Influence of laterality on endometriosis severity in patients with unilateral endometrioma: a retrospective study.

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Wataru Isono, Michiko Honda, Akira Tsuchiya, Ako Saito, Hiroko Tsuchiya, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.2.22842/v2 This work is licensed under a CC BY 4.0 License Status: Posted Version 2 posted You are reading this latest preprint version Show more versions Abstract Background: We compared the revised American Society for Reproductive Medicine (ASRM) scores determined during laparoscopic surgery to evaluate the effect of the location of the endometrioma (right vs. left ovary) on the severity of endometriosis. Methods: The medical records of 151 patients, including 58 right-sided and 93 left-sided cases, who underwent an initial laparoscopic surgery for unilateral ovarian endometrioma were reviewed retrospectively. We extracted the ASRM scores determined during surgery and some representative factors related to endometriosis that are separate from the tumour characteristics, such as the coexistence of uterine fibroids, adenomyoma, or other ovarian tumours, a history of use of assisted reproductive technology (ART), and tumour marker values. A statistical analysis was performed to assess the impact of each factor. We classified the ASRM scores into 4 categories to compare the tendency towards endometrial lesion spread with a focus on the “sidedness” of the endometrioma. We defined contralateral endometrial lesion (CEL), Douglas pouch endometrial lesion (DEL), same endometrial lesion (SEL) and peritoneal endometrial lesion (PEL). Results: The ASRM scores of patients with a right-sided endometrioma were significantly higher than patients with a left-sided endometrioma (41.5 ± 22.1 points vs. 32.9 ± 15.8 points, p<0.05). The higher ASRM scores of the patients with right-sided endometrioma may be caused by the frequent detection of endometrial lesions in the left tube, left ovary and Douglas pouch. According to the statistical analysis, the coexistence of uterine fibroids also exerted significant positive effects on increasing the ASRM score. Conclusions: Higher ASRM scores are possible in patients with right-sided endometrioma. The laterality of endometriosis severity should be considered. Sexual & Reproductive Medicine Endometrioma Laparoscopic Surgery Retrospective Study Severity of Illness Index Figures Figure 1 Figure 2 Background Endometriosis is one of the most common gynaecological diseases and is known to affect 2–10% of reproductive-age women [1, 2]. While many patients are asymptomatic [3], endometriosis is frequently associated with infertility and pain symptoms, including chronic pelvic pain, dysmenorrhoea, dyspareunia, and dyschezia [4]. Previous studies have revealed a relationship between symptom severity and disease stage according to the revised American Society for Reproductive Medicine (ASRM) scoring system [5]. In most cases, the diagnosis of endometrioma is obtained during an outpatient ultrasound examination [6], and laparoscopic surgeries are often performed to treat pelvic pain and subfertility [7]. During surgery, ovarian endometrioma, superficial implantation and deep infiltrating endometriosis are detected. The most frequent site of endometriotic lesions detected during surgery was the ovary [8]. According to some studies, left-sided endometriomas are more common than right-sided endometriomas [9]. This tendency is believed to be due to anatomical asymmetries in the pelvic organs, including the presence of the sigmoid colon and more frequent ovulation of right ovary caused by the varying paths of the vein [9, 10]. However, the recognition of this laterality is insufficient. Therefore, we aimed not only to verify this laterality but also to evaluate the effect of the side of endometrioma on disease severity. Specifically, the ASRM scores determined during laparoscopic surgery were compared. Methods Patient selection criteria This study was reviewed and approved by the Human Ethics Committee of the University of Teikyo (trial registration number: 18-233). The medical records of 151 female patients with unilateral endometrioma, including 58 right-sided and 93 left-sided cases, from June 1, 2014, to December 31, 2019, were reviewed retrospectively. We defined the former cases as the right-sided endometrioma group (REG, n = 58) and the latter cases as the left-sided endometrioma group (LEG, n = 93). In this study, we did not include patients with recurrent endometriosis. As shown in Figure 1, 151 of the 302 patients who underwent laparoscopic surgery for new onset endometrioma detected during outpatient examinations were excluded for the following reasons: 95 patients were excluded because they were diagnosed with bilateral endometrioma and 56 patients were excluded for other reasons, including a lack of cystic lesions detected during surgery (n = 23); a diagnosis of other main ovarian cystic diseases, such as mature cystic teratoma (n = 8); ruptured endometrioma (n = 4); and prior abdominal surgery (n = 21). Since patients meeting the last criterion (prior abdominal surgery) were excluded after patients meeting other criteria were excluded, this number may be an underestimation (n = 21). Among the 151 remaining patients, we performed 123 laparoscopic cystectomies, including 9 that were performed simultaneously with laparoscopic myomectomies; 9 laparoscopic hysterectomies; 23 laparoscopic salpingo-oophorectomies, including 3 surgeries performed simultaneously with laparoscopic hysterectomies; and 5 laparoscopic-assisted cystectomies, including 3 surgeries performed simultaneously with laparoscopic-assisted myomectomies. Collection of patient characteristics After extracting the medical records of these 151 patients, the following patient characteristics were collected: 1) size of the ovarian endometrioma before and during surgery; 2) ASRM score (points) [5]; 3) patient’s age at the time of the operation; 4) presence of adhesions predicted before the operation; 5) history of use of assisted reproductive technology (ART); 6) presence of complicated adenomyomas, uterine fibroids or other ovarian tumours; and 7) serum carbohydrate antigen 125 (CA125) level (U/ml). Magnetic resonance imaging (MRI) was performed on almost all patients (148/151 cases) to assess the size of the endometrioma. MRI was also used to predict adhesions, particularly in the Douglas pouch. In this study, ART included both in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). Twenty-eight of these 151 patients used hormone drugs, including oral contraceptives, gonadotropin-releasing hormone agonists and other drugs. However, the indications for the use of hormone drugs varied, and thus this factor was not considered in the present study. Classification of endometrial lesions We divided the endometrial lesions based on the location of the endometrioma to compare the tendency of endometrial lesion spread between patients with right or left ovarian endometrioma. Briefly, the so-called ASRM score chart, in which the severity of endometriosis is standardized by roughly classifying endometrial lesions [5], was divided into four parts. First, we calculated the total ASRM score for the uterine adnexa on the same side as the ovarian endometrioma and excluded the score for the endometrioma itself, as shown in Figure 2-A. Second, a similar calculation was performed for the uterine adnexa on the contralateral side of the ovarian endometrioma (Figure 2-B). The remaining endometrial lesions were divided into peritoneal (Figure 2-C) or Douglas pouch endometrial lesions (Figure 2-C). In summary, by referencing the sheet of “Revised ASRM classification of endometriosis, 1996.” [5], we classified the ASRM scores into the following four categories: 1) “same endometrial lesions (SELs)”, including Ovary-ENDOMETRIOSIS-Superficial, Ovary-ADHESIONS and Tube-ADHESIONS on the same side, as the main ovarian endometrioma; 2) “contralateral endometrial lesions (CELs)”, including Ovary-ENDOMETRIOSIS-Superficial, Ovary-ADHESIONS and Tube-ADHESIONS on the contralateral side of the main ovarian endometrioma; 3) “peritoneal endometrial lesions (PELs)”, including Peritoneum-ENDOMETRIOSIS; and 4) “Douglas pouch endometrial lesions (DELs)”, including POSTERIOR CULDESAC OBLITERATION. As an example, this classification is shown in Figure 2 for REG. The SEL (Figure 2-A), CEL (Figure 2-B), PEL (Figure 2-C) and DEL (Figure 2-C) scores are the total scores in each cell, as indicated by an italicized letter and thick-bordered box. In the patients with left ovarian endometrioma, the SEL and CEL scores were reversed. In this analysis, the theoretical maximum values of SEL, CEL, PEL and DEL were 36, 36, 10 and 40 points, respectively. We not only compared each average value of SEL, CEL, PEL and DEL between patients in the REG and LEG but also counted each number of patients with these four lesions in both the REG and LEG. Statistical analysis The primary outcomes included the difference in the ASRM scores detected during laparoscopic surgery between the patients with right- and