{"paper_id":"afebb48f-491e-451b-8162-7fdc519f0b9e","body_text":"Endometriosis is an inflammatory oestrogen-dependent\nchronic disease with a high prevalence among women of\nreproductive age, which is associated with negative impacts on fertility, quality of life, and functionality ( 1 ,  2 ).\nThis disease is as common as diabetes, as it is reported\nthat 1 in 10 women are affected by it ( 3 ). About 30 to\n50% of endometriosis patients also experience infertility\nimpairment ( 4 ). Endometriosis is associated with a high\ncomorbidity burden, increased use of medical resources,\nand excessive costs, especially for younger patients ( 5 ).\nDespite the particular importance of this disease, large\nprospective investigations in the field of endometriosis\nbased on validated and standardized data are still lacking\n( 3 ). Variations in the currently used methods of collecting\nand reporting data lead to large differences in the results\nof various studies, making it impossible to compare and/\nor combine data to use for a meta-analysis ( 3 ).\nThe World Endometriosis Research Foundation (WERF)\nis an international group of experts whose current goal is\nto standardize the collection of clinical and demographic\ninformation of endometriosis patients, as well as the collection and storage of biological samples, to facilitate joint\nand international endometriosis research. This foundation\nhas developed several standardized questionnaires, which\nhave been created with the collaboration of multidisciplinary experts ( 6 ,  7 ). This action is designed as a project\nto coordinate accurate clinical and demographic data of\nendometriosis patients and the endometriosis bio-bank.\nIt is hoped that this project will facilitate the conduct of\nmulticenter clinical trials on a large international scale\nand with appropriate conditions, leading to the discovery\nof biomarkers and therapeutic targets to help advance re\nsearch in the field of endometriosis ( 8 ).\nIn order to facilitate collaboration between endometriosis researchers, which is only possible through coordinated\ndata collection, it is suggested that all researchers around\nthe world use the standard clinical questionnaire of the\nendometriosis project ( 6 ). The Endometriosis Phenome\nand Biobanking Harmonisation Project (EPHect) clinical\nquestionnaire is currently available in Arabic, Assamese,\nChinese, Danish, Dutch/Finnish, French, German, Hindi,\nLatin American Spanish, Italian, Canadian, Malay, Mar\nathi, Portuguese, Spanish, and Turkish languages. Also,\ncurrently this questionnaire is being translated into Polish\nand Thai; however, it has not yet been translated into Persian. In addition, translation and cultural adaptation are\nnecessary for the content and face validity of the questionnaire in each different language. So far, this research\nhas been performed only in the Canadian, Turkish, and\nFrench languages, and there is no study available in the\nPersian language. The objective of the present study is\nto accurately translate, culturally validate, and assess the\nreliability of the Persian version of the standard endometriosis patient questionnaire (EPQ) for applications in\nepidemiological and clinical research on endometriosis in\nIran.\n\nIn this cross-sectional study, a total of 37 women aged\nbetween 18 and 45 years, who underwent diagnostic so\nnography or laparoscopy for endometriosis, or had symptoms of dysmenorrhea, dyspareunia, pelvic pain unrelated\nto menstruation for more than 6 months, were assessed.\nThe evaluations took place from May 2021 to December\n2023. The study protocol was approved by the Institutional Review Board and the Ethics Committee at Roy\nan Institute (IR.ACECR.ROYAN.REC.1400.156). EPQ\nclinical questionnaire contains 84 questions, which are\ndivided into 6 sections with 14 questions on average in\neach section ( 6 ).\nThe study participants were selected as an available\nsampling from the women’s infertility clinic and the ultra\nsound department of Royan Institute. Women who agreed\nto complete the questionnaire on the first visit prior to so\nnography at the clinic were included, and the validation\ntook place approximately two weeks later. Women with\na diagnosis of malignancy or any cognitive impairment\nhindering questionnaire completion were not included in\nthe study.\nThe research process was structured into two distinct\nphases: translation and cross-cultural adaptation, fol\nlowed by cross-cultural validation. The translation and\nadaptation of the Persian version of WERF EPHect were\nconducted in accordance with the established guidelines\n( 9 ). The entire process was executed in the following sequence: i. Ensuring conceptual equivalence, ii. Conduct\ning forward translation, iii. Performing backward transla\ntion, iv. Preparing the Persian pre-final version by an expert committee, v. Conducting cognitive interviews with\nthe target group, and vi. Finalizing with proofreading.