{"paper_id":"66072d1f-dee9-4b6a-97f0-cac19735d710","body_text":"Endometriosis is a chronic, recurrent, and disabling condition affecting\napproximately 5% to 10% of women [ 1 ].\nEndometriotic lesions are characterized by ectopic endometrial glands and stroma\noutside the uterine cavity, commonly involving the ovaries and other pelvic\nstructures [ 2 ]. These lesions trigger a\npersistent inflammatory response, forming scar tissue and adhesions [ 3 ]. Depending on the location of the lesions,\nendometriosis may impair the function of the bowel or bladder [ 4 ]. The clinical presentation of endometriosis varies widely.\nWhile some women may remain asymptomatic, most experience dysmenorrhea, dyspareunia,\nand chronic fatigue [ 5 ]. A considerable\nproportion of patients also report gastrointestinal symptoms. These may include\nsevere abdominal pain, constipation, bloating, flatulence, psychological distress\naffecting daily life, urgency in defecation, and a sensation of incomplete bowel\nevacuation [ 6 ].\nEndometriosis and gastrointestinal manifestations are two prevalent medical\nconditions that significantly affect the quality of life in a substantial number of\nwomen, adolescent girls, and even some postmenopausal women [ 6 ]. Affected individuals commonly experience menstrual\nirregularities, infertility, abdominal and pelvic pain, and disrupted bowel\nmovements. Moreover, approximately 61% of women and adolescent girls are diagnosed\nwith irritable bowel syndrome (IBS) [ 6 ]. Given\nthe chronic inflammatory nature of both conditions, endometriosis and IBS share\nconsiderable symptom overlap. A recent nationwide study in the United States\ndemonstrated that endometriosis increases the risk of developing IBS by nearly\nthreefold. However, it remains unclear whether endometriosis independently\ncontributes to bowel involvement or serves as a distinct risk factor for IBS [ 4 ]. Several theories have been proposed to\nexplain the association between endometriosis and IBS. These include immunological\nmechanisms involving mast cell activation, abnormal levels of inflammatory\ncytokines, and heightened activity of immune cells within the peritoneal cavity,\nobserved in both conditions. Fagervold et al. reported a direct correlation between\nthe severity of gastrointestinal symptoms and the depth of endometriotic\ninfiltration into the bowel; symptoms improved following surgical excision of the\nlesions [ 7 ].\nEndometriosis is a chronic condition, and like other chronic diseases, early\ndiagnosis plays a critical role in its management by improving prognosis and\nenhancing patients’ quality of life. The gold standard for diagnosing endometriosis\ninvolves surgical methods; however, due to the invasive nature and high cost of\nlaparoscopy, such approaches are typically reserved for specific clinical\nsituations. As a result, pelvic examination and imaging techniques are more commonly\nemployed to diagnose suspected cases of endometriosis [ 8 ]. On the other hand, there is no universally accepted standard\nfor diagnosing gastrointestinal symptoms. The most commonly used diagnostic\nframeworks are the Manning and Rome criteria. Consequently, definitively identifying\ngastrointestinal symptoms can vary depending on the diagnostic criteria. Patients\nwith endometriosis report a wide range of gastrointestinal symptoms, which often\noverlap significantly with those observed in irritable bowel syndrome (IBS), making\nthe differential diagnosis particularly challenging.\nIn the study conducted by Malin et al., patients with endometriosis reported\nsignificantly worsened abdominal pain, constipation, bloating, and urgency in\ndefecation [ 4 ]. Similarly, Khadija Saidi et\nal. reported that women diagnosed with endometriosis were two to three times more\nlikely to experience gastrointestinal symptoms [ \n9 ]. According to findings by Nicolas Bourdel et al., endometriosis\nadversely affects physical, psychological, and social health, with a negative impact\non health-related quality of life in these patients [ \n8 ]. Ballester et al. demonstrated that colorectal surgery for\nendometriosis followed by ICSI-IVF represents a favorable treatment strategy for\nwomen with established infertility, even in cases where prior ICSI-IVF attempts had\nfailed [ 10 ]. Given the importance of this\nissue, the present study was designed to evaluate the impact of laparoscopic surgery\nfor endometriosis on general and sexual quality of life, gastrointestinal symptoms,\nand IVF success in patients diagnosed with DIE .