left-sided endometriomas. We assessed the influences of the following 8 factors on the ASRM score: 1) “right-sided endometrioma”; 2) “predicted adhesion”, which was defined as the detection of the possible presence of an adhesion in a patient during a pelvic examination or MRI; 3) “ART history”, which was defined as patients who underwent ART; 4) “adenomyoma”, which was defined as the current presence of adenomyoma based on clinical images; 5) “uterine fibroid”, which was defined as the current presence of a uterine fibroid based on clinical images; 6) “other ovarian tumour”, which was defined as the current presence of an ovarian tumour other than endometrioma based on clinical images; 7) “positive marker”, which was defined as serum CA125 levels ≥ 35 U/ml; and 8) “large endometrioma”, which was defined as a tumour size of at least 50 mm (described in Table 2). All 151 patients were divided into two groups based on the presence (= 1) or absence (= 0) of these 8 factors. The difference in the ASRM score was compared using Welch’s t-test. We also performed a multivariate regression analysis using the least squares method to reduce confounding factors and confirm this difference. These statistical analyses were performed using JMP version 12 for Windows (SAS Institute, Inc., Tokyo, Japan). The total values of SEL, CEL, PEL and DEL between patients in the REG and LEG were also compared with Welch’s t-test. The data are presented as means ± standard deviations. A p-value less than 0.05 was considered statistically significant. Results Patient characteristics The 151 patients with unilateral endometrioma comprised 58 right-sided and 93 left-sided cases (REG and LEG). The average endometrioma size measured before and during surgery, patient age and ASRM score were 56.2 ± 23.2 mm, 58.9 ± 24.4 mm, 36.7 ± 7.2 years and 36.2 ± 18.9 points, respectively. The representative symptoms were dysmenorrhoea (n = 77), infertility (n = 51), pelvic pain (n = 38), coital pain (n = 7) and other symptoms, although the symptoms overlapped in some cases. By comparing the REG and LEG in a univariate analysis (Table 1), a significantly higher ASRM score was detected for the REG (41.5 ± 22.1 points vs. 32.9 ± 15.8 points, p = 0.0068). The endometrioma sizes before surgery (63.8 ± 23.8 mm vs. 57.7 ± 22.1 mm, p = 0.11) and during surgery (64.0 ± 26.6 mm vs. 55.7 ± 22.4 mm, p = 0.051), and the patients’ age (36.0 ± 6.6 years vs. 37.2 ± 7.5 years, p = 0.34) did not differ significantly. Influential factors increasing the ASRM scores We compared 8 factors using Welch’s t-test and a multivariate regression analysis to identify the significant factors associated with the severity of endometriosis (Table 2). We extracted the following 8 factors collected before surgery: 1) “right-sided endometrioma” (n = 58); 2) “predicted adhesion” (n = 32), which was defined as the possible presence of an adhesion detected during a pelvic examination or MRI; 3) “ART history” (n = 14), which was defined as patients who underwent ART; 4) “adenomyoma” (n = 16), which was defined as the current presence of adenomyoma based on clinical images; 5) “uterine fibroid” (n = 60), which was defined as the current presence of uterine fibroids based on clinical images; 6) “other ovarian tumour” (n = 13), which was defined as the current presence of an ovarian tumour other than endometrioma based on clinical images; 7) “positive marker” (n = 85), which was defined as serum CA125 levels ≥ 35 U/ml; and 8) “large endometrioma” (n = 82), which was defined as a tumour size of at least 50 mm. Welch’s t-test revealed that “right-sided endometrioma” (41.5 ± 22.1 points vs. 32.9 ± 15.8 points, p = 0.012) and “uterine fibroid” (40.4 ± 21.8 points vs. 33.5 ± 16.3 points, p = 0.037) were significant factors contributing to higher ASRM scores. The factor “adenomyoma” also had the tendency to increase the ASRM score (47.3 ± 23.0 points vs. 34.9 ± 18.0 points, p = 0.053). A multivariate regression analysis of the 8 factors using the least squares method indicated significant differences in 3 factors (right-sided endometrioma: p = 0.028, uterine fibroid: p = 0.033, adenomyoma: p = 0.027). However, the other 5 factors did not show significant differences. These results supported the hypothesis that the laterality of endometrioma affected the severity of endometriosis independent of the other 2 significant factors. Comparisons of the REG and LEG revealed the following findings: 26/58 patients in the REG and 34/93 patients in the LEG exhibited “uterine fibroid” (p = 0.32), and 9/58 patients in the REG and 7/93 patients in the LEG exhibited “adenomyoma” (p = 0.12). Laterality of endometrial lesion spread We compared the total values of SEL, CEL, PEL and DEL between patients in the REG and LEG to detect the tendency towards the spread of endometrial lesions. The actual maximal values of SEL, CEL, PEL and DEL were 32, 34, 7 and 40 points for patients in the REG and 32, 9, 6 and 40 points for patients in the LEG, respectively. The numbers of SEL, CEL, PEL and DEL cases were 51, 23, 26 and 30, respectively, in the REG (n=58) and 80, 24, 45 and 35, respectively, in the LEG (n=93). The proportion of patients with CEL or DEL was significantly higher among the REG than among the LEG. When comparing the scores of these 4 lesions, the CEL (3.5 ± 6.9 points vs. 1.0 ± 2.1 points, p = 0.0091) and DEL (9.5 ± 15.8 points vs. 4.2 ± 10.4 points, p = 0.026) scores were significantly higher among patients in the REG. The SEL (7.9 ± 7.1 points vs. 7.0 ± 7.0 points, p = 0.42) and PEL (1.3 ± 1.8 points vs. 1.2 ± 1.7 points, p = 0.69) scores did not differ significantly. Discussion One classically proposed pathogenic theory, i.e., the retrograde menstruation hypothesis [11], suggests that the tendency towards a frequent left-sided disease is attributed to the presence of the sigmoid colon [9]. In fact, more cases of left-sided endometrioma were detected at our hospital (93 vs. 58) after excluding 95 cases of bilateral endometrioma. In this study, the possible effect of laterality on the severity of endometriosis was also investigated because the stage of endometriosis is considered closely related to its symptoms, particularly infertility [12, 13], although we were limited because we were unable to assess the severity by comparing patients’ symptoms. As an index of severity, we compared the ASRM scores of two groups, i.e., REG and LEG. In this comparison, by excluding patients with bilateral endometrioma, we aimed to determine the main endometriosis lesion in each case. As expected, the ASRM score of patients in the REG was significantly higher than patients in the LEG, and this difference reached approximately 10 points (41.5 ± 22.1 points vs. 32.9 ± 15.8 points, p = 0.012). Similarly, “uterine fibroid” exerted a significant effect on the high ASRM scores and “adenomyoma” showed a similar tendency. The likely explanation is that endometriosis, adenomyosis and uterine fibroids can co-occur [1, 2, 14, 15]. Based on these results from the multivariate analysis, we ensured that the ratios of patients with “uterine fibroid” and “adenomyoma” were not significantly different before subsequently comparing the REG and LEG in more detail. By classifying the endometrial lesions into 4 patterns (SEL, CEL, PEL and DEL), the detailed characteristics of the endometrial lesions were also compared between the REG and LEG. In this analysis, the more frequent endometrial lesions in the Douglas pouch and the left ovary or tube increased the severity of endometriosis in the REG (Table 3). Of these lesion types, DEL was detected in more than 50% of the patients in the REG (30/58 patients) and exerted a greater effect on the ASRM score (9.5 ± 15.8 points; Table 3). Unfortunately, the possibility that the main endometrial lesion in these 30 cases was located in the Douglas pouch cannot be excluded because the pathogenesis of endometriosis is multifactorial and endometriosis does not always arise from the ovary [16]. Additionally, because endometrial lesions in the Douglas pouch are difficult to detect during a simplified outpatient examination, we mainly focused on “endometrioma”. However, the anatomical distribution of endometriotic lesions may also be consistent with the retrograde menstruation theory [11]. In addition to some severe symptoms, such as pelvic pain, these lesions are also associated with more difficult surgery [17]; thus, the differentiation between right or left endometrioma is meaningful. Conclusions We examined the associations between the laterality of ovarian endometrioma and its severity. Patients with right-sided endometrioma tended to have higher ASRM scores than patients with left-sided endometrioma. A detailed analysis of the distribution of endometrial lesions revealed the possible involvement of anatomical asymmetries in pelvic organs. List of Abbreviations ASRM: American Society for Reproductive Medicine, REG: right-sided endometrioma group, LEG: left-sided endometrioma group, ART: assisted reproductive technology, CA125: carbohydrate antigen 125, MRI: magnetic resonance imaging, IVF: in vitro fertilization, ICSI: intracytoplasmic sperm injection, SELs: same endometrial lesions, CELs: contralateral endometrial lesions, PELs: peritoneal endometrial lesions, DELs: Douglas pouch endometrial lesions Declarations Ethical approval and consent to participate This retrospective study was approved by the Institutional Review Board of Teikyo University. The study registry number, registry name and date of registration are as follows: 18-233, Clinical outcomes and carcinogenic risk of ovarian endometriomas: a retrospective analysis, 2019/3/20. Consent for publication Written informed consent was obtained from the patients for the publication of any images. A copy of the written informed consent form is available for review by the Editor-in-Chief of this journal. Availability of data and materials The authors agree to make all data of this study freely available. Competing interests The authors have no competing interests to declare. Funding The authors declare that no funding was received for this study. Authors’ contributions WI collected and analysed the data and wrote the manuscript. AT and ON supervised the entire study. MH, AT, AS, RM and HT performed all operations. AF and ON determined the methods of all operations and supervised all medical practice. All authors read and approved the final manuscript. Acknowledgements This study was supported by the Mizonokuchi Hospital of Teikyo University, which provided medical information. The author(s) disclose the receipt of the financial support from the Japan Society for the Promotion of Conventions for the research, authorship, and/or publication of this article. Author details Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, Kanagawa, 5-1-1 Kawasaki, Takatsu-ku, Futago, Kanagawa 213-8507, Japan. References Huang JQ, Lathi RB, Lemyre M, Rodriguez HE, Nezhat CH, Nezhat C. Coexistence of endometriosis in women with symptomatic leiomyomas. Fertil Steril. 2010;94(2):720-3. Khan KN, Kitajima M, Hiraki K, Fujishita A, Sekine I, Ishimaru T, et al. Changes in tissue inflammation, angiogenesis and apoptosis in endometriosis, adenomyosis and uterine myoma after GnRH agonist therapy. Hum Reprod. 2010;25(3):642-53. Kennedy S, Bergqvist A, Chapron C, D'Hooghe T, Dunselman G, Greb R, et al. ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod. 2005;20(10):2698-704. Sinaii N, Plumb K, Cotton L, Lambert A, Kennedy S, Zondervan K, et al. Differences in characteristics among 1,000 women with endometriosis based on extent of disease. Fertil Steril. 2008;89(3):538-45. American Society for Reproductive Medicine. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril. 1997;67(5):817-21. Bazot M, Darai E. Diagnosis of deep endometriosis: clinical examination, ultrasonography, magnetic resonance imaging, and other techniques. Fertil Steril. 2017;108(6):886-94. Singh SS, Suen MW. Surgery for endometriosis: beyond medical therapies. Fertil Steril. 2017;107(3):549-54. Audebert A, Petousis S, Margioula-Siarkou C, Ravanos K, Prapas N, Prapas Y. Anatomic distribution of endometriosis: A reappraisal based on series of 1101 patients. Eur J Obstet Gynecol Reprod Biol. 2018;230:36-40. Sznurkowski JJ, Emerich J. Endometriomas are more frequent on the left side. Acta Obstet Gynecol Scand. 2008;87(1):104-6. Shazly SA, Badee AY, Ali MK, Sobh AM, Aleem AA. The laterality of ovulation: how far does it matter? Eur J Obstet Gynecol Reprod Biol. 2013;167(1):8-13. Sampson JA. Peritoneal endometriosis due to menstrual dissemination of endometrial tissue into the peritoneal cavity. Am J Obstet Gynecol. 1927;14:442–69. Prefumo F, Rossi AC. Endometriosis, endometrioma, and ART results: Current understanding and recommended practices. Best Pract Res Clin Obstet Gynaecol. 2018;51:34-40. Isono W, Wada-Hiraike O, Shirane A, Fujimoto A, Osuga Y, Yano T, et al. Alternative strategies to in vitro fertilization/intracytoplasmic sperm injection treatment for aged infertile women. Reprod Med Biol. 2012;11(1):69-72. Naphatthalung W, Cheewadhanaraks S. Prevalence of endometriosis among patients with adenomyosis and/or myoma uteri scheduled for a hysterectomy. J Med Assoc Thai. 2012;95(9):1136-40. Isono W, Wada-Hiraike O, Osuga Y, Yano T, Taketani Y. Diameter of dominant leiomyoma is a possible determinant to predict coexistent endometriosis. Eur J Obstet Gynecol Reprod Biol. 2012;162(1):87-90. Osuga Y. Current concepts of the pathogenesis of endometriosis. Reprod Med Biol. 2010;9(1):1-7. Arion K, Aksoy T, Allaire C, Noga H, Williams C, Bedaiwy MA, et al. Prediction of Pouch of Douglas Obliteration: Point-of-care Ultrasound Versus Pelvic Examination. J Minim Invasive Gynecol. 2018. Tables Table 1: Patient characteristics We extracted the patient’s age, ASRM score, tumour size measured before and during surgery from the medical records of the 93 patients in the LEG and 58 patients in the REG. The data are presented as the means ± standard deviations and this difference was compared using Welch’s t-test. LEG REG P-value Total number (n) 93 58 Average age (years) 37.2 ± 7.5 36.0 ± 6.6 0.33 ASRM score 32.9 ± 15.8 41.5 ± 22.1 0.01 Endometrioma size before surgery (mm) 57.7 ± 22.1 63.8 ± 22.8 0.11 Endometrioma size during surgery (mm) 55.7 ± 22.4 64.0 ± 26.6 0.05 Table 2 : Influences of endometriosis-related factors on the ASRM score. For the 151 patients, we extracted the following 8 factors collected before surgery: 1) “right-sided endometrioma”; 2) “predicted adhesion”, which was defined as the possible presence of an adhesion based on a pelvic examination or MRI; 3) “ART history”, which was defined as patients who underwent ART; 4) “adenomyoma”, which was defined as the current presence of adenomyoma based on clinical images; 5) “uterine fibroid”, which was defined as the current presence of a uterine fibroid based on clinical images; 6) “other ovarian tumour”, which was defined as the current presence of an ovarian tumour other than endometrioma based on clinical images; 7) “positive marker”, which was defined as serum CA125 levels ≥ 35 U/ml; and 8) “large endometrioma”, which was defined as a tumour size of at least 50 mm. In Table 2, we show the number of patients with each factor. Because several factors overlapped in some cases, we divided the patients into two groups according to the presence or absence of each factor and used Welch’s t-test to assess the effects of the 8 factors. Then, we compared the average ASRM scores (points) between these two groups based on these factors. The p-values calculated using Welch’s t-test are shown in Table 2. Among the 8 factors, 2 factors, including “right-sided endometrioma” and “uterine fibroid”, were significantly different. The factor of “adenomyoma” also indicated the tendency of a high ASRM score. Factors N ASRM score (Positive vs. Negative) P-value Right-sided Endometrioma 58 41.5 ± 22.1 vs. 32.9 ± 15.8 0.01 Uterine fibroid 60 40.4 ± 21.8 vs. 33.5 ± 16.3 0.04 Adenomyoma 16 47.3 ± 23.0 vs. 34.9 ± 18.0 0.05 ART history 14 40.0 ± 14.8 vs. 35.9 ± 19.3 0.35 Large endometrioma 82 37.3 ± 18.7 vs. 35.0 ± 19.2 0.45 Positive marker 85 37.0 ± 18.0 vs. 35.2 ± 20.1 0.57 Predicted adhesion 32 36.0 ± 14.9 vs. 36.3 ± 19.9 0.92 Other ovarian tumour 13 36.3 ± 20.9 vs. 36.2 ± 18.8 0.99 Footnote ART: assisted reproductive technology Table 3 : Distribution of endometrial lesions . We classified the ASRM scores into four categories, including SEL, CEL, PEL, and DEL, to compare the tendency of endometrial lesions to spread between patients with right or left ovarian endometrioma. In Table 3, we compared the average of these scores (points) between the REG and LEG using Welch’s t-test (Note: n = the number of patients with each endometrial lesion). Lesion Right ovarian endometrioma Left ovarian endometrioma P-value CEL 3.5 ± 6.9 (n = 23) 1.0 ± 2.1 (n = 24) 0.01 DEL 9.5 ± 15.8 (n = 30) 4.2 ± 10.4 (n = 35) 0.03 SEL 7.9 ± 7.1 (n = 51) 7.0 ± 7.0 (n = 80) 0.42 PEL 1.3 ± 1.8 (n = 26) 1.2 ± 1.7 (n = 45) 0.69 Footnote CEL: contralateral endometrial lesion, DEL: Douglas pouch endometrial lesion, SEL: same endometrial lesion, PEL: peritoneal endometrial lesion Cite Share Download PDF Status: Posted Version 2 posted You are reading this latest preprint version Show more versions 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-13416","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":441736,"identity":"e8670de9-2c9b-4d1d-a5b8-72afe0255a9e","order_by":1,"name":"Wataru Isono","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIie3PvQrCMBDA8YSD6xLs2uDXKxQKgos+ixSc3FwUBRVBF8FV30KX7HKgiw+g6GAV3B0EXcS0m0tbN8H8h0DC/UjCmMn0o/E+YwUEPjjpjcgkjQsGEfFsC8gNDzAtqc2nWHfCk0RStaZrOWsd+YJEqX1vVHLIIDjv4m4RhHKxvYKrySGvfP0w9LxGHHF8lMGIMCJSgSYCs7GkeNHkRSIkTal6KYgDKJd9cuQQ6/ymKAXZ+l55tibXBqAsVxuBkPAXa7wK9pMu9Ub2anB7qk7VtobBJY58BCJa046H8cc30yaTyfQ3vQGD3EJjX+kcGgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-4589-328X","institution":"Teikyo University","correspondingAuthor":true,"prefix":"","firstName":"Wataru","middleName":"","lastName":"Isono","suffix":""},{"id":441737,"identity":"261031dc-438b-4f3b-8224-fb5165b2e255","order_by":2,"name":"Michiko Honda","email":"","orcid":"","institution":"Teikyo