{"paper_id":"f84ad04f-c1ce-4117-ae0c-0efac6b98178","body_text":"1291\n© Aluna Publishing\n   Wiadomości Lekarskie Medical Advances, VOLUME LXXVIII, ISSUE 7, JUL Y 2025\nINTRODUCTION\nEndometriosis is an estrogen-dependent and multifac-\ntorial, chronic inflammatory disease in women. Women \nwith endometriosis are at elevated risk for serious ad-\nverse outcomes [1-4]. \nAccording to the literature, women with endometrio-\nsis had higher odds of gestational hypertension and/or \npre-eclampsia, gestational diabetes, gestational cholestasis, \nplacenta praevia, antepartum hemorrhage, antepartum \nhospital admissions, and malpresentation [5,6]. In addition, \nin women with endometriosis were also more likely to have \npreterm birth and neonatal death [7]. Among women who \nconceived with the use of assisted reproductive technology, \nendometriosis associated with preterm birth [8, 9].\nObstetric and gynecological surgical procedures, and surgical \nsite infections as risk for the development of endometriosis: a \nmulticenter study\nAidyn G. Salmanov1,2, Volodymyr V. Artyomenko3, Olena A. Dyndar4, Iryna M. Lypko4, Victor O. Rud5,  \nLidiya V. Suslikova6, Andrey O. Semenyuk6, Oleksandr V. Zabudskyi6, Svitlana M. Korniyenko3, \nOlga V. Gorbunova6, Vitalii S. Strakhovetskyi7,8, Yuliia V. Strakhovetska8, Olena O. Lytvak9, \nKhrystyna V. Zarichanska6, Andriy I. Chubatyy4, Olexandr P . Kononets6,  Mykhailo V. Knyhin8\n1UKRAINIAN CENTER OF MATERNITY AND CHILDHOOD OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES OF UKRAINE, KYIV , UKRAINE\n2THE ZARIFA ALIYEVA INTERNATIONAL CENTER OF MEDICAL SCIENCE, KYIV , UKRAINE\n3ODESA NATIONAL MEDICAL UNIVERSITY , ODESA, UKRAINE\n4BOGOMOLETS NATIONAL MEDICAL UNIVERSITY , KYIV , UKRAINE\n5NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY , VINNYTSIA, UKRAINE\n6SHUPYK NATIONAL HEALTHCARE UNIVERSITY OF UKRAINE, KYIV , UKRAINE\n7KHARKIV NATIONAL MEDICAL UNIVERSITY , KHARKIV , UKRAINE\n8MEDICAL CENTRE “ASHERA” , KHARKIV , UKRAINE\n9 CLINICAL AND PREVENTIVE MEDICINE STATE INSTITUTION OF SCIENCE CENTER OF INNOVATIVE HEALTHCARE TECHNOLOGIES STATE \nADMINISTRATIVE DEPARTMENT , KYIV , UKRAINE\nABSTRACT\nAim: Aim this study was to evaluate the incidence of endometriosis in women with a recent history of surgical site infections (SSIs), and obstetric and gyne -\ncological surgical procedures.\nMaterials and Methods: A retrospective multicenter cohort was conducted on patients who have had obstetric or gynecological surgical procedures performed \nfrom January 2022 to December 2024 in 16 hospitals from six Ukrainian regions. Definitions of SSIs were adapted from the Centers for Disease Control and \nPrevention’s National Healthcare Safety Network. The criteria for endometriosis were adapted from the ESHRE endometriosis guideline.\nResults: The study included 33,126 reproductive women with endometriosis who had 16,724 obstetric and 32,383 gynecologic surgical procedures. The inci-\ndence of endometriosis in women with history of obstetric and gynecologic surgical procedures, and SSIs was 25.5% [95% confidence interval (CI), 24.3-26.4], \n33.3% (95% CI, 33.0-33.6), and 22,1% (20.8-24.2), respectively. Multivariate analysis identified SSIs, obstetric and gynecological surgical procedures as three \nfactors positively associated with the risk of endometriosis. Factors that increased the odds of endometriosis was SSIs (adjusted odds ratio [AOR], 3.76; 95% \nCI, 2.29–6.20), and obstetric and gynecological surgical procedures (AOR, 7.91; 95% CI, 3.68–37.3). An SSIs and obstetric and gynecological surgery history \nincreased the odds of an endometriosis >7-fold in the cohort (AOR, 7.96; 95% CI, 3.64–37.2).