\n\nThe present cross-sectional study (Ethics Code: IR.TUMS.MEDICINE.REC.1402.017) was\nconducted after obtaining approval from the Ethics Committee of Tehran University of\nMedical Sciences. A total of 129 women diagnosed with endometriosis who were\nreferred to Yas Infertility Center were enrolled. Patients with diagnosis of\nDIE-associated infertility were included if diagnosis was confirmed by medical and\nimaging findings. Exclusion criteria included a history of usage of\nimmunosuppressive medications, presence of malignancy, adenomyosis of the uterus, or\nsevere underlying medical conditions that contraindicated surgery, fertility, or IVF\ntreatment. Following history taking and clinical examinations, demographic data were\nrecorded using a researcher-designed questionnaire before surgery. Based on the\nnumber of eligible patients referred to Yas Hospital and using the following sample\nsize formula, considering a reported prevalence of gastrointestinal symptoms ranging\nfrom 70% to 77% in patients with endometriosis, the required sample size was\ncalculated to be 129 participants. A convenience sampling method was employed in\nthis study.\nInitially, demographic information, endometriosis-related parameters, including\nanatomical involvement and associated findings, were documented through surgical and\nimaging reports. Colonoscopy results were obtained from endoscopic evaluations.\nMedical histories were verified through patient interviews and chart reviews. The\nseverity and presence of gastrointestinal symptoms were recorded. These symptoms\nwere reassessed following the surgical procedure. In addition, participants were\nasked to complete the SF-36 and FSFI questionnaires before and one month after\nsurgery. The SF-36 Quality of Life Questionnaire consists of 36 items covering eight\ndomains: physical functioning (10 items), role limitations due to physical health\nproblems (4 items), role limitations due to emotional problems (3 items), vitality\n(4 items), emotional well-being (5 items), social functioning (2 items), pain (2\nitems), and general health perceptions (5 items). Items are measured using various\nLikert scales, including dichotomous, 3-point, 5-point, and 6-point formats. The\ntotal score ranges from 0 to 100, with higher scores indicating better quality of\nlife. This questionnaire was initially developed by Ware and Sherbourne in 1992 in\nthe United States, and its validity and reliability have been confirmed across\ndifferent patient populations [ 11 ]. The\nreliability and validity of the Persian version were also assessed by Dr. Montazeri\nand colleagues, reporting a Cronbach’s alpha of 0.79 [ 12 ].\nThe Female Sexual Function Index (FSFI) is a validated instrument widely used to\nassess female sexual function. It consists of 19 items scored on a 6-point Likert\nscale and evaluates six domains: sexual desire (2 items), arousal (4 items),\nlubrication (4 items), orgasm (3 items), satisfaction (3 items), and pain (3 items).\nHigher scores indicate better sexual functioning. Each domain has a maximum score of\n6; the total scale score can reach 36. A score of zero indicates no sexual activity\nduring the past four weeks. The FSFI was developed by Rosen in 2004, and its\nvalidity and reliability have been confirmed [ \n13 ]. Dr. Mohammadi and colleagues assessed the Persian version's\nreliability and validity, reporting a Cronbach’s alpha of 0.83 [ 14 ].