{"paper_id":"31833649-96e2-40ee-a887-9fdd964f514f","body_text":"www.jpccr.eu ORIGINAL  ARTICLE\nRate of caesarean sections is higher in \nendometriosis patients  – experience of \nsingle tertiary obstetric clinic in the light of \nepidemiologic data\nSusan Afshari-Stasiak1,2,A-B,D-E  \n , Sebastian Andrysiewicz3,B-D \n , Alicja Andrysiewicz3,B-D \n ,  \nJoanna Bamberska3,B-D \n , Maria Szubert1,A,E-F  \n1 Clinic of Surgical and Oncologic Gynecology, 1st Department of Gynaecology and Obstetrics, Medical University of \nŁódż, M. Pirogow’s Teaching Hospital, Poland  \n2 Clinic of Foetal Medicine and Gynecology, 1st Department of Gynaecology and Obstetrics, Medical University of Łódż, \nM. Pirogow’s Teaching Hospital, Poland  \n3 Student Scientific Society, 1st Department of Gynaecology and Obstetrics, Medical University, Łódż, Poland  \nA – Research concept and design, B – Collection and/or assembly of data, C – Data analysis and interpretation,  \nD – Writing the article, E – Critical revision of the article, F – Final approval of the article\nAfshari-Stasiak S, Andrysiewicz S, Andrysiewicz A, Bamberska J, Szubert M. Rate of cesarean sections is higher in endometriosis patients – \nexperience of single tertiary obstetric clinic in the light of epidemiologic data. J Pre-Clin Clin Res. 2023; 17(2): 56–61. doi: 10.26444/jpccr/163481\nAbstract\nIntroduction and Objective.  Endometriosis is defined as the presence of endometrium-like tissue outside the uterine \ncavity which can cause chronic pelvic pain, dysmenorrhea, infertility, and obstetric complications. The study was undertaken \nto elucidate the influence of endometriosis on conception, pregnancy and course of Latour, as well as outcomes for the \ngrowth of the foetus.   \nMaterials and method. A single centre study was undertaken of endometriosis patients who were followed-up for five years \nafter laparoscopy. The study group consisted of 30 patients with endometriosis who conceived, of whom 120 underwent \nlaparoskopy. The control group consisted of 30 healthy women who delivered children and were hospitalized in a two-month \nperiod in 2015. Each patient completed a questionnaire regarding endometriosis symptoms, infertility duration, gravidity, \nsmoking habits, education, metod of conception, incidence of pre-term labour, foetal growth restriction (FGR), small for \ngestational age (SGA) and pregnancy-induced hypertension (PIH). Analysis of the data was carried out using STATISTICA \nv.10.   \nResults. A significant difference was observed in maternal age (34.7 ±4.7 for the study group vs. 29.8±4.9 years for the control \ngroup; p=0.001). In the study group, an increased incidence of caesarean section was noted (OR 4.9; 95% CI 1.61–15.07). No \nsignificant differences were observed in the incidence of preterm labour, FGR, SGA and PIH.   \nConclusions. Delivering child at older age was observed in the endometriosis group, compared with controls, which suggests \nthat endometriosis extends the time to conceiving. Higher maternal age at delivery and prolonged time to pregnancy may \nbe the factors that influence the rate of caesarean section in endometriosis patients.\nKey words\npregnancy, infertility, endometriosis, cesarean section\nINTRODUCTION\nEndometriosis is a disease found in 7–15% of women at \nreproductive age in the general population, whereas in the \ngroup of infertile women the prevalence of the disease is 21–\n47%, and among patients with menstruation-associated pain \neven as high as 71–97 % [1,2]. Endometriosis is one of the most \ncost-consuming diseases. Social costs paid because of work \nabsences, other health related issues, medical and surgical \ntherapies for patients with endometriosis, are very high and \nsometimes difficult to estimate. It may take many years from \nfirst symptoms to final diagnosis, which is burdensome for \nboth the patients and the health care system [3].