\nConclusions: Obstetric and gynecological surgical injury, and the inflammation resulting from SSIs may play a role in developing endometriosis.\n KEY WORDS:  endometriosis, obstetric and gynecological surgery, surgical site infections, risk factor, Ukraine\nWiad Lek. 2025;78(7):1291-1297. doi: 10.36740/WLek/208988 DOI\nORIGINAL ARTICLE CONTENTS\n\nAidyn G. Salmanov et al. \n1292\nEndometriosis disease is the cause of depression. \nThis pathology leads to a loss of productivity at work. \nAccording to the literature, medical cost range of en-\ndometriosis from US$1459 to US$20,239 [10].\nCurrently, the pathophysiology and risk factors of the \ndisease are not fully understood. Previous studies have \nshown that inflammation related to genital tract infec-\ntion and surgical injury may cause endometriosis [11, \n12]. According to the literature, in patients with a pre-\nvious cesarean section presented a twofold increased \nrisk of endometriosis. Also, it has been reported that \ndissemination of endometrial cells may occur during \ncesarean section after entry into the uterine cavity [13]. \nAccording to the literature, Inflammation in the pel-\nvic cavity is one of the leading factors an important \npathologic process of endometriosis. Both pathogens \nand physical injury of tissue may cause inflammation \n[11]. Several researchers have focused on revealing the \nrelationship between inflammation and endometrio -\nsis. Researchers reported that intrauterine microbial \ncolonization and bacterial endotoxin were associated \nwith endometriosis [14]. Similar studies have not been \nconducted in Ukraine. A previous study has focused on \nthe prevalence of endometriosis and adverse pregnan-\ncy outcomes associated with endometriosis [3, 4, 9].\nAIM\nThe aim of this study was to evaluate the incidence of \nendometriosis in women with a recent history of SSIs \nand obstetric and gynecological surgical procedures.\nMATERIALS AND METHODS\nSTUDY DESIGN, SETTING AND PATIENTS\nA retrospective multicenter cohort study based on \nsurveillance data for endometriosis was conducted \non patients who have had obstetric or gynecological \nsurgical procedures performed from January 2022 \nto December 2024 in 16 hospitals from six Ukrainian \nregions (Kharkiv, Odessa, Kyiv, Vinnytsya, Lviv, Lutsk). \nThis study included patients after a clinical suspect of \nendometriosis confirmed by ultrasound or magnetic \nresonance imaging, and in case of laparoscopic diagno-\nsis with histopathological confirmation of stage III or IV \naccording to the r-ASRM (revised American Society for \nReproductive Medicine) classification for endometriosis \nwith ovarian localization. Patients were excluded: (a) in \ncase of a history of surgeries for endometriosis, and (b) \nlaparotomy, for staging or restaging of ovarian, tubal, \nor primary peritoneal malignancy (second look), with \nor without omentectomy, peritoneal washing, biopsy \nof abdominal and pelvic peritoneum, diaphragmatic \nassessment with pelvic and limited para-aortic lymph-\nadenectomy. Ultrasound evidence of DIE was confirmed \nby magnetic resonance imaging.