Article Sidebar
Main Article Content
Abstract
ABSTRACT
Introduction. The Endometriosis Fertility Index (EFI) is a validated tool for predicting natural conception after endometriosis surgery. However, its performance remains unassessed in Central Africa, where patients often present with advanced disease after prolonged infertility. This study aimed to evaluate the prognostic value of the EFI and its components in a population of Cameroonian women. Methodology. We conducted an analytical cross-sectional study at a referral hospital in Yaoundé, Cameroon (2018–2024). We included infertile women who underwent laparoscopic surgery for endometriosis. Patients were stratified into low (0-4), intermediate (5-7), and high (8-10) EFI prognostic groups. The primary outcome was time to spontaneous conception. We analyzed data using Kaplan-Meier curves and Cox proportional hazards regression. Results. Among 30 analyzed women (median age 31 years), 53.5% had severe endometriosis (rASRM stage III-IV). Most patients (56.7%) had a low Least Function Score (LFS). The overall post-surgical conception rate was 23.3% (n=7/30), with a spontaneous conception rate of 13.3% (n=4). Kaplan-Meier analysis showed a significant association between EFI score and time to conception (p=0.004). Multivariate Cox regression identified the surgical LFS as the only independent predictor of conception (Hazard Ratio=0.540, 95% CI: 0.304–0.958; p=0.035). Historical factors like age and infertility duration were not significant predictors in this model. Conclusion. In this Central African cohort characterized by late presentation and severe disease, the EFI retained significant prognostic value. The surgical LFS, reflecting post-operative tubo-ovarian function, was the dominant predictive component. This underscores that surgical technique and the preservation of pelvic anatomy are critical determinants of fertility outcomes, even when historical factors are unfavorable. The findings advocate for the EFI's use to guide post-operative counseling and to prioritize fertility-enhancing surgical precision.
RÉSUMÉ
Introduction. L’Endometriosis Fertility Index (EFI) est un outil validé pour prédire la conception naturelle après chirurgie de l’endométriose. Sa performance n’a pas été évaluée en Afrique centrale, où les patientes se présentent souvent à un stade avancé après une infertilité prolongée. Cette étude visait à évaluer la valeur pronostique de l’EFI dans une cohorte de femmes camerounaises. Méthodologie. Nous avons mené une étude transversale analytique dans un hôpital de référence à Yaoundé, Cameroun (2018–2024). Nous avons inclus les femmes infertiles opérées par coelioscopie pour endométriose. Les patientes ont été stratifiées en groupes pronostiques EFI bas (0-4), intermédiaire (5-7) et élevé (8-10). Le critère principal était le délai jusqu’à une conception spontanée. Les données ont été analysées par les courbes de Kaplan-Meier et la régression de Cox. Résultats. Parmi 30 femmes analysées (âge médian 31 ans), 53,5% avaient une endométriose sévère (stade rASRM III-IV). La majorité (56,7%) avait un faible Least Function Score (LFS). Le taux global de conception post-chirurgicale était de 23,3% (n=7/30), avec un taux de conception spontanée de 13,3% (n=4). L’analyse de Kaplan-Meier a montré une association significative entre le score EFI et le délai de conception (p=0,004). La régression de Cox multivariée a identifié le LFS chirurgical comme le seul prédicteur indépendant de conception (Risque Relatif=0,540, IC 95% : 0,304–0,958 ; p=0,035). Les facteurs historiques (âge, durée d’infertilité) n’étaient pas significatifs. Conclusion. Dans cette cohorte d’Afrique centrale caractérisée par un diagnostic tardif, l’EFI a conservé une valeur pronostique significative. Le LFS chirurgical, reflet de la fonction tubo-ovarienne postopératoire, était le composant prédictif dominant. Ceci souligne que la qualité chirurgicale et la préservation de l’anatomie pelvienne sont des déterminants clés du pronostic fertilité, même lorsque les antécédents sont défavorables.
Keywords
Article Details
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
References
- 1. Johnson NP, Hummelshoj L, Adamson GD, Keckstein J, Taylor HS, Abrao MS et al. World Endometriosis Society consensus on the classification of endometriosis. Hum Reprod. 2017 ;32(2):315-324. doi: 10.1093/humrep/dew293.
- 2. Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J Med. 2020 ; 382(13):1244-1256. doi: 10.1056/NEJMra1810764.
