Risk Factors for the Development of Tubo-ovarian Abscesses in Women with Ovarian Endometriosis: A Retrospective Matched Case-control Study

Risk Factors for the Development of Tubo-ovarian Abscesses in Women with Ovarian Endometriosis: A Retrospective Matched Case-control Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Risk Factors for the Development of Tubo-ovarian Abscesses in Women with Ovarian Endometriosis: A Retrospective Matched Case-control Study Yang Gao, Pengpeng Qu, Yang Zhou, Wei Ding This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-116785/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Jan, 2021 Read the published version in BMC Women's Health → Version 1 posted 7 You are reading this latest preprint version Abstract Background: The purpose of this study was to assess the risk factors associated with the development of tubo-ovarian abscesses in women with ovarian endometriosis cysts. Methods : This retrospective single-center study included 176 women: 44 with tubo-ovarian abscesses associated with ovarian endometriosis and 132 age-matched (1:3) patients with ovarian endometriosis but without tubo-ovarian abscesses. Diagnoses were made via surgical exploration and pathological examination. The potential risk factors of tubo-ovarian abscesses associated with ovarian endometriosis were evaluated using univariate analysis. The results ( p ≤ 0.05) of these parameters were analyzed using a multivariate model. Results : Five factors were included in the multivariate conditional logistic regression model, including in vitro fertilization, presence of an intrauterine device, lower genital tract infection, spontaneous rupture of ovarian endometriosis cysts, and diabetes mellitus. The presence of a lower genital tract infection (odds ratio 5.462, 95% confidence interval, 1.772–16.839) and spontaneous rupture of ovarian endometriosis cysts (odds ratio 2.572, 95% confidence interval, 1.071–6.174) were found to be statistically significant risk factors for tubo-ovarian abscesses associated with ovarian endometriosis. Conclusions: Of the factors investigated, the occurrence of tubo-ovarian abscesses associated with ovarian endometriosis was found to be associated with genital tract infections and spontaneous rupture of ovarian endometriosis cysts. Our findings indicate that tubo-ovarian abscesses associated with ovarian endometriosis may not be linked to in vitro fertilization as previously thought. Internal Medicine Preventive Medicine Tubo-ovarian abscess ovarian endometriotic cyst risk factors infection in vitro fertilization Figures Figure 1 Figure 1 Background Tubo-ovarian abscess (TOA) is a complex and severe complication found in as many as 15–34% of patients with pelvic inflammatory disease (PID). 1 , 2 PID and TOA occur more frequently and are more severe in women with endometriosis than in those without endometriosis. 3 A TOA associated with ovarian endometriosis (OE-TOA) is a potentially life-threatening condition, 4 which is also related to other morbidities, such as infertility, chronic pelvic pain, and ectopic pregnancy. 5 Previous studies have identified several risk factors for PID and TOA, including young age, multiple sexual partners, sexually transmitted infections, chlamydia and gonorrhea infections, uterine instrumentation, interruption of the cervical barrier, hysterosalpingography, hysteroscopy, and in vitro fertilization (IVF). 6 , 7 , 8 However, more comprehensive studies on the risk factors for OE-TOA are still needed. Only a few studies have reported that IVF or oocyte retrieval plays an important role in the development of OE-TOA. 9 , 10 This is not surprising considering the high rate of infertility among individuals with endometriosis. The prevalence of infertility among women with endometriosis is as high as 30–50%. 11,12 This may result in a vicious cycle of endometriosis leading to infertility, resulting in the need for IVF, which then leads to TOA, and further infertility. Unfortunately, whether IVF and oocyte retrieval are risk factors for OE-TOA still remains controversial. The aim of this study was to explore the risk factors associated with OE-TOA and to provide an experimental basis for its early diagnosis, prevention, and cure. The secondary objective was to evaluate whether IVF increases the risk of OE-TOA. Methods This was a retrospective comparative study performed in a single medical center. The study was approved by the hospital’s ethics committee, and informed consent was obtained from each patient that took part in this study. The medical records of 5,595 consecutive patients diagnosed with ovarian endometriosis (OE) who underwent laparoscopy or laparotomy at Tianjin Central Hospital of Gynecology and Obstetrics between January 1, 2010, and December 1, 2019, were retrospectively reviewed. Of these patients, 176 were evaluated in this study and were divided into a case group (composed of 44 patients with OE-TOA) and a control group (composed of 132 non-OE-TOA patients), based on the following inclusion criteria: the indication for surgery was the presence of an adnexal mass (greater than 4 cm in diameter). The case group and the control group were determined according to the following criteria. (1) The case group: pus observed during surgery and a confirmed diagnosis of OE-TOA by pathological examination (the pathological criteria included endometrial glands and stroma within the ovarian cyst, and neutrophils infiltrating into the capsule, with or without acute pyogenic salpingitis). (2) The control group: no pus found during surgery and pathological examination only showed OE cysts. The exclusion criteria were: (1) cancers of pelvic organs; (2) appendiceal abscesses; (3) appendicitis; and (4) cases with incomplete or unknown data (Fig. 1 ). All diagnoses were confirmed during surgery and later by a pathologist. For each TOA case, three contemporaneous non-TOA control patients were selected from the electronic health record-derived data and matched by age (± 3 years). For both cases and controls, clinical data, demographic data, and putative risk factors for OE-TOA were extracted from the electronic health record, including age, marital status, gravidity, parity, infertility, previous PID, history of ectopic pregnancy, previous removal of OE cysts, previous appendectomy, cesarean delivery, IVF, uterine cavity surgery within 15 days, presence of an intrauterine device (IUD), lower genital tract infection, spontaneous rupture of ovarian endometriotic cysts, dysmenorrhea, diabetes mellitus, hypertension, smoking status, and carbohydrate antigen 125 (CA125). Statistical analyses Continuous variables that followed a normal distribution pattern and had homogenous variance were expressed as means ± standard deviations and were compared using Student’s ttest. Nonnormally distributed data were expressed as medians and analyzed using the MannWhitney U test. Intergroup differences in categorical variables were compared using the chisquare test or Fisher’s exact test. In addition, a p -value of ≤ 0.05 was used in the univariate analysis for inclusion of putative risk factors. Multivariate conditional logistic regression analysis was used to evaluate risk factors. Data processing and statistical analyses were completed using SPSS version 