\nDEFINITION\nAn SSI was defined as an infection arising >48 h after \nsurgical procedures. The criteria for specific SSI site \nafter obstetric or gynecological surgical procedures \nwere adapted from the CDC/NHSN (Centers for Dis-\nease Control and Prevention’s and National Healthcare \nSafety Network’s) case definitions [15]. The postsurgical \nresidual was defined as visible evidence of unresectable \nendometriotic lesions. Ovarian endometriosis was iden-\ntified as an ovarian cyst with a regular wall containing \nthick-brown fluid. Peritoneal endometriosis was identi-\nfied as superficial black, dark-brown, or bluish-puckered \nlesions, nodules, or small cysts containing old hemor -\nrhage surrounded by fibrosis. Deeply infiltrative endo-\nmetriosis (DIE) was identified as nodules infiltrating the \npouch of Douglas, vagina, posterior vaginal fornices, \nlateral vaginal fornices, retrocervical area, uterosacral \nligaments, rectovaginal septum, bladder, rectosigmoid \njunction, or rectum [16]. \nDATA COLLECTION\nIn this study, we analyzed the inpatient data medical \nrecords patients with endometriosis to identify and \ndescribe the type of surgical procedures and post -\noperative SSIs. Medical records and epidemiological \ndata were used to find risk factors for endometriosis \nin patients with SSIs after obstetric and gynecological \nsurgical procedures. The surgical procedures involved \nthe abdominal hysterectomy (includes that by laparo-\nscope), Cesarean section, Laparotomy, Vaginal hysterec-\ntomy, and Ovarian surgery. In this study, all participants \nwere queried regarding history of SSIs after obstetric or \ngynecological surgical procedures, sociodemographic \ncharacteristics, reproductive and medical history.\nETHICS\nThe Zarifa Aliyeva International Center of Medical \nScience (Kyiv, Ukraine) approved this study. Patients \nagreed to participate in this study.\nSTATISTICAL ANALYSIS\nAll statistical analyses were performed using Microsoft® \nExcel (Microsoft Corporation, Redmond, WA, USA). The \ndata are presented as numbers and percentages. Pearson’s \n\n1293\nObstetric and gynecological surgical procedures, and surgical site infections as risk for the development...\nchi-square (χ2) test was performed to check the matching \nperformance between the case and comparison groups \nand compare the differences between groups for categor-\nical variables. The Cox model calculated the hazard ratio \n(HR) and 95% confidence interval (CI) of endometriosis in \npatients undergoing SSIs or obstetric and gynecological \nsurgical procedures compared to the comparison group. \nLogistic regression estimated the adjusted odds ratios \n(AORs) and 95% confidence intervals for each cohort. The \nP value under 0.05 was considered significant.\nRESUL TS\nThe study included 33,126 reproductive women with \nendometriosis who had 16,724 obstetric and 32,383 \ngynecologic surgical procedures. Of all endometri-\nosis cases, 18.7% (6,195/33,126) were peritoneal/\nsuperficial endometriosis, 67.4% (22,327/33,126) were \novarian endometriotic cyst/endometrioma and 13.9% \n(4,603/33,126) were deep infiltrating endometriosis. \nThe incidence of endometriosis in women with his-\ntory of obstetric and gynecologic surgical procedures, \nand SSIs was 25.5% [95% confidence interval (CI), 24.3-\n26.4], 33.3% (95% CI, 33.0-33.6), and 22,1% (20.8-24.2), \nrespectively. Most cases (28.6%, 95% CI, 27.2-29.3) of all \nendometriosis was diagnosed in women with history \nof operations on ovary and related structures. Endome-\ntriosis in women with history of vaginal hysterectomy, \nabdominal hysterectomy and obstetrical delivery by \ncesarean section was 9.3%, 5.3%, and 3.7%, respectively.