- 3. Bulun SE, Yilmaz BD, Sison C, Miyazaki K, Bernardi L, Liu S, Kohlmeier A, Yin P, Milad M, Wei J. Endometriosis. Endocr Rev. 2019 ;40(4):1048-1079. doi: 10.1210/er.2018-00242.
- 4. Prescott J, Farland LV, Tobias DK, Gaskins AJ, Spiegelman D, Chavarro JE, Rich-Edwards JW, Barbieri RL, Missmer SA. A prospective cohort study of endometriosis and subsequent risk of infertility. Hum Reprod. 2016 ;31(7):1475-82. doi: 10.1093/humrep/dew085.
- 5. Kyama CM, Mwenda JM, Machoki J, Mihalyi A, Simsa P, Chai DC, D'Hooghe TM. Endometriosis in African women. Womens Health (Lond). 2007 ;3(5):629-35. doi: 10.2217/17455057.3.5.629.
- 6. American Society for Reproductive Medicine. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril. 1997 ;67(5):817-21. doi: 10.1016/s0015-0282(97)81391-x.
- 7. Tuttlies F, Keckstein J, Ulrich U, Possover M, Schweppe KW, Wustlich M, et al. ENZIAN-Score, eine Klassifikation der tief infiltrierenden Endometriose , ENZIAN-score, a classification of deep infiltrating endometriosis. Zentralbl Gynakol. 2005 ;127(5):275-81. doi: 10.1055/s-2005-836904.
- 8. Abrao MS, Andres MP, Miller CE, Gingold JA, Rius M, Neto JS, Carmona F. AAGL 2021 Endometriosis Classification: An Anatomy-based Surgical Complexity Score. J Minim Invasive Gynecol. 2021 ;28(11):1941-1950.e1. doi: 10.1016/j.jmig.2021.09.709.
- 9. Adamson GD, Pasta DJ. Endometriosis fertility index: the new, validated endometriosis staging system. Fertil Steril. 2010 ;94(5):1609-15. doi: 10.1016/j.fertnstert.2009.09.035.
- 10. Tomassetti C, Geysenbergh B, Meuleman C, Timmerman D, Fieuws S, D'Hooghe T. External validation of the endometriosis fertility index (EFI) staging system for predicting non-ART pregnancy after endometriosis surgery. Hum Reprod. 2013 ;28(5):1280-8. doi: 10.1093/humrep/det017.
- 11. Vesali S, Razavi M, Rezaeinejad M, Maleki-Hajiagha A, Maroufizadeh S, Sepidarkish M. Endometriosis fertility index for predicting non-assisted reproductive technology pregnancy after endometriosis surgery: a systematic review and meta-analysis. BJOG. 2020 ;127(7):800-809. doi: 10.1111/1471-0528.16107.
- 12. Barnard A, Thomas V. The reproducibility of the Endometriosis Fertility Index: inter- and intra-observer variation in the least functional score. The Trocar. 2024; 5(4) :1-9. doi:10.36205/trocar5.2024018.
- 13. Ombelet W, Cooke I, Dyer S, Serour G, Devroey P. Infertility and the provision of infertility medical services in developing countries. Hum Reprod Update. 2008;14(6):605-21. doi: 10.1093/humupd/dmn042.
- 14. Fryer J, Mason-Jones AJ, Woodward A. Understanding diagnostic delay for endometriosis: a scoping review using the social-ecological framework. Health Care Women Int. 2024;46(3):335–351. doi:10.1080/07399332.2024.2413056.
- 15. Meuleman C, Tomassetti C, Wolthuis A, Van Cleynenbreugel B, Laenen A, Penninckx F, et al. Clinical outcome after radical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis: a prospective cohort study. Ann Surg. 2014 ;259(3):522-31. doi: 10.1097/SLA.0b013e31828dfc5c.
- 16. Vercellini P, Viganò P, Somigliana E, Fedele L. Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol. 2014 ;10(5):261-75. doi: 10.1038/nrendo.2013.255.
- 17. Ferrier C, Boujenah J, Poncelet C, Chabbert-Buffet N, Mathieu D'Argent E, Carbillon L, et al. Use of the EFI score in endometriosis-associated infertility: A cost-effectiveness study. Eur J Obstet Gynecol Reprod Biol. 2020 ;253:296-303. doi: 10.1016/j.ejogrb.2020.08.031.
References
1. Johnson NP, Hummelshoj L, Adamson GD, Keckstein J, Taylor HS, Abrao MS et al. World Endometriosis Society consensus on the classification of endometriosis. Hum Reprod. 2017 ;32(2):315-324. doi: 10.1093/humrep/dew293.
2. Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J Med. 2020 ; 382(13):1244-1256. doi: 10.1056/NEJMra1810764.
3. Bulun SE, Yilmaz BD, Sison C, Miyazaki K, Bernardi L, Liu S, Kohlmeier A, Yin P, Milad M, Wei J. Endometriosis. Endocr Rev. 2019 ;40(4):1048-1079. doi: 10.1210/er.2018-00242.
4. Prescott J, Farland LV, Tobias DK, Gaskins AJ, Spiegelman D, Chavarro JE, Rich-Edwards JW, Barbieri RL, Missmer SA. A prospective cohort study of endometriosis and subsequent risk of infertility. Hum Reprod. 2016 ;31(7):1475-82. doi: 10.1093/humrep/dew085.
5. Kyama CM, Mwenda JM, Machoki J, Mihalyi A, Simsa P, Chai DC, D'Hooghe TM. Endometriosis in African women. Womens Health (Lond). 2007 ;3(5):629-35. doi: 10.2217/17455057.3.5.629.
6. American Society for Reproductive Medicine. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril. 1997 ;67(5):817-21. doi: 10.1016/s0015-0282(97)81391-x.
7. Tuttlies F, Keckstein J, Ulrich U, Possover M, Schweppe KW, Wustlich M, et al. ENZIAN-Score, eine Klassifikation der tief infiltrierenden Endometriose , ENZIAN-score, a classification of deep infiltrating endometriosis. Zentralbl Gynakol. 2005 ;127(5):275-81. doi: 10.1055/s-2005-836904.
8. Abrao MS, Andres MP, Miller CE, Gingold JA, Rius M, Neto JS, Carmona F. AAGL 2021 Endometriosis Classification: An Anatomy-based Surgical Complexity Score. J Minim Invasive Gynecol. 2021 ;28(11):1941-1950.e1. doi: 10.1016/j.jmig.2021.09.709.
9. Adamson GD, Pasta DJ. Endometriosis fertility index: the new, validated endometriosis staging system. Fertil Steril. 2010 ;94(5):1609-15. doi: 10.1016/j.fertnstert.2009.09.035.
10. Tomassetti C, Geysenbergh B, Meuleman C, Timmerman D, Fieuws S, D'Hooghe T. External validation of the endometriosis fertility index (EFI) staging system for predicting non-ART pregnancy after endometriosis surgery. Hum Reprod. 2013 ;28(5):1280-8. doi: 10.1093/humrep/det017.
11. Vesali S, Razavi M, Rezaeinejad M, Maleki-Hajiagha A, Maroufizadeh S, Sepidarkish M. Endometriosis fertility index for predicting non-assisted reproductive technology pregnancy after endometriosis surgery: a systematic review and meta-analysis. BJOG. 2020 ;127(7):800-809. doi: 10.1111/1471-0528.16107.
12. Barnard A, Thomas V. The reproducibility of the Endometriosis Fertility Index: inter- and intra-observer variation in the least functional score. The Trocar. 2024; 5(4) :1-9. doi:10.36205/trocar5.2024018.
13. Ombelet W, Cooke I, Dyer S, Serour G, Devroey P. Infertility and the provision of infertility medical services in developing countries. Hum Reprod Update. 2008;14(6):605-21. doi: 10.1093/humupd/dmn042.
14. Fryer J, Mason-Jones AJ, Woodward A. Understanding diagnostic delay for endometriosis: a scoping review using the social-ecological framework. Health Care Women Int. 2024;46(3):335–351. doi:10.1080/07399332.2024.2413056.
15. Meuleman C, Tomassetti C, Wolthuis A, Van Cleynenbreugel B, Laenen A, Penninckx F, et al. Clinical outcome after radical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis: a prospective cohort study. Ann Surg. 2014 ;259(3):522-31. doi: 10.1097/SLA.0b013e31828dfc5c.
16. Vercellini P, Viganò P, Somigliana E, Fedele L. Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol. 2014 ;10(5):261-75. doi: 10.1038/nrendo.2013.255.
17. Ferrier C, Boujenah J, Poncelet C, Chabbert-Buffet N, Mathieu D'Argent E, Carbillon L, et al. Use of the EFI score in endometriosis-associated infertility: A cost-effectiveness study. Eur J Obstet Gynecol Reprod Biol. 2020 ;253:296-303. doi: 10.1016/j.ejogrb.2020.08.031.