19.0 (IBM, Armonk, NY, USA). P -values of < 0.05 were considered statistically significant. Results A total of 176 women were evaluated in this study. Of these, 44 were diagnosed with OE-TOA during the study period. The control group consisted of 132 non-OE-TOA patients. The demographic data of the two groups were comparable (Table 1 ). Table 1 Demographic data of cases and controls Cases (n = 44) Controls (n = 132) P- value Age, years 39.61 ± 8.99 39.56 ± 8.92 0.972 Married, n (%) 36 (81.8%) 110 (83.3%) 0.817 Gravidity, n 1.52 ± 1.29 1.66 ± 1.31 0.549 Parity, n 0.80 ± 0.63 0.81 ± 0.67 0.895 Infertility, n (%) 12 (27.3%) 35 (26.5%) 0.922 The distribution of risk factors associated with OE-TOA in both the case and control groups was also tabulated (Table 2 ). Histories of PID and ectopic pregnancy were found in similar proportions of women in both groups. No statistically significant differences were found in operation history, including removal of OE cysts, appendectomy, and cesarean delivery, between the two groups. A higher proportion of women with TOA than without TOA had undergone IVF (6.8% vs. 0.8%, p = 0.049). Three patients in the case group and two patients in the control group had undergone uterine cavity operations within 15 days of admission; this difference was not statistically significant ( p = 0.100). The number of women with IUDs in the case group was greater than that in the control group ( p = 0.042). In the case group, 14 (31.8%) patients reported lower genital tract infections; in the control group, only 4 (3.0%) patients reported lower genital tract infections ( p = 0.000). A greater number of patients had ruptured OE cysts in the case group than in the control group (9.1% vs. 1.5%, p = 0.016), as revealed by ultrasound results and surgical findings. The numbers of women with diabetes mellitus in the case and control groups were 5 (11.4%) and 3 (2.3%), respectively ( p = 0.037). Dysmenorrhea was diagnosed in a similar proportion of patients in both groups. The differences in hypertension and smoking status between the two groups were not significant. There was also no significant difference in the level of CA125. Table 2 Medical history and clinical characteristics of cases and controls Cases (n = 44) Controls (n = 132) P- value Previous pelvic inflammatory disease, n (%) 3 (6.8%) 2(1.5%) 0.100 Ectopic pregnancy, n (%) 2 (4.5%) 1 (0.8%) 0.155 Previous removal of ovarian endometriosis cysts, n (%) 7 (15.9%) 9 (6.8%) 0.130 Previous appendectomy, n (%) 3 (6.8%) 4 (3.0%) 0.504 Caesarean, n (%) 14 (31.8%) 34 (25.8%) 0.434 In vitro fertilization, n (%) 3 (6.8%) 1 (0.8%) 0.049 Uterine cavity surgery within 15 days, n (%) 3 (6.8%) 2 (1.5%) 0.100 Intrauterine device, n (%) 14 (31.8%) 23 (17.4%) 0.042 Lower genital tract infection, n (%) 14(31.8%) 4(3.0%) 0.000 Spontaneous rupture of ovarian endometriosis cysts, n (%) 4(9.1%) 2(1.5%) 0.016 Dysmenorrhea, n (%) 19(43.2%) 55(41.7%) 0.860 Diabetes mellitus, n (%) 5(11.4%) 3(2.3%) 0.037 Hypertension, n (%) 3(6.8%) 9(6.8%) 1.000 Smoking, n (%) 3(6.8%) 5(3.8%) 0.676 Carbohydrate antigen 125, U/ml 60.35 ± 32.29 53.08 ± 38.98 0.224 Finally, multivariate conditional logistic regression analysis (Table 3 ) revealed that, among the putative risk factors evaluated, lower genital tract infection (odds ratio [OR] 5.462, 95% confidence interval [CI], 1.772–16.839), and rupture of ovarian endometriotic cysts (OR 2.572, 95% CI, 1.071–6.174) were significantly associated with the development of OE-TOA. We found no relationship between IVF and OE-TOA ( p = 0.130). Table 3 Risk factors for the development of OE-TOA (multivariate conditional logistic regression). Odds ratio 95% Confidence interval P- value In vitro fertilization 2.267 0.435–3.987 0.130 Intrauterine device 1.456 0.734–3.089 0.160 Lower genital tract infection 5.462 1.772–16.839 0.003 Spontaneous rupture of ovarian endometriosis cysts 2.572 1.071–6.174 0.035 Diabetes mellitus 1.548 0.876–4.469 0.194 OE-TOA: tubo-ovarian abscess associated with ovarian endometriosis Discussion OE is a common benign gynecological disease, but a secondary TOA formation is seldom reported. Schmidt et al. reported the incidence of OE-TOA to be 2.15% in 1981; 13 this was consistent with previous reports that indicated that the incidence of OE-TOA was 2.3%. 14 Of the 5,595 patients with OE in this study, 44 (0.79%) were diagnosed with OE-TOA. The incidence in this study was lower compared to that in previous reports. Although OE-TOA is rare, it is serious and sometimes fatal. This area of study requires our attention, as it has long been neglected. Patients with OE are more susceptible than the general population to TOA. 14 Possible pathogeneses are as follows. (1) OE, which is itself is an immunodeficiency disease, leading to impairment in the ability of the immune system to wade off infections, at which point TOA easily emerges. (2) The OE capsule wall is thin and delicate, making it easy for bacteria to penetrate. (3) At the same time, OE blood content is an ideal culture medium that facilitates bacterial growth. 15 (4) The “bacterial contamination hypothesis” states that the incidence and occurrence of intrauterine microbial colonization and endometritis are significantly higher among women with endometriosis, especially after gonadotrophin-releasing hormone agonist treatment. 16 We observed a more than 5-fold increase in OE-TOA risk after lower genital tract infection, which is in line with reports of previous studies. This may be because the cervical mucosal barrier is impaired during pathogenic microorganism infection; hence, infection can spread along the endometrium to other pelvic organs such as the fallopian tubes and ovaries. 17 This is a classic pattern of spread. According to related studies in the United States and Nordic countries, the pathogenic microorganisms of PID or TOA most commonly identified were Neisseria gonorrhea and Chlamydia trachomatis . 18 , 19 This is not the case in China. Several domestic studies have indicated low detection rates for both microbes. A new study focusing on next-generation sequencing analysis of cervical mucus indicates that in a variable microbiota, two organisms, Enterobacteriaceae and Streptococcus , are more frequently detected in women with endometriosis. 20 Results of this study show that the microbial detection rate in the lower genital tract was significantly higher in cases than in controls. Furthermore, the main pathogen was Escherichia coli (50%), followed by Mycoplasma genitalium (21.4%) and Gardnerella vaginalis (21.4%). This is partially in agreement with reports of previous studies, emphasizing the need to promptly investigate and effectively treat these infections with appropriate antibiotics. Spontaneous rupture of ovarian endometriotic cysts was found to be a significant contributor to the risk of OE-TOA (OR = 2.572). To the best of our knowledge, rupturing of an ovarian endometriotic cyst as a risk factor for TOA has not been previously evaluated. Spontaneous rupture of an OE cyst is not usually a gynecological emergency. The incidence rate is seldom available in the literature from different countries, and the incidence rates reported in Chinese studies are inconsistent. The disease, characterized by abdominal pain and inflammation, 21 is easily misdiagnosed due to its nonspecific clinical features and the lack of knowledge regarding biomarkers for early diagnosis. 