\nA total 33,126 women with endometriosis had 11,042 \nhistories of SSIs. The highest number (>30%) of SSIs was \nTable 1. Incidence of surgical site infections (SSIs) after obstetrical and gynecological surgery procedures in Ukraine (2022-2024)\nType of procedure\nNumber \nof proce-\ndures, n \nSSIs Incidence \nof SSIs\n(95% CI)\nYes No\nn % n %\nAbdominal hysterotomy (e.g., for hydatidiform mole, abortion) 1,748 367 21.1 1381 79.0 20.0 – 22.0\nOperative vaginal delivery 985 218 22.1 767 77.9 20,9 – 23.4\nCesarean delivery 2,431 618 25.4 1,823 74.6 24.5 – 26.4\nPostpartum hemorrhage 2,017 362 17.9 1,655 82.1 17.1 – 18.8\nGenital tract lacerations after vaginal delivery 987 211 21.4 776 78.6 20.1 – 22.7\nManual removal of the placenta (vaginal or cesarean delivery) 1,887 488 25.9 1,399 74.1 24.9 – 26.9\nMultiple vaginal examinations after vaginal delivery 2,711 1,024 37.8 1,687 62.2 36.9 – 38.7\nInduced abortion with cervical dilation and hysterotomy 1,812 659 36.4 1,153 63.6 35.3 – 37.5\nSurgical curettage after vaginal delivery 2,146 817 38.1 1,329 61.9 37.1 – 39.2\nAbdominal hysterectomy (corpus and cervix), with or without removal of tube(s) or ovary(s)1,229 348 28.3 881 71.7 27.0 – 29.6\nSupracervical abdominal hysterectomy, with or without removal of tube(s) or ovary(s) 816 117 14.3 699 85.7 13.1 – 15.5\nLaparoscopy, surgical, supracervical hysterectomy, with removal of tube(s) and/or ovary(s) 1,533 336 21.9 1,197 78.1 20.8 – 23.0\nLaparoscopy, surgical, supracervical hysterectomy, with removal of tube(s) and/or ovary(s) 2,118 301 14.2 1817 85.8 13.4 – 15.0\nLaparoscopy, surgical, with vaginal hysterectomy, with removal of tubes(s) and /or ovary(s)1,926 411 21.3 1,515 78.7 20.4 – 22.2\nLaparoscopy, surgical, with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure)1,422 231 16.2 1,191 83.8 15.2 – 17.2\nLaparoscopy, surgical; with removal of adnexal structures (oophorectomy or salpingectomy)1,184 112 9.5 1,072 90.5 8.7 – 10.4\nLaparoscopy, surgical, with excision of lesions of the ovary, pelvic viscera, or peritoneal surface10,228 1,856 18.1 8,372 81.9 17.7 – 18.5\nSalpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) 512 85 16.6 427 83.4 15.0 – 18.2\nLysis of adhesions (salpingolysis, ovariolysis) 1,046 123 11.8 923 88.2 10.8 – 12.8\nDrainage of ovarian cyst(s), unilateral or bilateral (vaginal approach) 1,207 211 17.5 996 82.5 16.4 – 18.6\nDrainage of ovarian cyst(s), unilateral or bilateral (abdominal approach) 1,127 109 9.7 1,018 90.3 8.8 – 10.6\nDrainage of ovarian abscess (vaginal approach, open)  1,401 211 15.1 1,190 84.9 14.1 – 16.1\nDrainage of ovarian abscess (abdominal approach)  1,126 211 18.7 915 81.3 17.5 – 19.9\nBiopsy of ovary, unilateral or bilateral (separate procedure) 1,452 547 37.7 905 62.3 36.4 – 39.0\nOvarian cystectomy, unilateral or bilateral  1,283 427 33.3 856 66.7 32.0 – 34.6\nClosure of vesicouterine fistula; with hysterectomy 1,024 257 25.1 767 74.9 23.8 – 26.5\nVaginal hysterectomy, with removal of tube(s), and/or ovary(s) 986 233 23.6 753 76.4 22.3 – 25.0\nVaginal hysterectomy, with or without endoscopic control 763 152 19.9 611 80.1 27.1 – 28.2\nTotal 49,107 11,042 22,5 38,065 77,5 22.3 – 22.7\nSSIs, surgical site infections; CI, confidence interval\n\nAidyn G. Salmanov et al. \n1294\nfound after surgical curettage (38.1%, 95% CI, 37.1-39.2), \nmultiple vaginal examinations after vaginal delivery \n(37.8%, 95% CI, 36.9- 38.7), biopsy of ovary (37.7%, 95% \nCI, 36.4-39.0), induced abortion with cervical dilation \nand hysterotomy (36.4%, 95% CI, 35.3-37.5), and ovarian \ncystectomy (33.3% 95% CI,32.0-34.6). The analysis of \npost-operative infections (SSIs) is presented in Table 1. \nAnalysis of the structure of SSIs showed that post -\noperative infections have different localizations of the \npathological process. The most common types of SSI \nwere endometritis after induced abortion (15,4%, 95% \nCI, 4.5-16.3), endometritis after multiple vaginal exam-\ninations (12,5%, 95% CI, 11,6-13.4), endometritis after \ncesarean delivery (12%, 95% CI, 11.1-12.9), oophoritis \n(9,3% 95% CI, 8.4-10.2), and tubo-ovarian abscess (8,7%, \n95% CI, 7.8-9.6), followed by salpingitis (7.5%, 95% CI, \n6.6-8.4), episiotomy infections (7.2%, 95% CI, 6.3-8.1), \nand vaginal cuff infections (6.6%, 95% CI, 5.7-7.5). Other \ntypes of infections accounted for less than 5% (Table 2).