\nConceptual equivalence: the phase consisted of per\nforming a literature review on endometriosis, as well as\nhealth and well-being concepts in the target language database. Two gynecologists were involved in ensuring the\nclarity and relevance of all concepts and questions in the\nWERF EPHect, as well as making any necessary adjustments to avoid cultural insensitivity\nFor this purpose, after obtaining permission and receiving the instructions of the questionnaire from its developers on the translation of the EPQ questionnaire, the translation process was carried out according to the standard\nguideline ( 3 ). In the first stage, two researchers who had\nsufficient knowledge on the subject of the study (endometriosis) and were able to perform translation, translated\nthe questionnaire into Persian independently. The translators were fluent in English, while their native language was Persian. The two translators combined their translated\nversions of the questionnaire with each other after resolving the differences. As an output of this stage, in addition\nto the combined version of the translated questionnaire,\na written report on how to resolve the disagreements was\nalso prepared (consensus opinion of the two translators).\nThe final combined translated version (from the previ\nous stage) was next translated from Persian to English,\nwhich was the original language of the questionnaire.\nThe translation was done independently by two different\nexperts, who were fluent in both English and Persian. In\nthis stage, unlike the previous stage, the two translators\nwere not experts in the relevant scientific topic (endometriosis). These translators had not participated in the\nprevious stages and had no access to the original English\nquestionnaire. The translation was done conceptually and\nnot only word for word. The two translators along with\nthe observer of the process combined the two translated\nversions of the questionnaire with each other after resolving the differences. As an output of this stage, in addition\nto the combined version of the translated questionnaire,\ndisagreements were resolved through the consensus of the\ntwo translators.\nAt this stage, meetings were held under the supervision\nof the responsible researcher and coworkers to identify\nand eliminate inappropriate expressions or concepts in\nthe translated version and to check any differences be\ntween the original and the translated questionnaire. The\nfour previously mentioned translators, researchers in\nvolved in the study, methodologists, and one language\nexpert studied all the documents and reports of the previous stages, as well as the written reports regarding\nthe resolution of disagreements. Additionally, the group\ncommunicated with the designers of the original questionnaire and exchanged opinions. Then, considering all\nthe above, the pre-final version of the Persian questionnaire was prepared.\nIn this stage, to determine the acceptability and compre\nhensibility of the translated questionnaire and whether the\npatients will be able to complete the questionnaire alone\nand without requiring help from the health staff, a pre\ntest was conducted on 7 patients with endometriosis, who\nwere informed about the study prior to the test and verbal\nconsent was obtained from them. Due to the large number\nof questions, the questionnaire was given to the patients\nto fill it out at home. After completing the questionnaire,\nthe patients were called by one of the co-authors, and the\nitems that they could not understand, as well as their opinions on the questions, were asked.\nThe women who completed the questionnaire were con\ntacted at most three times, and if they did not respond or\ndid not attend, they were excluded from the study.\nThe following questions were asked of the pre-test participants:\nHow long did it take to fill out the questionnaire? Is\nit too long?\nAre all questions clear?\nAre all questions relevant?\nDo you have any suggestions for modification?\nDo you have any other comments about the question\nnaire?\nAt this stage, the answers and suggestions that the patients provided in the initial pilot test were informed to\nthe developer (World Endometriosis Society) on Febru\nary 10, 2022, and the association's response was received.\nFinally, after confirming and applying the collected opinions, the final version of the Persian questionnaire was\nprepared and entered the validity and reliability phase.