22 Through analysis, our data shows that the incidence rates of OE cyst rupture in the case and control groups were 9.1% and 1.5%, respectively. Women with spontaneous rupture of ovarian endometriotic cysts had an increased risk of developing TOA. The exact underlying mechanism of this remains unclear. One possible explanation is that the capsule wall easily ruptures because of bleeding of the cyst and increased pressure during the pre-menstruation and menstruation phases of the menstrual cycle. 23 When the cyst bursts, a chocolate-like fluid pours into the abdominal cavity, leading to peritonitis. In addition, the blood content of an OE cyst is a good culture medium for mixed anaerobic bacteria, aerobic bacteria, and facultative bacterial infections. 24 If treatment is not initiated promptly, this could progress to a much more severe condition such as a TOA. Finally, whether a patient with OE will develop TOA after IVF has been a controversial topic. Several studies propose that IVF and oocyte retrieval are major risk factors for the development of OE-TOA. Moreover, the condition is often more serious in these cases. The above conclusions are supported by the theory that the blood in an endometrioma offers a nutrient-rich culture for bacterial growth after transvaginal inoculation. 25 However, it is thought that the rate of TOA is low in patients suspected of having an ovarian endometriotic cyst after IVF and egg retrieval, even though no such patients have undergone laparoscopic exploration. 26 , 27 Another view is that endometriosis-related infectious disease may be unrelated to assisted reproductive technology and that once OE-TOA occurs, the best form of intervention is early surgical drainage combined with intravenous antibiotics. 28 The results of our study directly contradict the view that patients with OE are more likely to have TOA after IVF or oocyte retrieval. These patients may benefit from comprehensive disinfection, antibiotic treatment, and ultrasound guidance to avoid intestinal puncture during oocyte retrieval. This was a pilot study, and further studies with larger sample sizes are needed to confirm our findings. Some limitations of this work are its single-institutional retrospective design and the lack of larger clinical evidence. Conclusions In conclusion, we found that IVF was not associated with an increased risk of OE-TOA. The risk factors significantly associated with OE-TOA were lower genital tract infections and spontaneous rupture of ovarian endometriotic cysts. To suppress the formation of OE-TOA and improve prognosis, suspected patients should be provided with prompt treatment, including prophylactic antibiotics (against Escherichia coli ) as well as appropriate surgical interventions. Abbreviations IUD: intrauterine device; IVF: in vitro fertilization; OE: ovarian endometriosis; PID: pelvic inflammatory disease; TOA: tubo-ovarian abscess Declarations Ethics approval and consent to participate: All procedures were performed in accordance with the 1964 Helsinki Declaration and its later amendments. The study was approved by the Ethics Committee of Tianjin Central Hospital of Obstetrics and Gynecology(2019KY052) and written informed consent was obtained from each participant. No administrative permissions are required. Consent for publication: Not applicable. Availability of data and materials: The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding : No funding was obtained for this study. Authors' contributions: PQ and YG contributed to designing the study. YG collected the data and wrote the manuscript. YZ and WD contributed to data collection and data analyzing. All authors read and approved the final manuscript. Acknowledgments: We would like to express our gratitude to Professor Yingjun Zhu for her constant encouragement and guidance. We are also grateful to our beloved parents, who have always supported us. References Brunham RC, Gottlieb SL, Paavonen J. Pelvic inflammatory disease. N Engl J Med. 2015;372:2039–48. Granberg S, Gjelland K, Ekerhovd E. The management of pelvic abscess. Best Pract Res Clin Obstet Gynaecol. 2009;23:667–8. Grammatikakis I, Evangelinakis N, Salamalekis G, Tziortzioti V, Samaras C, Chrelias C, et al. Prevalence of severe pelvic inflammatory disease and endometriotic ovarian cysts: a 7-year retrospective study. Clin Exp Obstet Gynecol. 2009;36:235–6. To J, Aldape D, Frost A, Goldberg GL, Levie M, Chudnoff S. Image-guided drainage versus antibiotic-only treatment of pelvic abscesses: short-term and long-term outcomes. Fertil Steril. 2014;102:1155–9. 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Cite Share Download PDF Status: Published Journal Publication published 30 Jan, 2021 Read the published version in BMC Women's Health → Version 1 posted Editorial decision: Minor revision 15 Dec, 2020 Review # 1 received at journal 14 Dec, 2020 Reviewers invited by journal 09 Dec, 2020 Reviewer # 1 agreed at journal 09 Dec, 2020 Editor assigned by journal 16 Nov, 2020 Submission checks completed at journal 16 Nov, 2020 Editor invited by journal 16 Nov, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-116785","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":5417161,"identity":"91e4b39b-7f32-45e5-aa80-fdb2f94f248b","order_by":0,"name":"Yang Gao","email":"","orcid":"","institution":"Tianjin Central Hospital of Obstetrics and Gynecology","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Gao","suffix":""},{"id":5417162,"identity":"7b4d0856-4b16-400f-bdf3-22cc467d6d0e","order_by":1,"name":"Pengpeng 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1","display":"","copyAsset":false,"role":"figure","size":52980,"visible":true,"origin":"","legend":"Study flowchart.","description":"","filename":"Figure1.JPG","url":"https://assets-eu.researchsquare.com/files/rs-116785/v1/b56cfdc71ad4c746f21d5659.JPG"},{"id":3987404,"identity":"4cdf76b3-b276-438f-bb86-dceb61b56775","added_by":"auto","created_at":"2020-12-03 16:04:03","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":52980,"visible":true,"origin":"","legend":"Study flowchart.","description":"","filename":"Figure1.JPG","url":"https://assets-eu.researchsquare.com/files/rs-116785/v1/f24d7473238b9bc43dfcc792.JPG"},{"id":13621535,"identity":"80ab52c2-229f-46a3-9e5a-e11da41cc215","added_by":"auto","created_at":"2021-09-17 07:11:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":503562,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-116785/v1/98af84bf-15ba-4bde-8845-88a358cda291.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eRisk Factors for the Development of Tubo-ovarian Abscesses in Women with Ovarian Endometriosis: A Retrospective Matched Case-control Study\u003c/p\u003e","fulltext":[{"header":"Background","content":" \u003cp\u003eTubo-ovarian abscess (TOA) is a complex and severe complication found in as many as 15\u0026ndash;34% of patients with pelvic inflammatory disease (PID).\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e PID and TOA occur more frequently and are more severe in women with endometriosis than in those without endometriosis.