\nWe analysed the history of any surgical procedures \ngrouped by laparotomy, laparoscopy, gynecologically \nand obstetric related procedures. Multivariate analysis \nidentified SSIs, obstetric and gynecological surgical pro-\ncedures as three factors positively associated with the \nrisk of endometriosis. Factors that increased the odds \nof endometriosis was SSIs (adjusted odds ratio [AOR], \n3.76; 95% CI, 2.29–6.20), and obstetric and gynecolog-\nical surgical procedures (AOR, 7.91; 95% CI, 3.68–37.3). \nAn SSIs and obstetric and gynecological surgery history \nincreased the odds of an endometriosis >7-fold in the \ncohort (AOR, 7.96; 95% CI, 3.64–37.2) (Table 3). \nDISCUSSION\nThis study is the first to report an increased risk of en-\ndometriosis in women with a recent history of obstetric \nand gynecological surgical procedures and post-oper-\native healthcare-associated infections data. We inves-\ntigated the incidence of endometriosis in women with \na recent history of SSIs, obstetric and gynecological \nsurgical procedures, or both. Inflammation is one of the \nleading factors and an important pathologic process of \nendometriosis. Inflammation related to post-operative \ninfection and surgical injury may cause endometriosis. \nTherefore, we investigated the incidence of endome -\ntriosis in women with a recent history of SSIs, pelvic \nsurgery, or both. This study was undertaken to test the \nhypothesis that obstetric and gynecological surgical \nprocedures and SSIs increases the risk of endometriosis. \nWe recruited patients with endometriosis and retrieved \ninformation on the history of any surgical procedures, \ngrouped by obstetrical delivery by cesarean section \n(CSES), abdominal hysterectomy (includes that by \nlaparoscope), operations on ovary and related struc -\ntures, and vaginal hysterectomy (excludes the use of \nlaparoscope) and cases of SSIs after these procedures. \nWe then evaluated the association, if any, between \nendometriosis and history of surgical procedures and \nSSIs. This study showed that a history of obstetric and \ngynecological surgical procedures and SSIs increases \nthe future incidence of endometriosis.\nEndometriosis is an estrogen-dependent and mul-\ntifactorial, chronic inflammatory disease in women, \ncharacterized by the presence of endometrial tissue \noutside the uterine cavity. Endometriosis most com-\nmonly affects peritoneal surfaces, ovaries and uterine \nligaments and even may affect the vulva, vagina [17]. \nEndometriosis usually occurs in the pelvis. According \nto the literature, endometriosis usually develops in a \nprevious surgical scar [18] However, few publications \nhave focused on obstetric and gynecological surgical \nprocedure as risk factor for endometriosis. According to \nthe literature, сesarean scar endometriosis is the most \ncommon type of abdominal wall endometriosis [19]. \nGunes M, et al. [20] reported 11 cases of incisional endo-\nmetriosis after CSES, perineal episiotomy incision or the \nvaginal cuff after hysterectomy, and other gynecologic \nprocedures. In addition, Díaz-Barreiro G, et al. reported \na case of external endometriosis, pelvi-genital (vagina) \nand extrapelvic (on episiotomy scar) presentation [21]. \nMaillard C, et al. [22] reported that 95.3% presenting \nwith vulvo-perineal endometriosis have undergone \neither episiotomy, perineal trauma or vaginal injury or \nsurgery. Only 4.7% developed vulvo-vaginal endometri-\nosis spontaneously. The examination which confirmed \nthe diagnosis of endometriosis. Andolf et al. [23] and \nLiu et al. [24] reported that patients who underwent \na previous CS presented a high risk for endometriosis \ncompared with patients with vaginal deliveries only. \nThose studies focused on the surgical history before \nendometriosis diagnosis.