\nConsidering that the validity and reliability of the tool\nmay be affected during the translation process, there\nfore, after the translation, the following steps were taken\nto confirm the validity and reliability of the tool. Due to\nthe standardization of the translated tool, only qualita\ntive validity checking is efficient. In order to examine\nthe content validity of the questionnaire, the translated\nversion of this questionnaire was evaluated by 6 experts\n(infertility fellowships and academic staff members familiar with endometriosis disease with more than 10\nyears of work experience). In this part of the study, these\nexperts were asked to present their corrective views in\nwriting regarding the grammar, using appropriate words\naccording to the Iranian culture, placing the items in\ntheir proper places and giving appropriate points, after\nstudying the tool carefully. The items were edited according to the suggestions and recommendations of the\nexperts.\nThe reliability of the final version of the Persian EPQ\nquestionnaire was evaluated by the \"test-retest\" method.\nFor this purpose, the final adjusted questionnaire was\nmade available to 30 women on two occasions with an\ninterval of two weeks, and reliability in repeatability was\nassessed separately for each question using the Kappa statistics. For questions with binary classification, Cohen's\nkappa was used, and for rating scales with three categories or more, we used weighted kappa. The kappa coefficient is a variable between 0 and 1 and is expressed as\na percentage, and the minimum acceptable value of the\nKappa coefficient is higher than 0.4. Values higher than\n0.6 are good, and values higher than 0.8 are ideal\n( Table 1 ) ( 10 ).\nInterpretation of Cohen’s Kappa\n\nIn comparison of the Persian questionnaire and the\noriginal English questionnaire, no significant differences\nwere observed, and only in some cases there were slight\nvariations with regard to synonyms. In assessment of the\npre-final version, the following items needed to be adapted to the Iranian culture and were changed:\nQuestion A4 (hormonal drugs): Medicines that we do\nnot have access to in Iran or that do not exist in the Iranian pharmacopoeia drugs were removed from the Persian\nquestionnaire.\nQuestion B4.1: Due to the fact that sperm donation is\nnot allowed in Islamic religion, so the sperm donation\nitem was removed from the relevant table.\nQuestion F2-F4: Ethnicity and ancestry are completely\ndifferent in Iran, and we needed to change these things\naccording to our culture and ethnicity. For this purpose,\nquestion F3 was completely removed and questions F2\nand F4 were changed according to the Iranian population.\nQuestion F17: Alcoholic beverages are legally prohib\nited in Iran, so the names of alcoholic beverages were removed from the Persian questionnaire.\nThe answers provided by the participants to the questions inquired in the initial validation phase are as follows:\ni. The questionnaire was very long and boring, it took\nabout an hour and a half (5 participants), ii. The questions\nwere clear, except for the different type of hormonal drugs\nthat I did not know about (2 participants), iii. Some parts\nof the questionnaire were confusing and it seemed to be\nrepeated questions about the same topic. For example, it\nwas confusing that every question was asked about three\nmonths ago and the whole life-time in same places in the\ntable, which makes tables to be complex and the eyes\ntired. It would be better to ask questions related to the last\n3 months and questions related to the subject’s lifetime\nseparately (3 participants), iv. There were no questions\nabout nutrition or environmental factors. It would be bet\nter to ask about the type of nutrition, eating habits, the\nuse of plastic or disposable food containers, the type of\nsanitary napkin used or exposure to radiation, etc. (2 participants), v. There were no questions about the amount of\nstress and the subject’s sleeping habits (1 participant), vi.\nThe indiscriminate use of oral contraceptive pills or other\nhormones was not asked in the questions (1 participant),\nvii. It would be better to ask questions about anal intercourse during menstruation (1 participant), viii. It would\nbe better to ask about having or not having meditation\nor prayer and religious worship as relaxation methods (2\nparticipants), ix. It would be better to ask questions about\ncleaning methods after using the toilet (2 participants), x.\nIt was better to ask questions about the place of residence\nand the level of environmental pollution and the climate\nof the habitat (1 participant), and xi. It would be better to\nask questions about hookah smoking (2 participants).