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e A TOA associated with ovarian endometriosis (OE-TOA) is a potentially life-threatening condition,\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e which is also related to other morbidities, such as infertility, chronic pelvic pain, and ectopic pregnancy.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePrevious studies have identified several risk factors for PID and TOA, including young age, multiple sexual partners, sexually transmitted infections, chlamydia and gonorrhea infections, uterine instrumentation, interruption of the cervical barrier, hysterosalpingography, hysteroscopy, and in vitro fertilization (IVF).\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e However, more comprehensive studies on the risk factors for OE-TOA are still needed. Only a few studies have reported that IVF or oocyte retrieval plays an important role in the development of OE-TOA.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e This is not surprising considering the high rate of infertility among individuals with endometriosis. The prevalence of infertility among women with endometriosis is as high as 30\u0026ndash;50%.\u003csup\u003e11,12\u003c/sup\u003e This may result in a vicious cycle of endometriosis leading to infertility, resulting in the need for IVF, which then leads to TOA, and further infertility. Unfortunately, whether IVF and oocyte retrieval are risk factors for OE-TOA still remains controversial.\u003c/p\u003e \u003cp\u003eThe aim of this study was to explore the risk factors associated with OE-TOA and to provide an experimental basis for its early diagnosis, prevention, and cure. The secondary objective was to evaluate whether IVF increases the risk of OE-TOA.\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003eThis was a retrospective comparative study performed in a single medical center. The study was approved by the hospital\u0026rsquo;s ethics committee, and informed consent was obtained from each patient that took part in this study.\u003c/p\u003e \u003cp\u003eThe medical records of 5,595 consecutive patients diagnosed with ovarian endometriosis (OE) who underwent laparoscopy or laparotomy at Tianjin Central Hospital of Gynecology and Obstetrics between January 1, 2010, and December 1, 2019, were retrospectively reviewed. Of these patients, 176 were evaluated in this study and were divided into a case group (composed of 44 patients with OE-TOA) and a control group (composed of 132 non-OE-TOA patients), based on the following inclusion criteria: the indication for surgery was the presence of an adnexal mass (greater than 4\u0026nbsp;cm in diameter). The case group and the control group were determined according to the following criteria. (1) The case group: pus observed during surgery and a confirmed diagnosis of OE-TOA by pathological examination (the pathological criteria included endometrial glands and stroma within the ovarian cyst, and neutrophils infiltrating into the capsule, with or without acute pyogenic salpingitis). (2) The control group: no pus found during surgery and pathological examination only showed OE cysts. The exclusion criteria were: (1) cancers of pelvic organs; (2) appendiceal abscesses; (3) appendicitis; and (4) cases with incomplete or unknown data (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAll diagnoses were confirmed during surgery and later by a pathologist. For each TOA case, three contemporaneous non-TOA control patients were selected from the electronic health record-derived data and matched by age (\u0026plusmn;\u0026thinsp;3\u0026nbsp;years).\u003c/p\u003e \u003cp\u003eFor both cases and controls, clinical data, demographic data, and putative risk factors for OE-TOA were extracted from the electronic health record, including age, marital status, gravidity, parity, infertility, previous PID, history of ectopic pregnancy, previous removal of OE cysts, previous appendectomy, cesarean delivery, IVF, uterine cavity surgery within 15 days, presence of an intrauterine device (IUD), lower genital tract infection, spontaneous rupture of ovarian endometriotic cysts, dysmenorrhea, diabetes mellitus, hypertension, smoking status, and carbohydrate antigen 125 (CA125).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003eContinuous variables that followed a normal distribution pattern and had homogenous variance were expressed as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations and were compared using Student\u0026rsquo;s ttest. Nonnormally distributed data were expressed as medians and analyzed using the MannWhitney \u003cem\u003eU\u003c/em\u003e test. Intergroup differences in categorical variables were compared using the chisquare test or Fisher\u0026rsquo;s exact test. In addition, a \u003cem\u003ep\u003c/em\u003e-value of \u0026le;\u0026thinsp;0.05 was used in the univariate analysis for inclusion of putative risk factors. Multivariate conditional logistic regression analysis was used to evaluate risk factors. Data processing and statistical analyses were completed using SPSS version 19.0 (IBM, Armonk, NY, USA). \u003cem\u003eP\u003c/em\u003e-values of \u0026lt;\u0026thinsp;0.05 were considered statistically significant.\u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":"\u003cp\u003eA total of 176 women were evaluated in this study. Of these, 44 were diagnosed with OE-TOA during the study period. The control group consisted of 132 non-OE-TOA patients. The demographic data of the two groups were comparable (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDemographic data of cases and controls\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCases (n\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eControls (n\u0026thinsp;=\u0026thinsp;132)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eP-\u003c/em\u003evalue\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge, years\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39.61\u0026thinsp;\u0026plusmn;\u0026thinsp;8.99\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39.56\u0026thinsp;\u0026plusmn;\u0026thinsp;8.92\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.972\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMarried, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36 (81.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e110 (83.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.817\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGravidity, n\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.66\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.549\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eParity, n\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.80\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.895\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eInfertility, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (27.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35 (26.