\nAccording to the literature, the presence of ectopic \nendometrial tissue embedded in the subcutaneous \nadipose layer and the muscles of the abdominal wall \nassociation with a previous surgical procedure [25]. \nZhang P , et al. suggested that during CD (cesarean \ndelivery), the endometrial tissue is inoculated directly \nin the cesarean incision [19].\nInflammation is an important factor pathologic \nprocess of endometriosis, and several researchers \nhave focused on revealing the relationship between \ninflammation and endometriosis. According to the \nliterature, both pathogens and surgical injury of tissue \nmay cause inflammation. Khan et al. proposed a new \nconcept. They reported that intrauterine microbial \ncolonization and bacterial endotoxin were associated \n\n1295\nObstetric and gynecological surgical procedures, and surgical site infections as risk for the development...\neffect of unavailable confounding factors, which could \nincrease the risk of having both a surgical procedures \nand endometriosis. These findings should be supported \nby other cohort studies.\nCONCLUSIONS\nThe results of this study showed that obstetric and gy-\nnecological surgical procedures and post-operative SSI \nwas associated with an increased risk of endometriosis. \nEndometriosis seems to be common in women who have \nhad a cesarean section, although it does occur after other \nobstetric and gynecological surgical procedures. Surgical \nprocedure and adverse outcome history as SSIs seem to \nrepresent crucial factors in endometriosis pathogenesis \nthrough multiple mechanisms. Endometriotic lesions \nmay arise from minimal residual lesions undetected and \nunremoved from surgery or by de novo implants in the \narea traumatized during surgery or from spillage and \ndissemination of endometrial cells during the surgical \nprocedures. Therefore, a different approach to follow up \nmay be necessary for those patients, with closer or more \ntargeted evaluations and wider use of medical therapy \nwith endometriosis [26]. Our previous study showed \nthat post-operative infection (Pelvic abscess or cellulitis, \nSalpingitis, and Oophoritis) after gynecologic surgical \nprocedures had more risk for endometriosis [27]. In the \npresent study pot-operative infections after obstetric \nand gynecological surgical procedures were associat -\ned with endometriosis. Although many studies have \nshown the relationship between endometriosis and SSIs \nafter obstetric and gynecological surgical procedures, \ntheir causal relationship is unclear.\nSTRENGTHS AND LIMITATION\nOur study is the first to report an increased risk of en-\ndometriosis in women with a recent history of post-op-\nerative healthcare-associated infections after obstetric \nand gynecological surgical procedures. The strengths \nof the present study lay in having included a highly \nselected population of patients who had obstetric and \ngynecological surgical procedures, and SSIs history to \nstudy the association with endometriosis. However, the \nretrospective nature of the study may have limited this \nanalysis for the reduced possibility of evaluating the \nTable 2. Distribution of surgical site infections (n=11,042) after obstetric and