\nAll eligible patients diagnosed with endometriosis referred to Yas Hospital from 2022\nto 2023 (1401-1402 in the Iranian calendar) were enrolled in this study. Inclusion\ncriteria consisted of women diagnosed with endometriosis and DIE with a surgical\nindication, as well as those presenting with gastrointestinal symptoms. The presence\nor absence of gastrointestinal symptoms, including abdominal pain, bloating,\ndefecation disorders, constipation, diarrhea, cramping, nausea, and vomiting, was\nalso documented in the same questionnaire before the surgical intervention.\nGastrointestinal symptoms were reassessed one month postoperatively to determine\nimprovement or persistence of symptoms, and their association with IVF outcomes was\nevaluated. Additionally, changes in general and sexual quality of life before and\nafter surgery were assessed using the SF-36 and FSFI questionnaires.\nSix months later, documents were assessed and patents were called to ask about\nsuccuss of IVF, defined by pregnancy successfully being conceived and confirmed by\nchemical analysis.\nAll data were entered into SPSS software , version 24. Descriptive statistics for\nqualitative variables were presented using frequency tables and charts, while\nquantitative data were summarized using mean and standard deviation. For inferential\nanalysis, the Chi-square test was used to examine associations between qualitative\nvariables, and the independent t-test was employed to compare quantitative\nvariables. A P-value of less than 0.05 was considered statistically significant.\n\nA total of 129 eligible patients were included in the study, with a mean age of 34.82\n± 5.83\nyears and a mean body mass index (BMI) of 25.64 ± 3.77 kg/m². Data on patients’\nfindings\nassociated with endometriosis are presented in Table- 1\n  . Comorbidities like hypothyroidism (12.4%) and hypertension (3.9%) were\nreported,\nwith 61.2% having no medical history. DIE related findings of near-universal ovarian\ninvolvement (99.2%) and adhesions (99.2%) were prevalent. Common DIE sites included\nthe\nrectosigmoid (24.1%) and cervix/posterior cervix (29.5%), while müllerian anomalies\nwere\nrare (2.3%). Colonoscopy revealed 76.7% normal findings, though strictures (17.1%)\nand\nerythema (12.4%) were notable. Frequency of gastrointestinal symptoms were as\nfollows:\nrectal bleeding (10.1%), constipation (24.8%), abdominal pain (98.4%), abdominal\nbloating\n(37.9%), diarrhea (3.9%), dyspepsia (27.9%), and reflux (20.9%) before the\nintervention.\nA total of 16 patients (12.4%) experienced surgical complications , that the highest\ncomplication rate was due to hemoglobin drop that happened in 17.8% of patients\nwhile only\n1.5% needed blood transfusion. intestinal injury happened in 6.2%.\nChanges in patients’ clinical findings before and after the intervention are\npresented in\nTable- 2 . Rectal bleeding, initially reported\nin 10.1%\nof cases, was completely eliminated post-treatment. Similarly, diarrhea, which\naffected 3.9%\nof participants at baseline, disappeared entirely after the intervention.\nConstipation saw a\ndramatic drop from 24.8% to just 6.2%, a change that was highly statistically\nsignificant (P<0.0001).\nLikewise, abdominal bloating improved substantially, falling from 37.9% to 9.3% (P<0.0001).\nWhile dyspepsia and reflux also decreased (27.9% to 20.2% and 20.9% to 10.9%,\nrespectively),\ntheir improvements, though significant (P<0.0001), were less pronounced than\nother\nsymptoms. The most striking transformation was seen in abdominal pain. Before\ntreatment,\nnearly all patients (98.4%) experienced some level of pain, with 47.3% suffering\nsevere\n(Grade 4-5) discomfort. After the intervention, 90.7% were pain-free, and severe\ncases\nplummeted to just 0.8% (P<0.0001). Even moderate pain (Grade 3), initially\naffecting\n44.9%, was reduced to a mere 0.8%.\nThe results regarding changes in FSFI scores, the overall score, and individual\ndomains of\nthe SF-36 questionnaire before and after the intervention are presented in\nTable- 3 . The intervention led to remarkable\nimprovements in\nboth sexual function and overall quality of life. The FSFI total score, reflecting\nfemale\nsexual health, increased significantly from 57.6 ± 28.8 to 65.2 ± 27.4 (P<0.0001),\nsuggesting enhanced sexual well-being after treatment. For SF-36 domains, the most\ndramatic\nchange was seen in pain, which dropped by more than half (from 6.8 ± 1.2 to 2.7 ±\n0.9, P<0.0001).