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.922\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe distribution of risk factors associated with OE-TOA in both the case and control groups was also tabulated (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Histories of PID and ectopic pregnancy were found in similar proportions of women in both groups. No statistically significant differences were found in operation history, including removal of OE cysts, appendectomy, and cesarean delivery, between the two groups. A higher proportion of women with TOA than without TOA had undergone IVF (6.8% vs. 0.8%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.049). Three patients in the case group and two patients in the control group had undergone uterine cavity operations within 15 days of admission; this difference was not statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.100). The number of women with IUDs in the case group was greater than that in the control group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.042). In the case group, 14 (31.8%) patients reported lower genital tract infections; in the control group, only 4 (3.0%) patients reported lower genital tract infections (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000). A greater number of patients had ruptured OE cysts in the case group than in the control group (9.1% vs. 1.5%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.016), as revealed by ultrasound results and surgical findings. The numbers of women with diabetes mellitus in the case and control groups were 5 (11.4%) and 3 (2.3%), respectively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.037). Dysmenorrhea was diagnosed in a similar proportion of patients in both groups. The differences in hypertension and smoking status between the two groups were not significant. There was also no significant difference in the level of CA125.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eMedical history and clinical characteristics of cases and controls\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCases (n\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eControls (n\u0026thinsp;=\u0026thinsp;132)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eP-\u003c/em\u003evalue\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePrevious pelvic inflammatory disease, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3 (6.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2(1.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.100\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eEctopic pregnancy, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2 (4.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1 (0.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.155\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePrevious removal of ovarian endometriosis cysts, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7 (15.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9 (6.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.130\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePrevious appendectomy, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3 (6.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4 (3.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.504\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCaesarean, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14 (31.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e34 (25.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.434\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eIn vitro\u003c/span\u003e \u003cstrong\u003efertilization, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3 (6.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1 (0.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.049\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eUterine cavity surgery within 15 days, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3 (6.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2 (1.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.100\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eIntrauterine device, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14 (31.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23 (17.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.042\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLower genital tract infection, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14(31.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4(3.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSpontaneous rupture\u0026nbsp;of\u0026nbsp;ovarian endometriosis cysts, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4(9.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2(1.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.016\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDysmenorrhea, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e19(43.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e55(41.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.860\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDiabetes mellitus, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5(11.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3(2.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.037\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHypertension, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3(6.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9(6.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSmoking, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3(6.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5(3.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.676\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCarbohydrate antigen 125, U/ml\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e60.35\u0026thinsp;\u0026plusmn;\u0026thinsp;32.29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e53.08\u0026thinsp;\u0026plusmn;\u0026thinsp;38.98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.224\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, multivariate conditional logistic regression analysis (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e) revealed that, among the putative risk factors evaluated, lower genital tract infection (odds ratio [OR] 5.462, 95% confidence interval [CI], 1.772\u0026ndash;16.839), and rupture of ovarian endometriotic cysts (OR 2.572, 95% CI, 1.071\u0026ndash;6.174) were significantly associated with the development of OE-TOA. We found no relationship between IVF and OE-TOA (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.130).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eRisk factors for the development of OE-TOA (multivariate conditional logistic regression).