University","correspondingAuthor":false,"prefix":"","firstName":"Michiko","middleName":"","lastName":"Honda","suffix":""},{"id":441738,"identity":"7f40e3da-06fb-486e-b0d1-aba1859a35f9","order_by":3,"name":"Akira Tsuchiya","email":"","orcid":"","institution":"Teikyo University","correspondingAuthor":false,"prefix":"","firstName":"Akira","middleName":"","lastName":"Tsuchiya","suffix":""},{"id":441739,"identity":"e654bcc5-29b8-4272-aa08-d82003fafdcd","order_by":4,"name":"Ako Saito","email":"","orcid":"","institution":"Teikyo University","correspondingAuthor":false,"prefix":"","firstName":"Ako","middleName":"","lastName":"Saito","suffix":""},{"id":441740,"identity":"66056b48-5b7c-4086-b04b-c97570bbe282","order_by":5,"name":"Hiroko Tsuchiya","email":"","orcid":"","institution":"Teikyo University","correspondingAuthor":false,"prefix":"","firstName":"Hiroko","middleName":"","lastName":"Tsuchiya","suffix":""},{"id":441741,"identity":"7712697b-57ca-4b95-8946-c45c85fb8d96","order_by":6,"name":"Reiko Matsuyama","email":"","orcid":"","institution":"Teikyo University","correspondingAuthor":false,"prefix":"","firstName":"Reiko","middleName":"","lastName":"Matsuyama","suffix":""},{"id":441742,"identity":"b3ea61b8-886b-434b-b19c-04c383bd7abd","order_by":7,"name":"Akihisa Fujimoto","email":"","orcid":"","institution":"Teikyo University","correspondingAuthor":false,"prefix":"","firstName":"Akihisa","middleName":"","lastName":"Fujimoto","suffix":""},{"id":441743,"identity":"f3201455-cd3b-4516-bb17-8073dbb3cddf","order_by":8,"name":"Osamu Nishii","email":"","orcid":"","institution":"Teikyo University","correspondingAuthor":false,"prefix":"","firstName":"Osamu","middleName":"","lastName":"Nishii","suffix":""}],"badges":[],"createdAt":"2020-02-05 14:46:10","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.2.22842/v2","doiUrl":"https://doi.org/10.21203/rs.2.22842/v2","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":766428,"identity":"7d0dcd32-f419-4613-b0be-f83314561bff","added_by":"auto","created_at":"2020-03-30 15:21:13","extension":"tif","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":66069,"visible":true,"origin":"","legend":"Flowchart of data collection criteria.\nOf the 302 patients, 151 were excluded for the following reasons: 95 patients were excluded because they were diagnosed with bilateral endometrioma, and 56 patients were excluded for other reasons, including no cystic lesion detected during surgery (n = 23); other main ovarian cystic diseases, such as mature cystic teratoma (n = 8); ruptured endometrioma (n = 4); and past abdominal surgery (n = 21). This last factor (past abdominal surgery) was excluded after excluding other factors. Then, the medical records of 151 female patients with unilateral endometrioma, including 58 right-sided and 93 left-sided cases, were reviewed retrospectively.","description":"","filename":"20200204Figure1.tif","url":"https://assets-eu.researchsquare.com/files/rs-13416/v2/20200204 Figure 1.tif"},{"id":766429,"identity":"2a90dd85-3242-45fd-a714-ec7649a6027f","added_by":"auto","created_at":"2020-03-30 15:21:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":255155,"visible":true,"origin":"","legend":"Classification of endometrial lesions in patients with right-sided endometrioma.\nIn addition to the right or left endometriomas that are generally treated as deep endometriosis, we classified the ASRM scores into the following four categories: 1) “same endometrial lesions (SELs)”, including ovarian and tubal endometrial lesions on the same side as the main ovarian endometrioma; 2) “contralateral endometrial lesions (CELs)”, including ovarian and tubal endometrial lesions on the contralateral side of the main ovarian endometrioma; 3) “peritoneal endometrial lesions (PELs)”; and 4) “Douglas pouch endometrial lesions (DELs)”. For illustration, the classification of SEL (A), CEL (B), PEL (C) and DEL (C) in the REG is shown using the Chart of Revised ASRM score [5]. The scores of SEL, CEL, PEL and DEL are the total values of the scores in each cell, as indicated by an italic letter and thick-bordered box. In the LEG, the scores of SEL and CEL are reversed.","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-13416/v2/Figure 2.png"},{"id":13495937,"identity":"dd976833-9318-4a38-aa9b-debf5d8589b5","added_by":"auto","created_at":"2021-09-16 22:47:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":629086,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-13416/v2/b6a9199c-53a9-495e-81bd-3b54f5392eee.pdf"}],"financialInterests":"","formattedTitle":"Influence of laterality on endometriosis severity in patients with unilateral endometrioma: a retrospective study.","fulltext":[{"header":"Background","content":"\u003cp\u003eEndometriosis is one of the most common gynaecological diseases and is known to affect 2\u0026ndash;10% of reproductive-age women [1, 2]. While many patients are asymptomatic [3], endometriosis is frequently associated with infertility and pain symptoms, including chronic pelvic pain, dysmenorrhoea, dyspareunia, and dyschezia [4]. Previous studies have revealed a relationship between symptom severity and disease stage according to the revised American Society for Reproductive Medicine (ASRM) scoring system [5]. In most cases, the diagnosis of endometrioma is obtained during an outpatient ultrasound examination [6], and laparoscopic surgeries are often performed to treat pelvic pain and subfertility [7]. During surgery, ovarian endometrioma, superficial implantation and deep infiltrating endometriosis are detected. The most frequent site of endometriotic lesions detected during surgery was the ovary [8]. According to some studies, left-sided endometriomas are more common than right-sided endometriomas [9]. This tendency is believed to be due to anatomical asymmetries in the pelvic organs, including the presence of the sigmoid colon and more frequent ovulation of right ovary caused by the varying paths of the vein [9, 10]. However, the recognition of this laterality is insufficient. Therefore, we aimed not only to verify this laterality but also to evaluate the effect of the side of endometrioma on disease severity. Specifically, the ASRM scores determined during laparoscopic surgery were compared.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003ePatient selection criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Human Ethics Committee of the University of Teikyo (trial registration number: 18-233). The medical records of 151 female patients with unilateral endometrioma, including 58 right-sided and 93 left-sided cases, from June 1, 2014, to December 31, 2019, were reviewed retrospectively. We defined the former cases as the right-sided endometrioma group (REG, n = 58) and the latter cases as the left-sided endometrioma group (LEG, n = 93). In this study, we did not include patients with recurrent endometriosis. As shown in Figure 1, 151 of the 302 patients who underwent laparoscopic surgery for new onset endometrioma detected during outpatient examinations were excluded for the following reasons: 95 patients were excluded because they were diagnosed with bilateral endometrioma and 56 patients were excluded for other reasons, including a lack of cystic lesions detected during surgery (n = 23); a diagnosis of other main ovarian cystic diseases, such as mature cystic teratoma (n = 8); ruptured endometrioma (n = 4); and prior abdominal surgery (n = 21). Since patients meeting the last criterion (prior abdominal surgery) were excluded after patients meeting other criteria were excluded, this number may be an underestimation (n = 21). Among the 151 remaining patients, we performed 123 laparoscopic cystectomies, including 9 that were performed simultaneously with laparoscopic myomectomies; 9 laparoscopic hysterectomies; 23 laparoscopic salpingo-oophorectomies, including 3 surgeries performed simultaneously with laparoscopic hysterectomies; and 5 laparoscopic-assisted cystectomies, including 3 surgeries performed simultaneously with laparoscopic-assisted myomectomies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCollection of patient characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter extracting the medical records of these 151 patients, the following patient characteristics were collected: 1) size of the ovarian endometrioma before and during surgery; 2) ASRM score (points) [5]; 3) patient\u0026rsquo;s age at the time of the operation; 4) presence of adhesions predicted before the operation; 5) history of use of assisted reproductive technology (ART); 6) presence of complicated adenomyomas, uterine fibroids or other ovarian tumours; and 7) serum carbohydrate antigen 125 (CA125) level (U/ml). Magnetic resonance imaging (MRI) was performed on almost all patients (148/151 cases) to assess the size of the endometrioma. MRI was also used to predict adhesions, particularly in the Douglas pouch. In this study, ART included both in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). Twenty-eight of these 151 patients used hormone drugs, including oral contraceptives, gonadotropin-releasing hormone agonists and other drugs. However, the indications for the use of hormone drugs varied, and thus this factor was not considered in the present study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClassification of endometrial \u003c/strong\u003e\u003cstrong\u003elesions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe divided the endometrial lesions based on the location of the endometrioma to compare the tendency of endometrial lesion spread between patients with right or left ovarian endometrioma. Briefly, the so-called ASRM score chart, in which the severity of endometriosis is standardized by roughly classifying endometrial lesions [5], was divided into four parts. First, we calculated the total ASRM score for the uterine adnexa on the same side as the ovarian endometrioma and excluded the score for the endometrioma itself, as shown in Figure 2-A. Second, a similar calculation was performed for the uterine adnexa on the contralateral side of the ovarian endometrioma (Figure 2-B). The remaining endometrial lesions were divided into peritoneal (Figure 2-C) or Douglas pouch endometrial lesions (Figure 2-C). In summary, by referencing the sheet of \u0026ldquo;Revised ASRM classification of endometriosis, 1996.