J Gynecol Obstet Hum Reprod 50 (2021) 102208

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Journal of Gynecology Obstetrics

and Human Reproduction
journal homepage: www.elsevier.com

Original article

Role of ultrasonographic parameters for predicting tubal involvement in

infertile patients affected by endometriosis: A retrospective cohort study
Anna Katarzyna Stepniewskaa,*, Roberto Clariziaa, Paola De Mitria, Anna Pescib, Carlotta Zorzia,
Mara Albanesea, Giamberto Trivellaa, Massimo Guerrieroc,d, Francesco Paolo Improdae,
Marcello Ceccaronia
a
Department of Obstetrics and Gynecology, Gynecology Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy (ISSA), IRCCS
Ospedale Sacro Cuore - Don Calabria, Via Don A. Sempreboni, 5, 37024 Negrar (Verona), Italy
b
Department of Human Pathology, IRCCS Ospedale Sacro Cuore − Don Calabria, Via Don A. Sempreboni 5, 37024 Negrar (Verona), Italy
c
Department of Cultures and Civilizations, Unversity of Verona, Verona, Italy
d
Clinical Research Unit, IRCCS Ospedale Sacro Cuore - Don Calabria, Via Don A. Sempreboni, 5, 37024 Negrar (Verona), Italy
e
University of Naples Federico II, Department of Neuroscience, Reproductive Sciences and Dentistry, Naples, Italy

A R T I C L E I N F O A B S T R A C T

Article History: Introduction: Transvaginal ultrasound is fundamental for the mapping of endometriosis, and the imaging cri-
Received 15 June 2021 teria have been clearly described for different organs study. However, no specific ultrasonographic signs of
Revised 26 July 2021 tubal endometriosis have been reported, with the exception of hydrosalpinx, which is the expression of an
Accepted 16 August 2021
extreme tubal damage and obstruction. The detection of tubal pathology in infertile patients is fundamental,
Available online 18 August 2021
therefore the aim of the study was to evaluate incidence of tubal endometriosis in infertile patients, and to
Keywords: analyze ultrasonographic signs useful for detection of this condition.
Endometriosis Material and methods: It is a single-center, retrospective cohort study. All 500 consecutive infertile women
Fallopian tubes who underwent laparoscopic surgery for endometriosis were included. The preoperative workup included
Laparoscopy transvaginal ultrasound and was compared to intraoperative findings and histologic study.
Infertility Results: The incidence of tubal endometriosis in our study was 8%. Using hydrosalpinx as the ultrasono-
Salpingectomy graphic marker for tubal involvement the overall pooled, sensitivity and specificity of TVU were 12% (95%CI,
5−23%) and 99% (95%CI, 98−100%), respectively.
If at least one ultrasonographic parameter like hydrosalpinx, periadnexal adhesions or ovarian cyst was con-
sidered as a sign of tubal endometriosis, a sensitivity, VPN and specificity were 94% (95% IC, 85−98%), 97%
(95%IC, 93−99%) and 31% (95%CI, 27−36%), respectively.
Discussion: Hydrosalpinx as ultrasonographic sign alone is characterized by a high specificity but low sensi-
tivity for detection of tubal endometriosis; its sensitivity can be improved by the addition of other markers
such as endometrioma and/or periadnexal adhesions.
© 2021 Published by Elsevier Masson SAS.

Introduction According to a widely accepted theory of retrograde menstruation

Endometriosis is a chronic disease of women in the reproductive
age, characterized by the presence of endometrial tissue implants
outside the uterus.
Abbreviations: TVU, Transvaginal ultrasound scan; VAS, Visual analogue scale
Institution at which the work was carried out: Department of Obstetrics and
Gynecology, Gynecology Oncology and Minimally-Invasive Pelvic Surgery, Interna-
tional School of Surgical Anatomy (ISSA), IRCCS Ospedale Sacro Cuore - Don Calabria,
Via Don A. Sempreboni, 5, 37024 Negrar (Verona), Italy
* Corresponding author at: Via Rondinella 108, 37015, Sant’Ambrogio di Valpolicella
(Verona), Italy.
E-mail addresses: stepniewska.anna@gmail.com, anna.stepniewska@sacrocuore.it
(A.K. Stepniewska).
[1], the fallopian tube plays a fundamental role in the pathogenesis of
endometriosis. However, even if the retrograde menstruation blood
flowing through the fallopian tube gives origin to different endome-
triosis sites, tubal involvement is present only in a few number of
women.
Transvaginal ultrasound is fundamental for the mapping of endo-
metriosis, and it is characterized by a high sensibility and specificity
for the detection of lesions affecting different organs such as the ova-
ries, bladder, rectosigmoid tract, vaginal wall, ureters, and the imag-
ing criteria have been clearly described for this purpose [2].
However, actually no specific ultrasonographic signs suggestive
for tubal endometriosis have been evaluated, with the exception of
hydrosalpinx, haematosalpinx or sactosalpinx [3]. In these cases, a