\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003cth style=\"height: 35px;\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eOdds ratio\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e95% Confidence interval\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eP-\u003c/em\u003evalue\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eIn vitro\u003c/span\u003e \u003cstrong\u003efertilization\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e2.267\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.435\u0026ndash;3.987\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.130\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eIntrauterine device\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.456\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.734\u0026ndash;3.089\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.160\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLower genital tract infection\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e5.462\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.772\u0026ndash;16.839\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.003\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSpontaneous rupture\u0026nbsp;of\u0026nbsp;ovarian endometriosis cysts\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e2.572\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.071\u0026ndash;6.174\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.035\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDiabetes mellitus\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.548\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.876\u0026ndash;4.469\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.194\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr style=\"height: 13px;\"\u003e\n\u003ctd style=\"height: 13px;\" colspan=\"4\"\u003eOE-TOA: tubo-ovarian abscess associated with ovarian endometriosis\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":" \u003cp\u003eOE is a common benign gynecological disease, but a secondary TOA formation is seldom reported. Schmidt et al. reported the incidence of OE-TOA to be 2.15% in 1981;\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e this was consistent with previous reports that indicated that the incidence of OE-TOA was 2.3%.\u003csup\u003e14\u003c/sup\u003e Of the 5,595 patients with OE in this study, 44 (0.79%) were diagnosed with OE-TOA. The incidence in this study was lower compared to that in previous reports. Although OE-TOA is rare, it is serious and sometimes fatal. This area of study requires our attention, as it has long been neglected.\u003c/p\u003e \u003cp\u003ePatients with OE are more susceptible than the general population to TOA.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Possible pathogeneses are as follows. (1) OE, which is itself is an immunodeficiency disease, leading to impairment in the ability of the immune system to wade off infections, at which point TOA easily emerges. (2) The OE capsule wall is thin and delicate, making it easy for bacteria to penetrate. (3) At the same time, OE blood content is an ideal culture medium that facilitates bacterial growth.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e (4) The \u0026ldquo;bacterial contamination hypothesis\u0026rdquo; states that the incidence and occurrence of intrauterine microbial colonization and endometritis are significantly higher among women with endometriosis, especially after gonadotrophin-releasing hormone agonist treatment.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWe observed a more than 5-fold increase in OE-TOA risk after lower genital tract infection, which is in line with reports of previous studies. This may be because the cervical mucosal barrier is impaired during pathogenic microorganism infection; hence, infection can spread along the endometrium to other pelvic organs such as the fallopian tubes and ovaries.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e This is a classic pattern of spread. According to related studies in the United States and Nordic countries, the pathogenic microorganisms of PID or TOA most commonly identified were \u003cem\u003eNeisseria gonorrhea\u003c/em\u003e and \u003cem\u003eChlamydia trachomatis\u003c/em\u003e.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e This is not the case in China. Several domestic studies have indicated low detection rates for both microbes. A new study focusing on next-generation sequencing analysis of cervical mucus indicates that in a variable microbiota, two organisms, \u003cem\u003eEnterobacteriaceae\u003c/em\u003e and \u003cem\u003eStreptococcus\u003c/em\u003e, are more frequently detected in women with endometriosis.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Results of this study show that the microbial detection rate in the lower genital tract was significantly higher in cases than in controls. Furthermore, the main pathogen was \u003cem\u003eEscherichia coli\u003c/em\u003e (50%), followed by \u003cem\u003eMycoplasma genitalium\u003c/em\u003e (21.4%) and \u003cem\u003eGardnerella vaginalis\u003c/em\u003e (21.4%). This is partially in agreement with reports of previous studies, emphasizing the need to promptly investigate and effectively treat these infections with appropriate antibiotics.\u003c/p\u003e \u003cp\u003eSpontaneous rupture of ovarian endometriotic cysts was found to be a significant contributor to the risk of OE-TOA (OR\u0026thinsp;=\u0026thinsp;2.572). To the best of our knowledge, rupturing of an ovarian endometriotic cyst as a risk factor for TOA has not been previously evaluated. Spontaneous rupture of an OE cyst is not usually a gynecological emergency. The incidence rate is seldom available in the literature from different countries, and the incidence rates reported in Chinese studies are inconsistent. The disease, characterized by abdominal pain and inflammation,\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e is easily misdiagnosed due to its nonspecific clinical features and the lack of knowledge regarding biomarkers for early diagnosis.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Through analysis, our data shows that the incidence rates of OE cyst rupture in the case and control groups were 9.1% and 1.5%, respectively. Women with spontaneous rupture of ovarian endometriotic cysts had an increased risk of developing TOA. The exact underlying mechanism of this remains unclear. One possible explanation is that the capsule wall easily ruptures because of bleeding of the cyst and increased pressure during the pre-menstruation and menstruation phases of the menstrual cycle.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e When the cyst bursts, a chocolate-like fluid pours into the abdominal cavity, leading to peritonitis. In addition, the blood content of an OE cyst is a good culture medium for mixed anaerobic bacteria, aerobic bacteria, and facultative bacterial infections.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e If treatment is not initiated promptly, this could progress to a much more severe condition such as a TOA.\u003c/p\u003e \u003cp\u003eFinally, whether a patient with OE will develop TOA after IVF has been a controversial topic. Several studies propose that IVF and oocyte retrieval are major risk factors for the development of OE-TOA. Moreover, the condition is often more serious in these cases. The above conclusions are supported by the theory that the blood in an endometrioma offers a nutrient-rich culture for bacterial growth after transvaginal inoculation.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e However, it is thought that the rate of TOA is low in patients suspected of having an ovarian endometriotic cyst after IVF and egg retrieval, even though no such patients have undergone laparoscopic exploration.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Another view is that endometriosis-related infectious disease may be unrelated to assisted reproductive technology and that once OE-TOA occurs, the best form of intervention is early surgical drainage combined with intravenous antibiotics.