\nEndometriosis is defined as a pathology caused by the \npresence of foci of endometrial tissue outside the uterine \ncavity, so called ‘endometrium-like’ tissue. With the \nexception of the female genital organs, endometriosis can \nbe also located on the uterosacral ligaments, on the recto-\nvaginal septum in the pouch of Douglas, on the uterovesical \nfold, and other organs, including the bowels and bladder. \nNowadays, its pathology is one of the most studied of all \nhuman diseases, but through its complexity remains full of \nunknowns.\nThere are many hypotheses about endometriosis etiology, \nbut despite extensive studies, the exact mechanism of \nendometriosis is not clearly understood. The complex \npathogenesis and varied symptoms make the diagnostic \nand  therapeutic process difficult [3]. Endometriosis is \nassociated with many distressing symptoms, including \ndysmenorrhea, chronic pelvic pain, dyspareunia and \ninfertility [4, 5, 6].\nAddress for correspondence: Susan Afshari-Stasiak, Clinic of Surgical and Oncologic \nGynecology, 1st Department of Gynaecology and Obstetrics, Medical University, \nM. Pirogow’s Teaching Hospital, Wilenska 37, 94-029 Łódź, Poland\nE-mail: safsharistasiak@gmail.com\nReceived: 11.03.2023; accepted: 20.04.2023; first published: 04.05.2023\nJournal of Pre-Clinical and Clinical Research 2023, Vol 17, No 2, 56-61\n\nSusan Afshari-Stasiak, Sebastian Andrysiewicz, Alicja Andrysiewicz, Joanna Bamberska, Maria Szuber t. Rate of caesarean sections is higher in endometriosis patients …\nInfertility is often the only symptom of endometriosis. \nOnly many years of unsuccessful attempts to conceive lead \nto the diagnostic process and, as a consequence, diagnosis of \nendometriosis. According to Radwan J. et al., in women with \nasymptomatic endometriosis the probability of conception \nin the natural cycle drops significantly to 0.02–0.1, while in \nhealthy women – 0.15–0.2.\nAs a result of pathological processes occurring in \nendometriosis, pelvic anatomy disorders and adhesions may \nappear, as well as impaired function of the fallopian tubes, \novaries or implantation disorders in the endometrium [7]. \nThese women also often need ART (artificial reproduction \ntechnique) procedures, what sometimes can generate a \nslightly higher risk of pregnancy complications and risk of \ncaesarean section. According Ibiebele et al. Endometriosis \nand ART are independent risk factors of pregnancy outcomes, \nspecially ante-partum haemorrhage [8]. Additionally, Stern \net al. observed increased risk of plancetal disfunction [9]. \nThe rate of caesarean deliveries in patients after ART is much \nhigher than in patients who conceived naturally and in whom \nnot only elective section is performed significantly more \noften, but also emergency incisions are performed (usually as \na result of pregnancy complications). In addition, a different \npercentage of c-section was fund, depending on the assisted \nreproductive method used (more often after ICSI, and fresh \nor frozen embryo transfer) [10].\nThe percentage of caesarean deliveries in Poland is much \ntoo high, oscillating around 48%, while the WHO considers \nabout 10% to be normal. The percentage of c-sections above \n10% does not reduce maternal and neonatal mortality, which \nis the goal of caesarean sections [11] [12].\nIt is difficult to determine the exact cause, but taking \ninto account the risk of operative delivery and possible \ncomplications in subsequent pregnancies, efforts should be \nmade to reduce the cesarean section rate. So far, although \nsome studies have not found any association between \nendometriosis and pregnancy complications, others have \nfound such an association. Among them, a pre-term \ndelivery and a higher caesarean section rate are reported \npredominantly.\nLaparoscopy is usually the only method which enables to \nascertain the expected diagnosis of endometriosis. Diagnosis \nshould be reinforced by biopsy because visual diagnosis alone \ncan lead to misdiagnosis even in 25% of cases. Symptom \nrelief is achieved in most patients after successful ablation or \nresection of pathological tissues. Nevertheless, the recurrence \nrate is as high as 50–80% [13].