\nRegarding face validity, apart from the changes related\nto Persian grammar, the date of completion of the questionnaire was moved to the first page of the questionnaire,\nand the following items were modified and applied to the\nfinal version of the questionnaire due to the frequent mistakes of the patients:\nQuestion C17 (time of last sexual activity): A few days\nago was added to the items.\nIn the same question, the last item (avoidance of sex\ndue to pain) was moved to the next line for a better under\nstanding of the patient.\nQuestion C28 (last item of the pelvic pain severity\nscale): Visually, the shape of the lines has changed.\nQuestion C29.2: (last experience of pelvic pain), we\nadded last week.\nQuestion C41 (pelvic pain intervention with the patient's social activities): separate lines were allocated for\neducation and work and social or recreational activities\ndue to the patients’ inaccuracy in the completion time.\nQuestion D4 (history of previous surgeries): cases such\nas the removal of the appendix, which is performed only\nonce and cannot be repeated, were filled in black in the\ncolumn of the number of surgeries.\nSome patients had confused ovarian removal surgery\n(oophorectomy) with follicle puncture during in vitro fer\ntilization (IVF) treatments, so its English equivalent, oo\nphorectomy, was added in front of this item.\nQuestion D10 (history of endometriosis in first-degree\nrelatives): To increase the accuracy of patients’ responses,\nthe proportions of each maternal and paternal family were\nspecified in the column titles.\nQuestions E1, and E2 (history of taking painkillers and\nother drugs): yes and no were defined separately.\nQuestion F10 (person’s body shape in each age catego\nry): Due to carelessness in the answers, the photo and the\ncorresponding numbers were moved to the bottom of the\ntable.\nDemographic characteristics of the participants in the final validation stage (n=30)\nThirty endometriosis patients with an average age of\n33.8 ± 4 years and an average body mass index of 23.7 ±\n3.6 kg/m2 participated in the study. In Table 2, the ethnic\nity of the patients, their education levels, and their history\nof infertility and pregnancy records were reported. The\nsurvey shows that most of the patients were of Persian\nethnicity (43.2%), and also most of them had an academic\neducation (56.7%). Meanwhile, 63.3% of patients had no\nhistory of pregnancy, and 80% of the patients each had a\nhistory of primary infertility.\nDemographic and descriptive data of the participants (n=30)\nValues are presented as the mean ± standard deviation/error and number (%). BMI; Body\nmass index, and ART; Assisted reproductive technology.\nThe results of the Kappa test showed that in most questions of the questionnaire, the percentage of agreement\nbetween the two tests had an acceptable level and was\nabove the value of 0.4-0.9. Due to the large amount of\ndata, the  Tables S1-S5  (See Supplementary Online Information at  www.ijfs.ir ) related to this part of the article are\npresented in the supplementary section, which is attached\nto the article.\nThe first segment, which contains menstrual and hormonal history, includes 7 main questions. The response\nrate in questions A1 to A3 was 100%, but in A4 to A7,\nwhich was related to the use of hormones, there were cases of non-response to the questions, which remained as\n398\nmissing in the data. The results of the Kappa test showed\nthat in most questions of the questionnaire, the agreement\nbetween the two tests was acceptable and was above 0.6.\nThe response rate of the participants, as well as the results\nof the Kappa test, are shown in Table S1 (See Supplemen\ntary Online Information at  www.ijfs.ir ).\nThe second segment is related to pregnancy or fertility\nand includes 4 main questions. Eleven patients (36.7%)\nhad a history of pregnancy, and 19 patients (63.3%) had\nno previous pregnancy histories. The response rate of the\nother three questions of this section (B2-B4) was also 100\npercent (Table S2, See Supplementary Online Information at  www.ijfs.ir ).\nThe third segment is appertained to pain and includes\n43 main questions. The response rate of this section was\nlower than the other areas. However, the level of agree\nment between the two tests regarding this part of the questionnaire was moderate to strong, and the range of Kappa\nvalues was between 0.6 and 0.9 (Table S3, See Supple\nmentary Online Information at  www.ijfs.ir ).