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e The results of our study directly contradict the view that patients with OE are more likely to have TOA after IVF or oocyte retrieval. These patients may benefit from comprehensive disinfection, antibiotic treatment, and ultrasound guidance to avoid intestinal puncture during oocyte retrieval.\u003c/p\u003e \u003cp\u003eThis was a pilot study, and further studies with larger sample sizes are needed to confirm our findings. Some limitations of this work are its single-institutional retrospective design and the lack of larger clinical evidence.\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003eIn conclusion, we found that IVF was not associated with an increased risk of OE-TOA. The risk factors significantly associated with OE-TOA were lower genital tract infections and spontaneous rupture of ovarian endometriotic cysts. To suppress the formation of OE-TOA and improve prognosis, suspected patients should be provided with prompt treatment, including prophylactic antibiotics (against \u003cem\u003eEscherichia coli\u003c/em\u003e) as well as appropriate surgical interventions.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eIUD: intrauterine device; IVF: in vitro fertilization; OE: ovarian endometriosis; PID: pelvic inflammatory disease; TOA: tubo-ovarian abscess\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures were performed in accordance with the 1964 Helsinki Declaration and its later amendments. The study was approved by the Ethics Committee of Tianjin Central Hospital of Obstetrics and Gynecology(2019KY052) and written informed consent was obtained from each participant. No administrative permissions are required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eNo funding was obtained for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePQ and YG contributed to designing the study. YG collected the data and wrote the manuscript. YZ and WD contributed to data collection and data analyzing. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our gratitude to Professor Yingjun Zhu for her constant encouragement and guidance. We are also grateful to our beloved parents, who have always supported us.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBrunham RC, Gottlieb SL, Paavonen J. Pelvic inflammatory disease.\u0026nbsp;N Engl J Med. 2015;372:2039\u0026ndash;48.\u003c/li\u003e\n\u003cli\u003eGranberg S, Gjelland K, Ekerhovd E. The management of pelvic abscess.\u0026nbsp;Best Pract Res Clin Obstet Gynaecol. 2009;23:667\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eGrammatikakis I, Evangelinakis N, Salamalekis G, Tziortzioti V, Samaras C, Chrelias C, et al. Prevalence of severe pelvic inflammatory disease and endometriotic ovarian cysts: a 7-year retrospective study. Clin Exp Obstet Gynecol. 2009;36:235\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eTo J, Aldape D, Frost A, Goldberg GL, Levie M, Chudnoff S. Image-guided drainage versus antibiotic-only treatment of pelvic abscesses: short-term and long-term outcomes.\u0026nbsp;Fertil Steril. 2014;102:1155\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eCacciatore BR, Leminen AR, Ingman-Friberg SU, Yl\u0026ouml;stalo P, Paavonen J. Transvaginal sonographic findings in ambulatory patients with suspected pelvic inflammatory disease.\u0026nbsp;Obstet Gynecol. 1992;80:912\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eRoss J, Guaschino S, Cusini M, Jensen J. 2017 European guideline for the management of pelvic inflammatory disease.\u0026nbsp;Int J STD AIDS. 2018;29:108\u0026ndash;14.\u003c/li\u003e\n\u003cli\u003eBrun JL, Graesslin O, Fauconnier A, Verdon R, Agostini A, Bourret A, et al. Updated French guidelines for diagnosis and management of pelvic inflammatory disease.\u0026nbsp;Int J Gynaecol Obstet. 2016;134:121\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eChappell CA, Wiesenfeld HC. Pathogenesis, diagnosis, and management of severe pelvic inflammatory disease and tuboovarian abscess.\u0026nbsp;Clin Obstet Gynecol. 2012;55:893\u0026ndash;903.\u003c/li\u003e\n\u003cli\u003eFouks Y, Cohen Y, Tulandi T, Meiri A, Levin I, Almog B, et al. Complicated clinical course and poor reproductive outcomes of women with tubo-ovarian abscess after fertility treatments.\u0026nbsp;J Minim Invasive Gynecol. 2019;26:162\u0026ndash;8.\u0026nbsp;\u003c/li\u003e\n\u003cli\u003evan der Houwen LE, Schreurs AM, Schats R, Heymans MW, Lambalk CB, Hompes PG, et al. Efficacy and safety of intrauterine insemination in patients with moderate-to-severe endometriosis.\u0026nbsp;Reprod Biomed Online. 2014;28:590\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eVichinsartvichai P, Siriphadung S, Traipak K, Promrungrueng P, Manolertthewan C, Ratchanon S. The influence of women age and successfulness of intrauterine insemination (IUI) cycles. J Med Assoc Thai. 2015;98:833\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eMeuleman C, Vandenabeele B, Fieuws S, Spiessens C, Timmerman D, D'Hooghe T. High prevalence of endometriosis in infertile women with normal ovulation and normospermic partners. Fertil Steril. 2009;92:68\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003eSchmidt CL, Demopoulos RI, Weiss G. Infected endometriotic cysts: clinical characterization and pathogenesis. Fertil Steril. 1981;36:27\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eKubota T, Ishi K, Takeuchi H. A study of tubo-ovarian and ovarian abscesses, with a focus on cases with endometrioma. J Obstet Gynaecol Res. 1997;23:421\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eVichinsartvichai P. Bilateral tubo-ovarian abscesses presenting with huge pelvic mass after repeated intrauterine inseminations in a woman with severe endometriosis.\u0026nbsp;J Obstet Gynaecol Res. 2018;44:792\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eKhan KN, Fujishita A, Hiraki K, Kitajima M, Nakashima M, Fushiki S, et al. Bacterial contamination hypothesis: a new concept in endometriosis.\u0026nbsp;Reprod Med Biol. 2018;17:125\u0026ndash;33.\u003c/li\u003e\n\u003cli\u003eTai FW, Chang CY, Chiang JH, Lin WC, Wan L. Association of pelvic inflammatory disease with risk of endometriosis: a nationwide cohort study involving 141,460 individuals. J Clin Med. 2018;7:379.\u003c/li\u003e\n\u003cli\u003eBevan CD, Johal BJ, Mumtaz G, Ridgway GL, Siddle NC. Clinical, laparoscopic and microbiological findings in acute salpingitis: report on a United Kingdom cohort.\u0026nbsp;Br J Obstet Gynaecol. 1995;102:407\u0026ndash;14.\u0026nbsp;\u003c/li\u003e\n\u003cli\u003eCohen CR, Mugo NR, Astete SG, Odondo R, Manhart LE, Kiehlbauch JA, et al. Detection of Mycoplasma genitalium in women with laparoscopically diagnosed acute salpingitis.\u0026nbsp;Sex Transm Infect. 2005;81:463\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eAkiyama K, Nishioka K, Khan KN, Tanaka Y, Mori T, Nakaya T, et al. Molecular detection of microbial colonization in cervical mucus of women with and without endometriosis.\u0026nbsp;Am J Reprod Immunol. 2019;82:e13147.\u003c/li\u003e\n\u003cli\u003eTanaka K, Kobayashi Y, Dozono K, Shibuya H, Nishigaya Y, Momomura M, et al. Elevation of plasma D-dimer levels associated with rupture of ovarian endometriotic cysts. Taiwan J Obstet Gynecol. 