\nIt is speculated that endometriosis may promote the \noccurrence of adverse obstetric outcomes in affected pregnant \nwomen. The eutopic endometrium and junctional zone have \nbeen reported to be abnormal at molecular and functional \nlevels, which leads to impairment of endometrial growth, \nmaturation and decidualization, endometrial receptivity, \ndefective spiral artery remodeling, and defective deep \nplacentation [6,14,15]. Defective artery remodeling is a typical \nfeature of preeclampsia and associated with a spectrum of \npregnancy complications, including preterm labour and FGR.\nProgesteron resistance is also known in endometriosis \npatients as a disturbing factor for embryo implementation [16]. \nThis is the result of a reduced expression of the progesterone \nreceptor B/A due to the activity of pro-inflammatory \nimmunomodulators in the peritoneal fluid in women with \nendometriosis [17].\nThe pathological mechanisms mentioned above are well \nknown, but clinical data regarding pregnancy outcomes are \nhighly ambiguous.\nThe current study was designed to examine the influence \nof endometriosis on pregnancy and course of labour in \npatients diagnosed with endometriosis in the Clinic of Foetal \nMedicine and Gynaecology at the Medical University in \nŁódż, Poland. Based on the results obtained, the authors \ndiscuss the current literature and highlight the necessity \nfor the close observation of endometriosis patients at child \nbearing age.\nOBJECTIVES\nThe aim of the study was to elucidate the influence of \nendometriosis on pregnancy and the course of labour, as \nwell as outcomes for foetal growth.\nMATERIALS AND METHOD\nA retrospective case-control study was conducted in the \n1st Department of Gynaecology and Obstetrics of Medical \nUniversity in Łódż. 120 medical records were analyzed of \nwomen diagnosed laparoscopically for infertility or infertility \nand pelvic pain, who were followed-up for 5 years after initial \ndiagnosis. The endometriosis group consisted of 30 women \ndiagnosed and pharmacologically-treated for endometriosis \nat the above Gynaecological and Obstetrics Department, who \nbecame pregnant after confirmation and treatment of the \ndisease. This group of patients was closely followed-up since \nthe diagnosis because of their participation in a separate study \non angiogenesis and danazol treatment in endometriosis. A \ncontrol group consisted of 30 healthy mothers who were \nselected randomly from the patients hospitalized for labour \n– from the years corresponding the 5-year follow-up period \nfor the endometriosis group. Endometriosis was excluded \nin these women during a routine interview and medical \nexamination while they were hospitalized because of the \nlabour. They denied painful periods, painful intercourses, \nany other pain symptoms in the pelvis, infertility, being \ndiagnosed for ovarian endometrial cysts or deep infiltrating \nendometriosis. Exclusion criteria for both groups were also \nbecause of any other comorbidities, e.g. hypothyroidism, \nhypertension, anamnesis of cancer or pelvic inflammatory \ndisease, auto-immunological disorders or impaired glucose \ntolerance before pregnancy.\nThe study was conducted in accordance with the \nDeclaration of Helsinki for Medical Research involving \nhuman subjects. The study protocol was approved by the \nBioethical Commission of Medical University of Łódż. \nInformed consent was obtained from the patients either \non-site or during a phone call.\nA questionnaire was applied in which following factors \nwere evaluated:\n•\t Demographic\n•\t Obstetric\n•\t Complications during pregnancy\nDefinitions.  Preterm labour – the state of delivery 37 weeks \nprior to gestation. PIH(pregnancy-induced hypertension) \nincludes gestational hypertension and preeclampsia.