\nThe fourth field is related to the patients' medical his\ntories and includes 10 main questions. In this section, the\nparticipation rate was high, and 100% of the questions\nwere answered (Table S4, See Supplementary Online\nInformation at  www.ijfs.ir ). The fifth area is related to\nthe patients’ drug histories and includes two main questions. The response rate regarding the main questions was\n100%; however, in answering the sub-questions related to\neach medication, the response rate was decreased (Table\nS5, See Supplementary Online Information at  www.ijfs.\nir ). The sixth area is related to personal information and\nlifestyle of the patients and includes 19 main questions\nthat had a high percentage of participation in answering\n(Table S6, See Supplementary Online Information at\n www.ijfs.ir ).\n\nThe EPHect clinical questionnaire is currently available\nin Arabic, Assamese, Chinese, Danish, Dutch/Finnish,\nFrench, German, Hindi, Latin American Spanish, Ital\nian, Canadian, Malay, Marathi, Portuguese, Spanish, and\nTurkish languages. Also, this questionnaire is being translated into Polish and Thai languages, but it has not been\ntranslated into Persian yet. The present study is the first\nstudy that has accurately translated this questionnaire into\nthe Persian language and adapted it to the Iranian culture.\nIn general, our study showed that the Persian version of\nthe WERF-EPHect questionnaire is practical and accept\nable to endometriosis patients.\nAfter the completion of the translation process and the\npreparation of the pre-final version, changes including the\nremoval of some hormonal drugs and a number of pain\nkillers (due to their unavailability in the Iranian pharma\ncopoeia), the removal of items such as donated sperm and\nthe names of Alcoholic beverages (due to incompatibility\nwith Iran's Islamic culture), and modifying the classification\nof race and ethnicity according to Iran's ethnic struc\nture were necessary.\nThe results of the pilot study based on this pre-final\nversion showed that about 70% of the participants com\nplained about the length of the questionnaire, since it had\ntaken them about 1 to 1.5 hours to complete the questionnaire. About 71% of the study participants found the\nquestionnaire instructions clear and easy to understand;\nhowever, they thought that it was difficult for them to\ncomplete the questionnaire at home, as it was not possible to ask questions from the researchers. Therefore,\nsome items of the questionnaire remained incomplete due\nto misunderstanding or insufficient knowledge of the patients, which were mainly seen in the section of hormonal\nmedication use history. In addition, more than 50% of the\nwomen complained about the tables in the questionnaire\nfor being confusing. Due to the lack of familiarity with\nthis type of table, which generally asks questions related\nto different stages of lifetime, it is probably helpful to\nuse the assistance of the treatment staff to complete these\nitems, or it is necessary to present the items in the form\nof an online questionnaire. Although the questionnaire\ndemands a large amount of detail, the success in identify\ning endometriosis requires obtaining this important data\nregarding pain, symptoms, menstrual status, reproductive\nand medical histories, as well as the demographic and\nlifestyle information.\nTo promote successful completion of the questionnaire,\nwe made the skip patterns more visible by using format\nting techniques, such as highlighting the relevant font, in\nthe text. However, some participants, even with a high\nlevel of education, were careless about the skip points\nand therefore we recommend that while completing the\nform, the participants should be informed about the skip\npatterns to prevent unnecessary questions from being\ncompleted by the researchers. Another method is to use\nbrackets and parentheses or to change colors (if there is\nno color print limit) to separate the skip pattern. Further\nmore, the usage of an electronic online platform to man\nage the questionnaire may automatically perform the skip\nfunction depending on the client’s reply, and on the other\nhand, the questionnaire data may be used for analysis with\na greater accuracy and at a higher speed. This study con\nfirmed the cultural validity of the Persian version of the\nWERF-EPHect. Questionnaire validity is very important\nbecause it ensures that the obtained results are an accurate\nrepresentation of what we intend to measure. We were\nconcerned that our study sample, which was collected at\nan infertility treatment center, may not be representative\nof the average Persian-speaking Iranian women with endometriosis, but our population was diverse in terms of\nage, clinical presentation, education, as well as marital\nand financial status. therefore, it