2015;54:294\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eDai X, Jin C, Hu Y, Zhang Q, Yan X, Zhu F, et al. High CA-125 and CA19-9 levels in spontaneous ruptured ovarian endometriomas.\u0026nbsp;Clin Chim Acta. 2015;450:362\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eBrosens IA. Endometriosis--a disease because it is characterized by bleeding.\u0026nbsp;Am J Obstet Gynecol. 1997;176:263\u0026ndash;7.\u0026nbsp;\u003c/li\u003e\n\u003cli\u003eLipscomb GH, Ling FW, Photopulos GJ. Ovarian abscess arising within an endometrioma.\u0026nbsp;Obstet Gynecol. 1991;78:951\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eYounis JS, Ezra Y, Laufer N, Ohel G. Late manifestation of pelvic abscess following oocyte retrieval, for in vitro fertilization, in patients with severe endometriosis and ovarian endometriomata. J Assist Reprod Genet. 1997;14:343\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eBenaglia L, Somigliana E, Iemmello R, Colpi E, Nicolosi AE, Ragni G. Endometrioma and oocyte retrieval-induced pelvic abscess: a clinical concern or an exceptional complication? Fertil Steril. 2008;89:1263\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eAragona C, Mohamed MA, Espinola MS, Linari A, Pecorini F, Micara G, et al. Clinical complications after transvaginal oocyte retrieval in 7,098 IVF cycles. Fertil Steril. 2011;95:293\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eVillette C, Bourret A, Santulli P, Gayet V, Chapron C, de Ziegler D. Risks of tubo-ovarian abscess in\u0026nbsp;cases of endometrioma and assisted reproductive technologies are both under- and overreported.\u0026nbsp;Fertil Steril. 2016;106:410\u0026ndash;5.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tubo-ovarian abscess, ovarian endometriotic cyst, risk factors, infection, in vitro fertilization","lastPublishedDoi":"10.21203/rs.3.rs-116785/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-116785/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u0026nbsp;\u003c/strong\u003eThe\u0026nbsp;purpose\u0026nbsp;of\u0026nbsp;this\u0026nbsp;study\u0026nbsp;was\u0026nbsp;to assess the risk factors associated with the development of tubo-ovarian abscesses in women with ovarian endometriosis\u0026nbsp;cysts.\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This retrospective single-center study included 176 women: 44 with tubo-ovarian abscesses associated with ovarian endometriosis and 132 age-matched (1:3) patients with ovarian endometriosis but without tubo-ovarian abscesses. Diagnoses were made via surgical exploration and pathological examination. The potential risk factors of tubo-ovarian abscesses associated with ovarian endometriosis were evaluated using univariate analysis. The results (\u003cem\u003ep \u003c/em\u003e≤ 0.05) of these parameters were analyzed using a multivariate model.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003cem\u003e: \u003c/em\u003e\u003c/strong\u003eFive factors were included in the multivariate conditional logistic regression model, including \u003cem\u003ein vitro\u003c/em\u003e fertilization, presence of an intrauterine device, lower genital tract infection, spontaneous rupture\u0026nbsp;of\u0026nbsp;ovarian endometriosis\u0026nbsp;cysts, and diabetes mellitus. The presence of a lower genital tract infection (odds ratio 5.462, 95% confidence interval, 1.772–16.839) and spontaneous rupture of ovarian endometriosis cysts (odds ratio 2.572, 95% confidence interval, 1.071–6.174) were found to be statistically significant risk factors for tubo-ovarian abscesses associated with ovarian endometriosis.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eOf the factors investigated, the occurrence of tubo-ovarian abscesses associated with ovarian endometriosis was found to be associated with genital tract infections and spontaneous rupture\u0026nbsp;of\u0026nbsp;ovarian endometriosis\u0026nbsp;cysts. Our findings indicate that tubo-ovarian abscesses associated with ovarian endometriosis may not be linked to in vitro fertilization as previously thought.\u003c/p\u003e","manuscriptTitle":"Risk Factors for the Development of Tubo-ovarian Abscesses in Women with Ovarian Endometriosis: A Retrospective Matched Case-control Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-12-03 16:04:01","doi":"10.21203/rs.3.rs-116785/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2020-12-16T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-12-15T00:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nOverall the topic is interesting and this study can add any new data to the present medical literature, however the study has some methodological drawbacks:\n\n1) The title is clear and accurately reflects the study contents\n2) I would suggest a more extensive description of the link between PID/TOA and endometriosis in the introduction section. Please add other studies on this issue (doi: 10.1016/j.jogoh.2020.101811; PMID: 24050031)\n3) Methods: did you include all consecutive patients? what was your preoperative work-up and why patients were submitted to surgery (subfertilty, control of pain, urinary or bowel stenosis due to DIE nodule?)? did you perform in all cases surgery for tuboovarian abscess in patients with endometriosis or did you prefer in some cases to postpone surgery giving them antibiotics as first line therapy? did you add a selection bias adding only women submitted to surgery and not all women treated also with medical therapy for abscess\n4) sample size calculation lacks. Please provide it.\n5) Results: data about coexistent DIE nodule and recent sonosalpingography lack. Please discuss the role of hormonal therapy for endometriosis (doi: 10.1016/j.jmig.2011.04.008) and its possible impact on PID ethiology. Please discuss and compare data with other studies (doi: 10.1016/j.jogoh.2020.101811; PMID: 24050031)\n6) The grammar and syntax must be corrected by native speaker\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. 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Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **No**\n"},{"type":"reviewersInvited","content":"","date":"2020-12-10T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-12-10T00:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-11-17T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-11-16T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-11-16T23:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4cca9aa9-82a2-4dfb-af47-8f05769d3075","owner":[],"postedDate":"December 3rd, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":1310824,"name":"Internal Medicine"},{"id":1310825,"name":"Preventive Medicine"}],"tags":[],"updatedAt":"2021-01-31T15:02:32+00:00","versionOfRecord":{"articleIdentity":"rs-116785","link":"https://doi.org/10.1186/s12905-021-01188-6","journal":{"identity":"bmc-womens-health","isVorOnly":false,"title":"BMC Women's Health"},"publishedOn":"2021-01-30 15:00:38","publishedOnDateReadable":"January 30th, 2021"},"versionCreatedAt":"2020-12-03 16:04:01","video":"","vorDoi":"10.1186/s12905-021-01188-6","vorDoiUrl":"https://doi.org/10.1186/s12905-021-01188-6","workflowStages":[]},"version":"v1","identity":"rs-116785","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-116785","identity":"rs-116785","version":["v1"]},"buildId":"B-jG_2CBjPDmsCi4Wdhf-","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}