\n57Journal of Pre-Clinical and Clinical Research 2023, Vol 17, No 2\n\nSusan Afshari-Stasiak, Sebastian Andrysiewicz, Alicja Andrysiewicz, Joanna Bamberska, Maria Szuber t. Rate of caesarean sections is higher in endometriosis patients …\nGestational hypertension – refers to elevated blood pressure \n≥140/90 mmHg after 20 weeks of gestation in a previously \nnormotensive woman.\nPreeclampsia – gestational hypertension with proteinuria \n(≥300 mg/24 h).\nPlacenta previa  – the presence of placental tissue that \nreaches or extends over the internal cervical os.\nPlacental abruption  – bleeding at the decidual placental \ninterface that causes partial or total placental detachment \nbefore delivery of the fetus.\nFGR (Foetal Growth Restriction) – defined as an estimated \nfoetal weight below the tenth percentile for gestational age \nand gender based on sonography when foetus is unable \nto achieve its genetically determined potential size due to \nvarious pathological conditions.\nSGA (Small for Gestational Age) – birth weight below the \ntenth percentile for gestational age and gender (for term \ninfants, the standard is <2500 g.).\nPPROM – preterm premature rupture of membranes; \nrupture of membranes usually should occur during labour.\nStatistical analysis.  Analysis of the data was performed \nusing STATISTICA version 10. The categorical variables were \nassessed using the Chi-square test with Yates correction. \nContingency tables were used to evaluate the association \nbetween endometriosis and adverse obstetric outcomes. \nOdds ratios (ORs) and 95% confidence intervals (CIs) were \ncalculated using MedCalc. P<0.05 was considered to be \nstatistically significant.\nRESULTS\nThe exposed group with endometriosis and the control group \nwithout endometriosis were compared by age, gravidity, smoking \nand education. In the endometriosis group an increased risk \nof caesarean section was noted in comparison with women \nwithout endometriosis. (OR 4.9, 95% CI 1.61–15.07).\nA significant difference was observed in maternal age – \nwomen with endometriosis were older than those without \nendometriosis (34.7 ±4.7 vs. 29.8±4.9 years; p=0.001). Both \ngroups were also compared by obstetric’s complications \n(Tab. 3).\nTable 1. Demographic data in the questionnaire\n 1. Have you ever smoked   cigarettes?  Yes,  No\n 2. What is your education?  Primary \n Secondary \n Higher\n 3. Age\nPregnancy\n 4. How did you conceive your baby?  natural \n stimulation \n insemination \n in vitro\n 5. Was it your first pregnancy?  Yes,  No\n  If it was your first pregnancy, please go to question number 7.\n 6. If it was not your first pregnancy, how many  \n  pregnancies have you had?\n 7. Have you ever had:\n  a) a miscarriage a)  Yes,  No\n  b) an ectopic pregnancy b)  Yes,  No\n 8. Was it a singleton pregnancy?  Yes,  No\n 9. How long have you been trying to conceive \n  a baby after confirmation of the diagnosis?\n10. What symptoms of endometriosis occured  \n  before a pregnancy?\nObstetric complications\n11. Were you suffering from a pregnancy-induced  \n  hypertension during pregnancy?\n Yes,  No\n12. Did you have a preeclapmsia?  Yes,  No\n13. Did you have a placenta previa?  Yes,  No\n14. Did you have a placental abruption?  Yes,  No\n15. Did you have a preterm labour?  No \n Spontaneous preterm \ndelivery \n Premature rupture of \nmembranes \n Maternal or fetal \nindications for cesarean \nsection\n16. Was the baby delivered by caesarean section?  Yes,  No\n17. Was foetal growth restriction diagnosed  \n  in the USG examination?\n Yes,  No\n18. Was the state of small-for-gestation-age  \n  recognized in the newborn?