\nPhysical functioning also improved notably, rising from 10.2 ± 0.5 to 11.5 ± 1.3 (P<0.0001),\nwhile general health perceptions saw a meaningful boost (12.0 ± 1.3 to 13.9 ± 1.9, P<0.0001).\nInterestingly, role limitations due to physical health decreased (6.7 ± 1.7 to 4.2 ±\n0.7, P<0.0001),\npossibly indicating fewer activity restrictions post-intervention. A similar but\nsmaller\nreduction occurred in emotional role limitations (4.2 ± 1.4 to 3.4 ± 1.0, P<0.0001).\nHowever, some areas remained unchanged: Vitality (energy/fatigue), emotional\nwell-being, and\nsocial functioning showed no statistically significant differences (P>0.05),\nsuggesting\nthese aspects were less affected by the intervention. Despite this, the total SF-36\nscore\nstill improved significantly (65.9 ± 3.3 to 68.0 ± 3.5, P<0.0001) Overall, 67.44%\nof\nindividuals attempting pregnancy successfully conceived.\n\nIn this study, analysis of the SF-36 questionnaire domains revealed a significant\nimprovement in physical functioning and general health scores following surgical\nintervention.\nConversely, scores related to role limitations due to physical health, role\nlimitations due to\nemotional problems, and pain significantly decreased after surgery. These findings\nare broadly\nconsistent with those reported by Ballester and Meuleman [ 15 ].\nThe study by Viganò et al. highlighted that irritable bowel syndrome (IBS) and\nendometriosis are two\nconditions that independently or concurrently affect a substantial proportion of the\nfemale\npopulation and have significant implications for their quality of life. Their\nassociation may not be\npurely epidemiological but could reflect a shared pathophysiological basis, which is\nsupported by\noverlapping mechanisms such as mast cell activation, neuroinflammation, dysbiosis,\nand increased\nintestinal permeability—all of which are exacerbated in individuals with\nendometriosis. Recognizing\nthis association is crucial due to the high prevalence of both conditions and their\nshared clinical\npresentation, particularly chronic abdominal pain [ \n16 ].\nLea et al. reported that both irritable bowel syndrome (IBS) and endometriosis are\ncommon\nconditions; however, gastrointestinal manifestations of endometriosis are relatively\nrare. In many\npatients initially diagnosed with IBS, subsequent laparoscopy revealed the presence\nof endometriosis\nand even small bowel obstruction. These findings highlight the importance of\nconsidering alternative\ndiagnoses, particularly endometriosis, in patients with an initial IBS diagnosis\nwhen there is\ndiagnostic uncertainty [ 17 ]. In another\nstudy, Lee et al.\nidentified several factors associated with the severity of gastrointestinal symptoms\nin patients\nwith endometriosis. These included early-stage endometriosis, mood disorders,\ntenderness during\nphysical examination, a history of sexual abuse, and sleep disturbances [ 18 ]. In the present study, several distressing\ngastrointestinal\nsymptoms—including constipation, abdominal pain, bloating, dyspepsia, and\nreflux—showed significant\nimprovement following surgical treatment for endometriosis. Similarly, Schomacker et\nal.\ndemonstrated that women with endometriosis experience more frequent and more severe\ngastrointestinal\nsymptoms compared to women without the condition. Their cross-sectional study, which\ncollected\nonline questionnaire responses from 373 women, found that the prevalence of\ngastrointestinal\nsymptoms was significantly higher in women with endometriosis (OR=5.32). Bowel\ninvolvement was also\nmore common in this group. The study concluded that proper treatment and management\nof endometriosis\ncan substantially reduce the severity of gastrointestinal symptoms and, in some\ncases, lead to\ncomplete resolution [ 19 ]. The findings of\nboth studies, as\nmentioned above, are in complete agreement with the present research results,\nfurther supporting the\neffectiveness of endometriosis treatment in alleviating or eliminating\ngastrointestinal symptoms.