\u0026rdquo; [5], we classified the ASRM scores into the following four categories: 1) \u0026ldquo;same endometrial lesions (SELs)\u0026rdquo;, including Ovary-ENDOMETRIOSIS-Superficial, Ovary-ADHESIONS and Tube-ADHESIONS on the same side, as the main ovarian endometrioma; 2) \u0026ldquo;contralateral endometrial lesions (CELs)\u0026rdquo;, including Ovary-ENDOMETRIOSIS-Superficial, Ovary-ADHESIONS and Tube-ADHESIONS on the contralateral side of the main ovarian endometrioma; 3) \u0026ldquo;peritoneal endometrial lesions (PELs)\u0026rdquo;, including Peritoneum-ENDOMETRIOSIS; and 4) \u0026ldquo;Douglas pouch endometrial lesions (DELs)\u0026rdquo;, including POSTERIOR CULDESAC OBLITERATION. As an example, this classification is shown in Figure 2 for REG. The SEL (Figure 2-A), CEL (Figure 2-B), PEL (Figure 2-C) and DEL (Figure 2-C) scores are the total scores in each cell, as indicated by an italicized letter and thick-bordered box. In the patients with left ovarian endometrioma, the SEL and CEL scores were reversed. In this analysis, the theoretical maximum values of SEL, CEL, PEL and DEL were 36, 36, 10 and 40 points, respectively. We not only compared each average value of SEL, CEL, PEL and DEL between patients in the REG and LEG but also counted each number of patients with these four lesions in both the REG and LEG.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcomes included the difference in the ASRM scores detected during laparoscopic surgery between the patients with right- and left-sided endometriomas. We assessed the influences of the following 8 factors on the ASRM score: 1) \u0026ldquo;right-sided endometrioma\u0026rdquo;; 2) \u0026ldquo;predicted adhesion\u0026rdquo;, which was defined as the detection of the possible presence of an adhesion in a patient during a pelvic examination or MRI; 3) \u0026ldquo;ART history\u0026rdquo;, which was defined as patients who underwent ART; 4) \u0026ldquo;adenomyoma\u0026rdquo;, which was defined as the current presence of adenomyoma based on clinical images; 5) \u0026ldquo;uterine fibroid\u0026rdquo;, which was defined as the current presence of a uterine fibroid based on clinical images; 6) \u0026ldquo;other ovarian tumour\u0026rdquo;, which was defined as the current presence of an ovarian tumour other than endometrioma based on clinical images; 7) \u0026ldquo;positive marker\u0026rdquo;, which was defined as serum CA125 levels \u0026ge; 35 U/ml; and 8) \u0026ldquo;large endometrioma\u0026rdquo;, which was defined as a tumour size of at least 50 mm (described in Table 2). All 151 patients were divided into two groups based on the presence (= 1) or absence (= 0) of these 8 factors. The difference in the ASRM score was compared using Welch\u0026rsquo;s t-test. We also performed a multivariate regression analysis using the least squares method to reduce confounding factors and confirm this difference. These statistical analyses were performed using JMP version 12 for Windows (SAS Institute, Inc., Tokyo, Japan). The total values of SEL, CEL, PEL and DEL between patients in the REG and LEG were also compared with Welch\u0026rsquo;s t-test. The data are presented as means \u0026plusmn; standard deviations. A p-value less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 151 patients with unilateral endometrioma comprised 58 right-sided and 93 left-sided cases (REG and LEG). The average endometrioma size measured before and during surgery, patient age and ASRM score were 56.2 \u0026plusmn; 23.2 mm, 58.9 \u0026plusmn; 24.4 mm, 36.7 \u0026plusmn; 7.2 years and 36.2 \u0026plusmn; 18.9 points, respectively. The representative symptoms were dysmenorrhoea (n = 77), infertility (n = 51), pelvic pain (n = 38), coital pain (n = 7) and other symptoms, although the symptoms overlapped in some cases.\u003c/p\u003e\n\u003cp\u003eBy comparing the REG and LEG in a univariate analysis (Table 1), a significantly higher ASRM score was detected for the REG (41.5 \u0026plusmn; 22.1 points vs. 32.9 \u0026plusmn; 15.8 points, p = 0.0068). The endometrioma sizes before surgery (63.8 \u0026plusmn; 23.8 mm vs. 57.7 \u0026plusmn; 22.1 mm, p = 0.11) and during surgery (64.0 \u0026plusmn; 26.6 mm vs. 55.7 \u0026plusmn; 22.4 mm, p = 0.051), and the patients\u0026rsquo; age (36.0 \u0026plusmn; 6.6 years vs. 37.2 \u0026plusmn; 7.5 years, p = 0.34) did not differ significantly.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInfluential factors increasing the ASRM scores\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe compared 8 factors using Welch\u0026rsquo;s t-test and a multivariate regression analysis to identify the significant factors associated with the severity of endometriosis (Table 2). We extracted the following 8 factors collected before surgery: 1) \u0026ldquo;right-sided endometrioma\u0026rdquo; (n = 58); 2) \u0026ldquo;predicted adhesion\u0026rdquo; (n = 32), which was defined as the possible presence of an adhesion detected during a pelvic examination or MRI; 3) \u0026ldquo;ART history\u0026rdquo; (n = 14), which was defined as patients who underwent ART; 4) \u0026ldquo;adenomyoma\u0026rdquo; (n = 16), which was defined as the current presence of adenomyoma based on clinical images; 5) \u0026ldquo;uterine fibroid\u0026rdquo; (n = 60), which was defined as the current presence of uterine fibroids based on clinical images; 6) \u0026ldquo;other ovarian tumour\u0026rdquo; (n = 13), which was defined as the current presence of an ovarian tumour other than endometrioma based on clinical images; 7) \u0026ldquo;positive marker\u0026rdquo; (n = 85), which was defined as serum CA125 levels \u0026ge; 35 U/ml; and 8) \u0026ldquo;large endometrioma\u0026rdquo; (n = 82), which was defined as a tumour size of at least 50 mm. Welch\u0026rsquo;s t-test revealed that \u0026ldquo;right-sided endometrioma\u0026rdquo; (41.5 \u0026plusmn; 22.1 points vs. 32.9 \u0026plusmn; 15.8 points, p = 0.012) and \u0026ldquo;uterine fibroid\u0026rdquo; (40.4 \u0026plusmn; 21.8 points vs. 33.5 \u0026plusmn; 16.3 points, p = 0.037) were significant factors contributing to higher ASRM scores. The factor \u0026ldquo;adenomyoma\u0026rdquo; also had the tendency to increase the ASRM score (47.3 \u0026plusmn; 23.0 points vs. 34.9 \u0026plusmn; 18.0 points, p = 0.053). A multivariate regression analysis of the 8 factors using the least squares method indicated significant differences in 3 factors (right-sided endometrioma: p = 0.028, uterine fibroid: p = 0.033, adenomyoma: p = 0.027). However, the other 5 factors did not show significant differences. These results supported the hypothesis that the laterality of endometrioma affected the severity of endometriosis independent of the other 2 significant factors. Comparisons of the REG and LEG revealed the following findings: 26/58 patients in the REG and 34/93 patients in the LEG exhibited \u0026ldquo;uterine fibroid\u0026rdquo; (p = 0.32), and 9/58 patients in the REG and 7/93 patients in the LEG exhibited \u0026ldquo;adenomyoma\u0026rdquo; (p = 0.12).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLaterality of endometrial lesion spread\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe compared the total values of SEL, CEL, PEL and DEL between patients in the REG and LEG to detect the tendency towards the spread of endometrial lesions. The actual maximal values of SEL, CEL, PEL and DEL were 32, 34, 7 and 40 points for patients in the REG and 32, 9, 6 and 40 points for patients in the LEG, respectively. The numbers of SEL, CEL, PEL and DEL cases were 51, 23, 26 and 30, respectively, in the REG (n=58) and 80, 24, 45 and 35, respectively, in the LEG (n=93). The proportion of patients with CEL or DEL was significantly higher among the REG than among the LEG. When comparing the scores of these 4 lesions, the CEL (3.5 \u0026plusmn; 6.9 points vs. 1.0 \u0026plusmn; 2.1 points, p = 0.0091) and DEL (9.5 \u0026plusmn; 15.8 points vs. 4.2 \u0026plusmn; 10.4 points, p = 0.026) scores were significantly higher among patients in the REG. The SEL (7.9 \u0026plusmn; 7.1 points vs. 7.0 \u0026plusmn; 7.0 points, p = 0.42) and PEL (1.3 \u0026plusmn; 1.8 points vs. 1.2 \u0026plusmn; 1.7 points, p = 0.69) scores did not differ significantly.