\n Yes,  No\nTable 3. Adverse obstetric outcomes in women with and without \nendometriosis\nADVERSE \nOBSTETRIC \nOUTCOME\nWOMEN WITH \nENDOMETRIOSIS\nn=30 (n [%])\nWOMEN WITHOUT \nENDOMETRIOSIS\nn=30 (n [%])\nOR (95% CI) P\nCaesarean \nsection\n18 (60) 7 (23) 4.9 (1.61-15.07) 0.0052\nPreterm \nlabour\n5 (16.7) 7 (23) 0.657 (0.18-2.36) 0.5\nFGR 10 (33.3) 5 (16.7) 2.5 (0.735-8.5) 0.14\nSGA 9 (30) 5 (16.7) 2.14 (0.62-7.39) 0.227\nPlacenta \nprevia\n1 0 - -\nPlacental \nabruption\n1 0 - -\nPIH 4 (13.3) 2 (6.67) 2.15 (0.36-12.76) 0.398\nTable 2. Demographic characteristic of women with and without \nendometriosis\nCHARACTERISTICS WOMEN WITH \nENDOMETRIOSIS\nn=30 (n [%])\nWOMEN WITHOUT \nENDOMETRIOSIS\nn=30 (n [%])\nP\nMaternal age (years) mean ± SD 34.7±4.7 29.8±4.9 0.001\nGravidity\n 1\n 2\n 3\n20 (66.7)\n10 (33.3)\n0\n15 (50)\n13 (43.3)\n2 (6.7)\n0.14\nSmoking\n Yes\n No\n7 (23.3)\n23 (76.7)\n6 (20)\n24 (80)\n0.75\nEducation\n Higher\n Secondary/Primary\n26 (86.6)\n4 (13.4)\n21 (70)\n9 (30)\n0.13\n58 Journal of Pre-Clinical and Clinical Research 2023, Vol 17, No 2\n\nSusan Afshari-Stasiak, Sebastian Andrysiewicz, Alicja Andrysiewicz, Joanna Bamberska, Maria Szuber t. Rate of caesarean sections is higher in endometriosis patients …\nNo significant differences were observed in the incidence of \npreterm labour, FGR, SGA and PIH between the two groups. \nTwo outcomes: placenta previa and placental abruption could \nnot be compared due to lack of cases in the control group.\nDISCUSSION\nEndometriosis is associated with a chronic pelvic \ninflammatory process, for which there are well documented \nstudies confirming increased levels of neuromodulators \nand other markers in the peritoneal fluid of women with \nendometriosis [3,18]. Abnormal endometrial function and \ndifficulties with implantation of pregnancies have also been \ndescribed [7].\nIt is speculated that endometriosis may promote the \noccurrences of adverse obstetric outcomes in affected \npregnant women. The results of current studies are \nconflicting: while some studies found no association, others \ndid find an association. Kobayashi et  al. summarized the \ncurrent reports and concluded that there are more data on \ndifferent complications during pregnancy in endometriosis \npatients. He also suggested that there is limited evidence \nfrom a few studies that surgical excision of endometriosis \nmay not reduce the risk of adverse pregnancy outcomes [19].\nAmong those authors who did find an association, preterm \nlabour is reported as being predominating [20,21,22,23]. \nHowever, according to Juang et al. and Shin et al., the risk \nof preterm birth is higher only in women with adenomyosis \n[24,25], whereas Fernando et al. came to the same conclusion \nonly with endometrioma [26]. He pointed out that the rates of \npreterm birth and SGA babies doubled in infertility patients \nwith ovarian endometriomata who required ART [26]. On the \nother hand, Bengalia et al. did not observe any relationship \nbetween preterm delivery and SGA in endometriosis patients, \ncompared to healthy controls. Furthermore, he observed \nthat neither endometriosis nor IVF increased rate of preterm \nbirths [27].\nConti et al. noticed that the frequency of diabetes and SGA \nis higher in patients with endometriosis in anamnesis [21]. \nOn the other hand, Warzecha et al. found no increased risk \nof PIH, preeclampsia or FGR [28]. The same conclusion, that \nendometriosis is not a risk factor of pregnancy complications, \nwas reached by Tzur et al. [29]. Both Warzecha and Tzur \nobserved a higher rate of acesarean sections in patients \nidentified with endometriosis.\nHong Lin et  al., examining a group of 249 patients \nendometriosis, found that women with endometriosis were \nat a higher risk of preterm labour, placenta previa, and \ncaesarean section during pregnancy [30]. Sorrentino et al, \nalso attempted to show correlation between women with a \nhistory of endometriosis and further obstetric complications. \nThey confirmed the relationship between the percentage of \noperative deliveries, and all the complications studied in the \nquestionnaires used in the current study [1].