\nIn a study by Nnoaham et al. conducted on 1,418 women aged 18 to 45 years with\nendometriosis,\nit was reported that endometriosis adversely affects HRQoL and work productivity\nacross countries\nand ethnicities. Nevertheless, women face diagnostic delays in primary care settings\n[ 20 ]. The present study's findings align with\nthis research,\nshowing that surgical intervention for endometriosis significantly improved general\nand sexual\nhealth scores, with notable improvements in physical functioning, emotional\nwell-being, and pain\nreduction. Similarly, Fourquet et al. reported that endometriosis-related symptoms,\nsuch as chronic\ndisabling pelvic pain and infertility, negatively and substantially affect physical\nand\npsychological health, health-related quality of life, and work productivity in\nwomen. Their findings\nalso emphasized that proper management and treatment of endometriosis can\nsignificantly improve\nphysical and sexual quality of life [ 21 ].\nThese results are\nconsistent with those of the current study and demonstrate that effective management\nof\nendometriosis can substantially enhance quality of life, particularly in physical,\nemotional, and\npsychological domains.\nMoore et al. also reported that women with endometriosis are frequently misdiagnosed\nwith\nirritable bowel syndrome (IBS) before receiving an accurate diagnosis. Among 160\nwomen who met the\nRome III criteria for gastrointestinal symptoms, 36% were found to have concurrent\nendometriosis\n[ 22 ]. The severity and stage of endometriosis\nmay influence\nthe success rates of assisted reproductive technologies (ART), particularly in vitro\nfertilization\n(IVF) [ 23 ]. Various studies have reported\ninconsistent\nresults regarding IVF success rates in patients with endometriosis. Some studies\nhave found no\nsignificant difference in pregnancy outcomes between women with and without\nendometriosis undergoing\nIVF [ 18 ]. However, a survey by Hamdan et al.\nin 2015\ndemonstrated that the treatment of endometriosis could significantly affect IVF\nsuccess rates. The\nlive birth rate among women with untreated endometriosis undergoing IVF was 27.7%,\ncompared to 43.6%\nin those undergoing early-stage treatment and 46.3% in those at the final stages of\nendometriosis\nmanagement [ 24 ].\nIn a prospective cohort study by Bianchi et al., conducted on 179 infertile women\ndiagnosed\nwith both endometriosis and irritable bowel syndrome, IVF outcomes were compared in\nwomen with\nDIE-associated infertility who underwent extensive laparoscopic resection of\nendometriosis before\nIVF. The study demonstrated that comprehensive laparoscopic excision of DIE\nsignificantly improved\nIVF pregnancy rates in women with DIE. Moreover, it was observed that surgical\ntreatment of DIE also\nled to a considerable reduction in the severity of gastrointestinal symptoms [ 25 ].\n\nSurgical treatment of endometriosis, particularly DIE, significantly reduces the\nseverity of\nvarious gastrointestinal symptoms such as constipation, abdominal pain, bloating,\ndyspepsia, and\nreflux. It also leads to a meaningful improvement in quality of life, especially in\nthe domains\nof physical functioning and general health, as well as in the sexual function of\nwomen\nundergoing assisted reproductive treatments like IVF. However, due to the\nconsiderable overlap\nin clinical manifestations between endometriosis and irritable bowel syndrome, a\nhigh level of\nclinical vigilance is required when evaluating patients presenting with such\nsymptoms. Both\nconditions should be carefully considered in the differential diagnosis.\nLarger-scale and more\ncomprehensive studies are recommended to enhance diagnostic accuracy and improve\ndifferentiation\nbetween these two disorders.\n\nNone.","source_license":"CC-BY-4.0","license_restricted":false}