was in fact a representa\ntive population suitable for different strata of Iranian so\nciety. The significant strength of this study was the inclusion of women with endometriosis at different ages. This\nincreased the diversity of the history of the participants\nwith endometriosis, as well as diversity in their approach\nto the semantics and the concept of the questionnaire. The\neducation level of the participants was an important factor in the participants’ understanding of the medical terms\nin the questionnaire. In addition, we noticed that the participants with a lower level of education seemed to pay\nless attention to the instructions at the beginning of the\nquestionnaire, so the presence of the researcher next to the\npeople completing the questionnaire seemed necessary to\nprovide possible explanations. In order to avoid data errors, participants’ contact information should be collected\nin a separate section of the questionnaire.\nIn comparison to the previously published articles, explaining their translation and cross-cultural adaptation of\nthe WERF EPHect EPQ profoundly, we realized that our\nmethod and findings are equivalent. The present study in\ncluded the highest recommended number of participants.\nThe results of the present study are in accord with previous studies in other parts of the world. In the study by Dimentberg et al. ( 3 ), for example, a culturally valid French\nCanadian version of the EPHect Endometriosis Patient\nQuestionnaire-Standard (EPQ-S) from the WERF was\ndeveloped. The results showed that a total of 22 women\nagreed to participate in the study, and ultimately, 17 of\nthem participated in the final validation. These women\nwere in pre-menopausal age and had symptoms of pelvic\npain or suspected endometriosis, and had been referred to\nthe women's health clinic in Quebec City, Canada. In the\nfirst visit of these subjects to the clinic, they completed\nthe French version of the questionnaire, and one week\nlater, its cultural validation was performed. The average\nage of the participants was 38.9 years, and 15 (88%) had\na confirmed diagnosis of endometriosis. Fourteen participants (82%) found the questionnaire clear and relevant.\nThe average time to complete the questionnaire was 36.25\n± 10.8 minutes. Five participants (29%) considered the\nquestionnaire to be long. The validation process resulted\nin the addition of lines at the end of each section to provide space for specific comments and some clarifications\nregarding the timelines ( 3 ). Similarly, the Danish trans\nlation of the EPHect EPQ-S questionnaire and its cross\ncultural adaptation, as well as the equivalency of the\nelectronic version of the questionnaire were evaluated by\nThomsen Holdgaard and his colleagues. For this purpose,\n10 patients with confirmed diagnosis of endometriosis\nthrough ultrasound, laparoscopy or histology were in\ncluded in the study to evaluate the written questionnaire,\nand 5 patients for the electronic format through the Dan\nish Endometriosis Association or the endometriosis clinic\nat Copenhagen University Hospital. The reported median\ntime-to-complete was 62 minutes (range: 29-110). In general, it was easy for 50% of the patients to understand\nthe questionnaire. About 80% of the patients described\nthe questionnaire as long and time-consuming, but only\none participant considered it too long (10%). 60% of the\npatients stated that they had problems with remembering\nwhen answering the questions that were related to the history of their adolescence years or that they could not an\nswer the questions, in which many details were required.\nFinally, the researchers concluded that the Danish version\nof the EPQ questionnaire, both in paper and electronic\nforms, was similar and comparable to the original English questionnaire. However, it is argued that questions\nof measurement units, ethnicity, and education systems\nshould be addressed before cross-country comparisons\ncan be made ( 11 ). In another study, Mis et al. ( 12 ) in\nvestigated the Turkish translation and cultural adaptation\nof a shorter version of the EPHect EPQ questionnaire.