\nBorisova et  al. summed up studies which confirmed a \nhigher risk for miscarriage in endometriosis patients [31]. \nOnly single studies by Gonzaleza et  al. and Yanga et  al. \nfailed to find any such correlation [32,33]. Lalani et al. also \nobserved an increased risk of PPROM [34]. An increased risk \nof PE or hypertensive conditions and placental abnormalities \n(placenta previa, placental abruption) is also debatable, \nalthough most studies confirm an increased risk.\nBorisova summarized the likely pathogenesis of pregnancy \ncomplications by analyzing the available literature, and \nconcluded that in patients with endometriosis as a result of \nchronic inflammation, the activity of immunomodulators \n(natural killers, macrophages, IL-6, IL-1ß, TNF-a, \nprostaglandin E2 and cyclooxygenase (COX)-2) occurs in \nestrogen dependent reactions. Also, the junctional zone \n(between endometrium and myometrium) becomes defective \nby modulation of the extracellular matrix by prostaglandin \nsecretion, as well as the influence of hormones, cytokines, \nneurohormones, and growth factors (vascular endothelial \ngrowth factors – VEGF, by VEGFR receptor-1 or Soluble \nFMS-like tyrosine kinase-1 [sFlt-1]). Luteal phase deficiency, \nprogesterone resistance and adhesions are also an important \nphenomenon that could be responsible for early pregnancy \ncomplications in endometriosis patients [31]. On the other \nhand, Perez-Lopez denied any increased risk of PE, HELLP \nor increased blood pressure in endometriosis pregnant \npopulation [35].\nAlmost all the cited papers confirm the increased \npercentage of caesarean sections performed in patients with \na history of endometriosis. The current study also confirms \nan increased percentage of caesarean sections, but without \nanalyzing the indications for caesarean section other than \nthe outcomes studied.\nWarzecha et al. described the differences between indications \nfor caesarean section in endometriosis patients and healthy \nsubjects. He confirmed a higher rate of caesarean sections in the \nstudy group, with the main indications being a previous history \nof infertility/ART (elective CS, 27.9%) and excessive bleeding/\nhaemorrhage during labour (emergency CS, 13.9%). In the \nstudy group, the most frequent known reason for obstetric \nhaemorrhage was placental abruption. On the contrary, the \nmost frequent indications for performing an operative delivery \nin healthy subjects was previous caesarean section and labour \narrest [28]. Zullo et al. also confirmed the increased risk of \ncaesarean delivery and pregnancy complications [23].\nOn the basis of the above-mentioned data, it is easy to \nconclude that one of the indirect causes of the operative \ndelivery is long infertility and conceiving through ART \nprocedure. Women with endometriosis are significantly \nolder when they become pregnant, they are also often after \nprolonged infertility treatment which is also sometimes an \nindication for caesarean section\nSome studies report that the advanced age of the mother \nis a risk for pregnancy complications that require a quick \ntermination by caesarean section [36]. Moreover adenomyosis \nin anamnesis is a risk factor of operative delivery [15,37]. \nThere are unfortunately only very low quality data concerning \nendometriosis resulting in a highest risk emergency delivery \ndue to intra-labour haemorrage.\nSome limitations of the current study have to be \nrecognized: 1) although the sample size was relatively small, \nsome significant results were obtained. 2) The women with \nendometriosis selected for the study were treated with \ndanazol, and then followed-up in another study for five years. \n3) Both methods of conception: spontaneous and artificial \nwere reported by the patients. In the study group seven of the \n30 patients tried assisted reproductive technology, whereas in \nthe control group, all 30 patients embraced natural methods. \n4) Finally, the study is was a single-center analysis. In the \nlight of the most recently published opinion, this could be \nthe most biasing factor.