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOne classically proposed pathogenic theory, i.e., the retrograde menstruation hypothesis [11], suggests that the tendency towards a frequent left-sided disease is attributed to the presence of the sigmoid colon [9]. In fact, more cases of left-sided endometrioma were detected at our hospital (93 vs. 58) after excluding 95 cases of bilateral endometrioma. In this study, the possible effect of laterality on the severity of endometriosis was also investigated because the stage of endometriosis is considered closely related to its symptoms, particularly infertility [12, 13], although we were limited because we were unable to assess the severity by comparing patients\u0026rsquo; symptoms. As an index of severity, we compared the ASRM scores of two groups, i.e., REG and LEG. In this comparison, by excluding patients with bilateral endometrioma, we aimed to determine the main endometriosis lesion in each case. As expected, the ASRM score of patients in the REG was significantly higher than patients in the LEG, and this difference reached approximately 10 points (41.5 \u0026plusmn; 22.1 points vs. 32.9 \u0026plusmn; 15.8 points, p = 0.012). Similarly, \u0026ldquo;uterine fibroid\u0026rdquo; exerted a significant effect on the high ASRM scores and \u0026ldquo;adenomyoma\u0026rdquo; showed a similar tendency. The likely explanation is that endometriosis, adenomyosis and uterine fibroids can co-occur [1, 2, 14, 15]. Based on these results from the multivariate analysis, we ensured that the ratios of patients with \u0026ldquo;uterine fibroid\u0026rdquo; and \u0026ldquo;adenomyoma\u0026rdquo; were not significantly different before subsequently comparing the REG and LEG in more detail.\u003c/p\u003e\n\u003cp\u003eBy classifying the endometrial lesions into 4 patterns (SEL, CEL, PEL and DEL), the detailed characteristics of the endometrial lesions were also compared between the REG and LEG. In this analysis, the more frequent endometrial lesions in the Douglas pouch and the left ovary or tube increased the severity of endometriosis in the REG (Table 3). Of these lesion types, DEL was detected in more than 50% of the patients in the REG (30/58 patients) and exerted a greater effect on the ASRM score (9.5 \u0026plusmn; 15.8 points; Table 3). Unfortunately, the possibility that the main endometrial lesion in these 30 cases was located in the Douglas pouch cannot be excluded because the pathogenesis of endometriosis is multifactorial and endometriosis does not always arise from the ovary [16]. Additionally, because endometrial lesions in the Douglas pouch are difficult to detect during a simplified outpatient examination, we mainly focused on \u0026ldquo;endometrioma\u0026rdquo;. However, the anatomical distribution of endometriotic lesions may also be consistent with the retrograde menstruation theory [11]. In addition to some severe symptoms, such as pelvic pain, these lesions are also associated with more difficult surgery [17]; thus, the differentiation between right or left endometrioma is meaningful.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe examined the associations between the laterality of ovarian endometrioma and its severity. Patients with right-sided endometrioma tended to have higher ASRM scores than patients with left-sided endometrioma. A detailed analysis of the distribution of endometrial lesions revealed the possible involvement of anatomical asymmetries in pelvic organs.\u003c/p\u003e"},{"header":"List of Abbreviations","content":"\u003cp\u003eASRM: American Society for Reproductive Medicine, REG: right-sided endometrioma group, LEG: left-sided endometrioma group, ART: assisted reproductive technology, CA125: carbohydrate antigen 125, MRI: magnetic resonance imaging, IVF: in vitro fertilization, ICSI: intracytoplasmic sperm injection, SELs: same endometrial lesions, CELs: contralateral endometrial lesions, PELs: peritoneal endometrial lesions, DELs: Douglas pouch endometrial lesions\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study was approved by the Institutional Review Board of Teikyo University. The study registry number, registry name and date of registration are as follows: 18-233, Clinical outcomes and carcinogenic risk of ovarian endometriomas: a retrospective analysis, 2019/3/20.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patients for the publication of any images. A copy of the written informed consent form is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors agree to make all data of this study freely available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWI collected and analysed the data and wrote the manuscript. AT and ON supervised the entire study. MH, AT, AS, RM and HT performed all operations. AF and ON determined the methods of all operations and supervised all medical practice. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Mizonokuchi Hospital of Teikyo University, which provided medical information. The author(s) disclose the receipt of the financial support from the Japan Society for the Promotion of Conventions for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, Kanagawa, 5-1-1 Kawasaki, Takatsu-ku, Futago, Kanagawa 213-8507, Japan.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHuang JQ, Lathi RB, Lemyre M, Rodriguez HE, Nezhat CH, Nezhat C. Coexistence of endometriosis in women with symptomatic leiomyomas. Fertil Steril. 2010;94(2):720-3.\u003c/li\u003e\n\u003cli\u003eKhan KN, Kitajima M, Hiraki K, Fujishita A, Sekine I, Ishimaru T, et al. Changes in tissue inflammation, angiogenesis and apoptosis in endometriosis, adenomyosis and uterine myoma after GnRH agonist therapy. Hum Reprod. 2010;25(3):642-53.\u003c/li\u003e\n\u003cli\u003eKennedy S, Bergqvist A, Chapron C, D'Hooghe T, Dunselman G, Greb R, et al. ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod. 2005;20(10):2698-704.\u003c/li\u003e\n\u003cli\u003eSinaii N, Plumb K, Cotton L, Lambert A, Kennedy S, Zondervan K, et al. Differences in characteristics among 1,000 women with endometriosis based on extent of disease. Fertil Steril. 2008;89(3):538-45.\u003c/li\u003e\n\u003cli\u003eAmerican Society for Reproductive Medicine. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril. 1997;67(5):817-21.\u003c/li\u003e\n\u003cli\u003eBazot M, Darai E. Diagnosis of deep endometriosis: clinical examination, ultrasonography, magnetic resonance imaging, and other techniques. Fertil Steril. 2017;108(6):886-94.\u003c/li\u003e\n\u003cli\u003eSingh SS, Suen MW. Surgery for endometriosis: beyond medical therapies. Fertil Steril. 2017;107(3):549-54.\u003c/li\u003e\n\u003cli\u003eAudebert A, Petousis S, Margioula-Siarkou C, Ravanos K, Prapas N, Prapas Y. Anatomic distribution of endometriosis: A reappraisal based on series of 1101 patients. Eur J Obstet Gynecol Reprod Biol. 2018;230:36-40.\u003c/li\u003e\n\u003cli\u003eSznurkowski JJ, Emerich J. Endometriomas are more frequent on the left side. Acta Obstet Gynecol Scand. 2008;87(1):104-6.\u003c/li\u003e\n\u003cli\u003eShazly SA, Badee AY, Ali MK, Sobh AM, Aleem AA. The laterality of ovulation: how far does it matter? Eur J Obstet Gynecol Reprod Biol. 2013;167(1):8-13.\u003c/li\u003e\n\u003cli\u003eSampson JA. Peritoneal endometriosis due to menstrual dissemination of endometrial tissue into the peritoneal cavity. Am J Obstet Gynecol. 1927;14:442\u0026ndash;69.\u003c/li\u003e\n\u003cli\u003ePrefumo F, Rossi AC. Endometriosis, endometrioma, and ART results: Current understanding and recommended practices. Best Pract Res Clin Obstet Gynaecol. 2018;51:34-40.\u003c/li\u003e\n\u003cli\u003eIsono W, Wada-Hiraike O, Shirane A, Fujimoto A, Osuga Y, Yano T, et al. Alternative strategies to in vitro fertilization/intracytoplasmic sperm injection treatment for aged infertile women. Reprod Med Biol. 2012;11(1):69-72.\u003c/li\u003e\n\u003cli\u003eNaphatthalung W, Cheewadhanaraks S. Prevalence of endometriosis among patients with adenomyosis and/or myoma uteri scheduled for a hysterectomy. J Med Assoc Thai. 2012;95(9):1136-40.\u003c/li\u003e\n\u003cli\u003eIsono W, Wada-Hiraike O, Osuga Y, Yano T, Taketani Y. Diameter of dominant leiomyoma is a possible determinant to predict coexistent endometriosis. Eur J Obstet Gynecol Reprod Biol. 2012;162(1):87-90.\u003c/li\u003e\n\u003cli\u003eOsuga Y. Current concepts of the pathogenesis of endometriosis. Reprod Med Biol. 2010;9(1):1-7.\u003c/li\u003e\n\u003cli\u003eArion K, Aksoy T, Allaire C, Noga H, Williams C, Bedaiwy MA, et al. Prediction of Pouch of Douglas Obliteration: Point-of-care Ultrasound Versus Pelvic Examination. J Minim Invasive Gynecol. 2018.