present study, laparoscopic evaluation \nrevealed that among infertile women with endometriosis, \n7.1% had Stage I, 3.1% had Stage II, 3.1% had Stage III, \nand 5.5% had Stage IV disease. These findings are \ngenerally in line with those of Mishra et al. [18], who \nreported 66.3% with Stage I, 17.77% with Stage II, \n8.33% with Stage III, and 7.6% with Stage IV \nendometriosis, highlighting the varied presentation of \nendometriosis are evident among infertile women, \nreinforcing the role of laparoscopy in accur ate staging \nand clinical decision-making. \n \nIn the present study, the mean age of women \nwith Stage I endometriosis was 32.44 years, followed by \n28 years for Stage II, 30 years for Stage III, and 31.43 \nyears for Stage IV, with a statistically significant \nassociation noted for Stage I (p = 0.016). These findings \nshow a trend of increasing age with advancing stages of \nendometriosis, consistent with the observations of \nRadhika et al. [19], who reported that the majority (73%) \nof patients with moderate to severe endometriosis were \nin the 21 –30 years age g roup, with a mean participant \nage of 29.6 years. This similarity reinforces the pattern \n\n \n \nSayeeda Pervin et al; Sch Int J Obstet Gynec, May. 2025; 8(5): 173-179 \n© 2025 | Published by Scholars Middle East Publishers, Dubai, United Arab Emirates                                                                                       178 \n  \n \nthat endometriosis severity tends to increase with \nadvancing reproductive age in infertile women. \n \nIn this study, a notable association was found \nbetween higher socioeconomic status and the presence of \nendometriosis, with 58.3% of affected women belonging \nto the upper class, compared to just 23.3% of women \nwithout the condition (p = 0.003). This finding  is \nconsistent with the research by Fyfe et al. [20], which \nindicated that women with endometriosis were more \nlikely to come from higher socioeconomic backgrounds. \nThese similarities suggest that greater health awareness, \nbetter access to specialist care, and timely diagnostic \nprocedures such as laparoscopy in higher socioeconomic \ngroups may contribute to the increased detection of \nendometriosis among these women. \n \nIn the present study, a significant association \nwas noted between lower BMI and Stage IV (severe) \nendometriosis, with affected women having a mean BMI \nof 23.05 ± 3.17 compared to 27.05 ± 5.12 in women \nwithout severe disease (p = 0.043). Although no \nstatistically significant associations were found for \nearlier stages, a trend of decreasing BMI with increasing \ndisease severity was observed. This pattern aligns with \nfindings from Yi et al. [21], who reported that women \nwith moderate to severe endometriosis had  significantly \nlower BMIs than those with minimal or mild disease, \nindicating a possible link between leanness and \nadvanced endometriosis. Similarly, Liu et al . [22] \nsuggested an inverse association, proposing that women \nwith higher BMI may have a reduced risk of developing \nendometriosis. These observations support the \nhypothesis that lower BMI may be a contributing factor \nor marker for more severe forms of endo metriosis in \ninfertile women. \n \nIn this study, a clear trend was observed \nbetween clinical presentations —particularly \ndysmenorrhea, dyspareunia, and chronic pelvic pain —\nand increasing severity of endometriosis on laparoscopy, \nwith symptoms more frequently reported in advanced \nstages. Dys menorrhea demonstrated a statistically \nsignificant correlation in both Stage II (p = 0.004) and \nStage IV (p = 0.016) of endometriosis, while symptoms \nsuch as dyspareunia and chronic pelvic pain were \nmarkedly more prevalent in the advanced stages, \nparticularly Stage IV (p = 0.010 and p = 0.000, \nrespectively). These findings are in line with those of \nThakral et al. [23], who reported high prevalence rates of \ndyspareunia (73.3%), dysmenorrhea (65.2%), and \nchronic pelvic pain (63.2%) among women with \nendometriosis. Similarly, Riazi et al. [24] also identified \nsignificant associations between these hallmark \nsymptoms and the presence of endometriosis. The \nconsistency of these results across studies reinforces the \nrole of these clinical symptoms as potential marker s of \ndisease progression, aiding in early suspicion and timely \ndiagnostic laparoscopy among infertile women. \n \nLimitations of the study \nThis study had some limitations: \n• The study was conducted at a single tertiary \ncare center, which may limit the \ngeneralizability of the findings to the broader \npopulation. \n• Due to the time constraints associated with \nconducting this study as part of a thesis, the \nsample size was limited; a larger cohort could \nhave yielded more robust and generalizable \nresults. \n• As laparoscopy is an invasive and costly \nprocedure requiring specialized surgical \nexpertise, its application may have been \nlimited, potentially affecting the uniformity of \ndiagnostic staging. \n \nCONCLUSION \nThis study demonstrates that socio -\ndemographic and clinical factors are distinctly associated \nwith endometriosis severity in infertile women. 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