\n59Journal of Pre-Clinical and Clinical Research 2023, Vol 17, No 2\n\nSusan Afshari-Stasiak, Sebastian Andrysiewicz, Alicja Andrysiewicz, Joanna Bamberska, Maria Szuber t. Rate of caesarean sections is higher in endometriosis patients …\nFrom 1997–2014, Berlac et  al. conducted retrospective \nresearch based on a national cohort in Denmark that included \nall delivering women and their newborns; they concluded \nthat almost all pregnancy complications occurred more \nfrequently in women with endometriosis [38]. However, \nwhile analyzing such a large study, one should keep in mind \nthat it is a study on data gathered for a national healthcare \nsystem which could not exactly reflect the severity of the \ncomplications. Another limitation of Berlacs’ study is that \ndata were adjusted for maternal age and obesity, but not for \nother important factors, such as previous surgery on the \nuterus (i.e. caesarean section, myoma excision) which could \nhave biased the rate of placental complications in women \nwith endometriosis.\nThe women in the current study were closely monitored both \nduring and after treatment (surgical and pharmacological) \nfor endometriosis. This fact may be responsible for the small \nrate of other complications during pregnancy in the studied \nendometriosis patients. Many researchers have considered \nthe effects of endometriosis at each stage of pregnancy, and \nmany studies have been carried out done on this topic; \nhowever, most studies have been conducted in small centres \nwith small groups of patients, which makes it impossible to \ndraw uniform general conclusions about the relationship of \nthe effects on complications.\nThe increasing percentage of caesarean sections worldwide \nis worrying in the context of long-term effects for the women \nand the children born. Caesarean delivery is a procedure, \ncombined with risk during the operation and after procedure \n(bleeding, surgical complications, infections, prolonged \nhospitalization), as well as the long-term effects for the \nwomen and children: risk of future uterine rupture in the \nnext pregnancy or abnormal placentation of the gestational \nsac or trofobast, adhesions, formation of new endometriosis \nfoci, infertility, and many others [37].\nThe benefits of caesarean section, e.g. lowering the risk \nof perinatal hypoxia, urinary incontinence in the mother, \nor prolapse of the reproductive organ, do not outweigh the \npossible risks of a too high rate of operative deliveries when \ntaking the whole population into consideration [39]. In order \nto reduce the rate of caesarean sections in endometriosis \npatients, this population should be very closely monitored, \neven before pregnancy. Special attention should also be \ngiven them during pregnancy to lower the patient’s fear \ncombined with possible complications. Prospective studies \non prophylaxis, psychological help or the influence of \ncooperation with midwifes on endometriosis women are \nhighly required to prove whether the rate of operative \ndeliveries can be reduced in this special group of patients.\nCONCLUSION\nThe study suggests that women with endometriosis are at \nhigher risk of caesarean section as a method of delivery. \nThese females concerned also need more time to conceive, \nwith the implication that they are at an older age at the time \nof pregnancy.\nProspective studies on a large and diverse group of patients \nare needed to establish clear associations between different \nendometriosis forms and pregnancy complications, and to \nfind the best management strategy for this special group of \npatients during pregnancy.\nConflict of interest\nThe authors have no conflict of interest to declare.\nAcknowledgement\nThe authoirs extend their special thanks to dr Tomasz \nWierzbowski who performed laparoscopies in ednometriosis \npatients in 2010–2011.\nREFERENCES\n1. 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