gynecological surgical procedures by localization of the pathological \nprocess in Ukraine (2022-2024)\nType of infection\nSSI\n95% CI\nn %\nEndometritis after induced abortion 1695 15,4 14.5 – 16.3\nEndometritis after multiple vaginal examinations 1382 12,5 11,6 – 13.4\nEndometritis after cesarean delivery 1322 12 11.1 – 12.9\nOophoritis 1022 9,3 8.4 – 10.2\nTubo-ovarian abscess 964 8,7 7.8 – 9.6\nSalpingitis 823 7,5 6.6 – 8.4\nEpisiotomy infections 786 7,2 6.3 – 8.1\nVaginal cuff infections 697 6,6 5.7 – 7.5\nEndometritis after manual removal of the placenta 649 5,9 5.0 – 6.8\nPelvic abscess or cellulitis 489 4,4 3.5 – 5.3\nCervicitis 417 4,1 3.1 – 5.1\nAdnexa utery 412 3,7 2.8 – 4.6\nParametritis 229 2,1 1.2 – 3.1\nOther 155 0,7 0.5 – 0.9\nSSIs, surgical site infections; CI, confidence interval.\nTable 3. Logistic multivariate regression analyses of the factors associated with endometriosis in the study participants (2022-2024)\nRisk factor P value Unadjusted OR \n(95% CI) P value Adjusted OR \n(95% CI)\nSociodemographic Ref Ref\nHistory of SSI <0.001 3.78 (2.36–6.05) <0.001 3.76 (2.29–6.20)\nHistory of obstetric and gynecological surgery <0.001 4.44 (2.42–8.16) <0.001 4.47 (2.39–8.38)\nHistory of SSI and obstetric and gynecological surgery <0.001 7.13 (1.72–29.6) <0.001 7.91 (1.69–37.2)\n\nAidyn G. Salmanov et al. \n1296\ninflammatory and immunity-related mechanisms. The \ninflammation resulting from SSIs after obstetric and gy-\nnecological surgical procedures and surgical injury may \nplay a role in developing endometriosis. Prevention of \nSSIs and careful surgical procedures to minimize tissue \ninjury may reduce the incidence of endometriosis. \nafter surgical procedures. 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Bacterial contamination hypothesis: a new concept in endometriosis. Reprod Med Biol. 2018;17(2):125-\n133. doi: 10.1002/rmb2.12083. DOI\n 27.  Salmanov AG, Yuzko OM, Tofan BYu et al Epidemiology of endometriosis in Ukraine: results a multicenter study (2019-2021). Pol Merkur \nLek,2024;52(3):277-285. doi: 10.36740/Merkur202403103. DOI\nThe authors wish to acknowledge all the study subjects who provided us with the information required for conducting \nthis study. The findings and conclusions in this study are those of the authors.\nCONFLICT OF INTEREST\nThe Authors declare no conflict of interest\nCORRESPONDING AUTHOR\nAidyn G. Salmanov \nUkrainian Center of Maternity and Childhood of the \nNational Academy of Medical Sciences of Ukraine,\n9 Dorohozhytska St, 04112 Kyiv, Ukraine \ne-mail: mozsago@gmail.com\nORCID AND CONTRIBUTIONSHIP\nAidyn G. Salmanov: 0000-0002-4673-1154  \nVolodymyr V. Artyomenko: 0000-0003-2490-375X  \nOlena A. Dyndar: 0000-0002-0440-0410  \nIryna M. Lypko: 0009-0006-3338-3484  \nVictor O. Rud: 0000-0002-0768-6477  \nLidiya V. Suslikova: 0000-0002-3039-6494  \nAndrey O. Semenyuk: 0009-0001-0652-7562  \nOleksandr V. Zabudskyi: 0000-0003-1969-7031  \nSvitlana M. Korniyenko: 0000-0003-3743-426X  \nOlga V. Gorbunova: 0000 0001 7323 5546  \nVitalii S. Strakhovetskyi: 0000-0002-7528-1498  \nYuliia V. Strakhovetska: 0009-0008-7996-924X  \nOlena O. Lytvak: 0000 0001 5362 670X  \nKhrystyna V. Zarichanska: 0000 0003 0357 3261  \nAndriy I. Chubatyy: 0000-0003-0375-5556  \nOlexandr P . Kononets: 0000-0001-6605-6902  \nMykhailo V. Knyhin: 0009-0009-8622-338X  \n – Work concept and design,  – Data collection and analysis,  – Responsibility for statistical analysis,  – Writing the article,  – Critical review,  – Final approval of the article\nRECEIVED: 11.01.2025\nACCEPTED: 27.06.2025\n CREATIVE COMMONS 4.0","source_license":"public-domain-us","license_restricted":false}