\nThe reported duration of questionnaire completion ranged\nfrom 30 to 60 minutes. Also, it was reported that most of\nthe participants found the questionnaire to be clear, but\nall stated that the questionnaire was too long. 40% of the\nparticipants commented on the length of the questionnaire\nafter completing part D, and the rest of the patients commented that the questionnaire was long after completing\nthe entire questionnaire. Despite the fact that jumping patterns were included in the questionnaire, 10% of the par\nticipants ignored it. Consequently, we enhanced the visual\ndistinction of the skip patterns within the questionnaire\nand recommend that the participants be informed about\nthese patterns prior to beginning the questionnaire. Notably, 20% of the participants with primary or secondary\neducation reported that certain questions appeared repetitive, specifically, questions regarding pelvic pain (section\nC2), pain during or after vaginal intercourse (section C15),\nand general pelvic pain (section C27). When research as\nsistants clarified the differences among these sections, it\nbecame evident that the participants had not adequately\nread or comprehended the initial instructions for these\nsections. Therefore, the researchers improved the visual clarity of the instructions and advised participants to\nthoroughly review the instructions for these sub-sections\nbefore beginning the questionnaire ( 12 ). Finally, as the\nresults of the previous studies were mentioned earlier, except for one study that examined the shortened version of\nthe questionnaire, in the rest of the studies similar to the\npresent study, the average time required to complete the\nquestionnaire was reported to be approximately one hour.\nAlso, in all of the recent studies, most of the patients mentioned that the questionnaire was too long and some questions were repetitive. In agreement with previous studies,\nin our study, most of the patients mentioned the length of\nthe questionnaire, and some patients did not notice the\nskipping pattern in the study, and they did not answer all\nthe questions in section C of the questionnaire. Most of\nthe patients stated that too many details were asked in the\nquestionnaire, some of which were questions related to\ntheir adolescence age that they could not remember, so\nmost of the patients left the questions related to the severity of pelvic pain in their adolescence age unanswered.\nThe time interval between the test and the retest is one\nof the challenges when using the \"test-retest\" reliability method of the scales of a questionnaire. In the pre\nsent study, the time interval of two weeks is considered\nto avoid forgetting of the terms of the questionnaire for\nthe participants. On the other hand, based on our observations, no change occurred in the measured variables, and\nthe high values of the Kappa coefficient showed that the\nPersian questionnaire has a high level of reliability.\nCurrently, the EPQ-S questionnaire is used by various\ncenters around the world to examine pain, menstrual and\nfertility history, history of hormone use and infertility,\nand demographic characteristics and lifestyle in women\ndiagnosed with or suspected of endometriosis. Validation\nof the EPHect EPQ-S in different languages and cultures\nallows for standardized and high-quality assessment of\nwomen with endometriosis, comparison between studies, and aggregation of the results obtained nationally\nand internationally. Collaborations of this nature result in\nstudies that are demographically diverse and exhibit high\nlevels of reliability and validity, thereby advancing significant research and discoveries for the millions of pa\ntients affected by endometriosis globally. Clinical trials\nthat utilize non-standardized questionnaires for data collection frequently encounter issues related to the validity\nand comparability of their findings ( 3 ). The evaluation of\npain symptoms is associated with challenges such as subjectivity, which is used in the EPHect EPQ-S question\nnaire, a valid tool of visual analog scales. In the present\nstudy, a paper version of the questionnaire was used; it is\nsuggested that an electronic version be designed to make\nit easier for patients to answer and access it.\n\nThe present study is the first study that has translated\nthis questionnaire into the Persian language and adapted\nit to the Iranian culture. In general, our study showed that\nthe Persian version of the WERF-EPHect questionnaire\nwas practical and acceptable to patients, and it is a valid\nand reliable tool. Small changes related to jump points,\nexplanations related to drugs and hormones are necessary\nfor the patients’ better understanding. Also, the presence\nof a research assistant at the time of completing the questionnaire by patients will help to solve possible issues.\nValidation studies in different languages and cultures\nprevent the differences in those languages and cultures\nfrom creating obstacles for future collaborations and in\nternational research on endometriosis. In addition, the opportunity to compare and aggregate the results of various\nstudies at national and international levels is provided.","source_license":"CC0","license_restricted":false}