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:justify;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12px; font-family: Helvetica;\"\u003eTable 1: Patient characteristics\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:justify;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u0026nbsp;We extracted the patient’s age, ASRM score, tumour size measured before and during surgery from the medical records of the 93 patients in the LEG and 58 patients in the REG. The data are presented as the means ± standard deviations and this difference was compared using\u0026nbsp;Welch’s t-test.\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border: none;width:382.75pt;border-collapse:collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:191.4pt;border:none;border-top:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:70.85pt;border:none;border-top:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003eLEG\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:70.9pt;border:none;border-top:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003eREG\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.6pt;border:none;border-top:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003eP-value\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:191.4pt;border:none;border-top:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003eTotal number (n)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:70.85pt;border:none;border-top:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e93\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:70.9pt;border:none;border-top:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e58\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.6pt;border:none;border-top:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:191.4pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003eAverage age (years)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:70.85pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e37.2 ± 7.5\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:70.9pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e36.0 ± 6.6\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.6pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e0.33\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:191.4pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003eASRM score\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:70.85pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e32.9 ± 15.8\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:70.9pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e41.5 ± 22.1\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.6pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e0.01\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:191.4pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003eEndometrioma size before surgery (mm)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:70.85pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e57.7 ± 22.1\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:70.9pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e63.8 ± 22.8\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.6pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e0.11\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:191.4pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:19.5pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003eEndometrioma size during surgery (mm)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:70.85pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:19.5pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e55.7 ± 22.4\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:70.9pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:19.5pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e64.0 ± 26.6\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.6pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:19.5pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-size: 12px; font-family: Helvetica;\"\u003e\u003cspan style=\"color: black;\"\u003e0.05\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cbr\u003e\u003cbr\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:justify;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12px; font-family: Helvetica;\"\u003eTable 2\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cstrong\u003e: Influences of endometriosis-related factors on the ASRM score.\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:justify;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;text-indent:6.0pt;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003eFor the 151 patients, we extracted the following 8 factors collected before surgery: 1) “right-sided endometrioma”; 2) “predicted adhesion”, which was defined as the possible presence of an adhesion based on a pelvic examination or MRI; 3) “ART history”, which was defined as patients who underwent ART; 4) “adenomyoma”, which was defined as the current presence of adenomyoma based on clinical images; 5) “uterine fibroid”, which was defined as the current presence of a uterine fibroid based on clinical images; 6) “other ovarian tumour”, which was defined as the current presence of an ovarian tumour other than endometrioma based on clinical images; 7) “positive marker”, which was defined as serum CA125 levels ≥ 35 U/ml; and 8) “large endometrioma”, which was defined as a tumour size of at least 50 mm. In Table 2, we show the number of patients with each factor.\u0026nbsp;Because\u0026nbsp;several factors\u0026nbsp;overlapped\u0026nbsp;in some cases, we divided the patients into two groups according to the presence or absence of each factor and used\u0026nbsp;Welch’s t-test\u0026nbsp;to assess the effects of the 8 factors. Then, we compared the average ASRM scores (points) between these two groups based on these factors. The p-values calculated using\u0026nbsp;Welch’s t-test\u0026nbsp;are shown in Table 2. Among the 8 factors, 2 factors, including\u0026nbsp;“right-sided endometrioma” and “uterine fibroid”, were significantly different. The factor of “adenomyoma” also indicated the tendency of a high ASRM score.\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border: none;width:5.75in;margin-left:4.2pt;border-collapse:collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 146.5pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003eFactors\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.7pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003eN\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177.15pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003eASRM score (Positive vs. Negative)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.65pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003eP-value\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 146.5pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003eRight-sided Endometrioma\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.7pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e58\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177.15pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e41.5 ± 22.1 vs. 32.9 ± 15.8\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.65pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e0.01\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 146.5pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003eUterine fibroid\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.7pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e60\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177.15pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e40.4 ± 21.8 vs. 33.5 ± 16.3\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.65pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e0.04\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 146.5pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003eAdenomyoma\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.7pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e16\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177.15pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e47.3 ± 23.0 vs. 34.9 ± 18.0\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.65pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e0.05\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 146.5pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003eART history\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.7pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e14\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177.15pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e40.0 ± 14.8 vs. 35.9 ± 19.3\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.65pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e0.35\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 146.5pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003eLarge endometrioma\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.7pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e82\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177.15pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e37.3 ± 18.7 vs. 35.0 ± 19.2\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.65pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e0.45\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 146.5pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003ePositive marker\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.7pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e85\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177.15pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e37.0 ± 18.0 vs. 35.2 ± 20.1\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.65pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e0.57\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 146.5pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003ePredicted adhesion\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.7pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e32\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177.15pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e36.0 ± 14.9 vs. 36.3 ± 19.9\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.65pt;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e0.92\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 146.5pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003eOther ovarian tumour\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.7pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e13\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177.15pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e36.3 ± 20.9 vs. 36.2 ± 18.8\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.65pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 4.95pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e0.99\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:justify;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003eFootnote\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:justify;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003eART: assisted reproductive technology\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 12px; font-family: Helvetica;\"\u003e\n \u003cbr\u003e \n \u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:justify;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;text-indent:6.0pt;\"\u003e\n \u003cbr\u003e\n\u003c/p\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:justify;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12px; font-family: Helvetica;\"\u003eTable 3\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cstrong\u003e: Distribution of endometrial\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003elesions\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:justify;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003eWe classified the ASRM scores into four categories, including SEL, CEL, PEL, and DEL, to compare the tendency of endometrial lesions to spread between patients with right or left ovarian endometrioma. In Table 3, we compared the average of these scores (points) between the REG and LEG using Welch’s t-test (Note: n = the number of patients with each endometrial lesion).\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border: none;width:384.9pt;margin-left:4.95pt;border-collapse:collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:42.6pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003eLesion\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:150.9pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003eRight\u0026nbsp;ovarian endometrioma\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:141.75pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003eLeft\u0026nbsp;ovarian endometrioma\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.65pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003eP-value\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:42.6pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003eCEL\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:150.9pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e3.5 ± 6.9 (n = 23)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:141.75pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e1.0 ± 2.1 (n = 24)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.65pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e0.01\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:42.6pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003eDEL\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:150.9pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e9.5 ± 15.8 (n = 30)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:141.75pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e4.2 ± 10.4 (n = 35)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.65pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e0.03\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:42.6pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003eSEL\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:150.9pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e7.9 ± 7.1 (n = 51)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:141.75pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e7.0 ± 7.0 (n = 80)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.65pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e0.42\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:42.6pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:left;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003ePEL\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:150.9pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e1.3 ± 1.8 (n = 26)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:141.75pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e1.2 ± 1.7 (n = 45)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:center;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: black;\"\u003e0.69\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:justify;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: white;\"\u003eFootnote\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;text-align:justify;font-size:14px;font-family:\u0026quot;Century\u0026quot;,serif;\"\u003e\u003cspan style=\"font-size: 12px; font-family: Helvetica;\"\u003eCEL: contralateral endometrial lesion, DEL: Douglas pouch endometrial lesion, SEL: same endometrial lesion, PEL: peritoneal endometrial lesion\u003c/span\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Endometrioma, Laparoscopic Surgery, Retrospective Study, Severity of Illness Index","lastPublishedDoi":"10.21203/rs.2.22842/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.2.22842/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: We compared the revised American Society for Reproductive Medicine (ASRM) scores determined during laparoscopic surgery to evaluate the effect of the location of the endometrioma (right vs. left ovary) on the severity of endometriosis. Methods: The medical records of 151 patients, including 58 right-sided and 93 left-sided cases, who underwent an initial laparoscopic surgery for unilateral ovarian endometrioma were reviewed retrospectively. We extracted the ASRM scores determined during surgery and some representative factors related to endometriosis that are separate from the tumour characteristics, such as the coexistence of uterine fibroids, adenomyoma, or other ovarian tumours, a history of use of assisted reproductive technology (ART), and tumour marker values. A statistical analysis was performed to assess the impact of each factor. We classified the ASRM scores into 4 categories to compare the tendency towards endometrial lesion spread with a focus on the “sidedness” of the endometrioma. We defined contralateral endometrial lesion (CEL), Douglas pouch endometrial lesion (DEL), same endometrial lesion (SEL) and peritoneal endometrial lesion (PEL). Results: The ASRM scores of patients with a right-sided endometrioma were significantly higher than patients with a left-sided endometrioma (41.5 ± 22.1 points vs. 32.9 ± 15.8 points, p\u0026lt;0.05). The higher ASRM scores of the patients with right-sided endometrioma may be caused by the frequent detection of endometrial lesions in the left tube, left ovary and Douglas pouch. According to the statistical analysis, the coexistence of uterine fibroids also exerted significant positive effects on increasing the ASRM score. Conclusions: Higher ASRM scores are possible in patients with right-sided endometrioma. The laterality of endometriosis severity should be considered.\u003c/p\u003e","manuscriptTitle":"Influence of laterality on endometriosis severity in patients with unilateral endometrioma: a retrospective study.","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2020-03-30 15:21:12","doi":"10.21203/rs.2.22842/v2","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-02-07 16:23:12","doi":"10.21203/rs.2.22842/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a8dd9317-4ed6-4b62-ae43-2348ac1b4d34","owner":[],"postedDate":"March 30th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56648,"name":"Sexual \u0026 Reproductive Medicine"}],"tags":[],"updatedAt":"2020-05-29T02:59:25+00:00","versionOfRecord":[],"versionCreatedAt":"2020-03-30 15:21:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v2","identity":"rs-13416","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"identity":"rs-13416","version":["v2"]},"buildId":"0U-iFTyB6qxOgVj8rjrZV","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}