https://doi.org/10.1016/j.jogoh.2021.102208
2468-7847/© 2021 Published by Elsevier Masson SAS.
A.K. Stepniewska, R. Clarizia, P. De Mitri et al.
fluid filled distended structure is observed as the expression of an
extreme tubal damage and obstruction, which implicate an indication
to tubal removal, to enhance the pregnancy rate [4]. Therefore, the
detection of tubal pathology in infertile patients is fundamental [5].
In a recent study, performed on a heterogeneous population of
patients who underwent salpingectomy for different gynecological
pathologies, the diagnosis of tubal endometriosis was more fre-
quently reported in patients who presented endometrioma during
surgery [6]. Another possible marker of endometriosis in the adnexal
region, could be represented by periadnexal adhesions, which can be
suspected on ultrasonographic study [1,7,8].
Therefore, we wanted to focus attention on women with endome-
triosis-associated infertility and the aim of the present study was to
assess the prevalence of tubal endometriosis in this selected popula-
tion and to analyze ultrasonographic signs useful for the detection of
tubal endometriosis.
Methods
This was a retrospective cohort study conducted at a single center
in Italy, referral center for endometriosis (Sacred Heart Hospital−
Negrar, Italy). All consecutive infertile women, who underwent lapa-
roscopic surgery for endometriosis, from within 5 years were
included in this study. Patients who underwent surgery because of
signs of acute PID associated to endometriosis were not included, to
avoid a possible bias related to the presence of acute tubal pathology.
All women underwent detailed transvaginal ultrasound (TVU)
scan in ten days before surgery. TVU examinations were performed
by gynecologists with a high level of expertise in gynecologic sonog-
raphy (range, 15 − 40 years). In our institution, TVU protocol is stan-
dardized and performed as previously reported [9], and in line with
international recommendations [2]. Preoperative study on TVU
included an accurate study for the presence of hard and soft markers
of endometriosis and examination of the uterus, adnexa, anterior and
posterior compartment, according to steps previously described by
other authors [2,7,10-12].
The sonographic characteristics of endometriomas were described
using the International Ovarian Tumor Analysis terminology [2,13].
Ovarian mobility on ultrasound was verified by a bimanual approach,
with a combination of gentle pressure with the probe in the posterior
vaginal fornix and abdominal pressure with the examiner’s free
hand, and lateral and medial sliding sign of ovary was verified. Peri-
adnexal adhesions to the surrounding structures were suspected if
lateral or medial sliding sign was reduced or absent. Other signs con-
sidered suspected for the presence of periadnexal adhesions were:
loculated peritoneal fluid adherent to the ovary, signs of periadnexal
peritoneal psedocys, and “kissing ovaries” [2,7,10].
The study of the fallopian tubes included examination in the
adnexal region for signs of hydrosalpinx, hematosalpinx or sactosal-
pinx [11]. If a fallopian tube was not visualized on ultrasound, it was
considered normal. If any dilatation of the tube was detected, the
presence of adhesions to the surrounding organs was evaluated with
the bimanual ultrasonographic approach.
No preoperative hormonal therapy was given for at least four
months before surgery.
Preoperative evaluation included a detailed personal history and
an assessment of pain using a visual analogue scale (VAS; 10-point
rating scale: 0=absent, 10=unbearable) for four components of endo-
metriosis-related pain: dysmenorrhea, non-menstrual pelvic pain,
dyspareunia and dyschezia.
Surgical procedures were performed laparoscopically by surgeons
with extensive experience in laparoscopic surgery for deep endome-
triosis (range, 10−25 years) [14-16].
Evaluation of endometriosis localization was based on surgical
description and successive histology.
2
Journal of Gynecology Obstetrics and Human Reproduction 50 (2021) 102208
In the present study, in line with other reports [16], the definition
of tubal endometriosis consisted of a clear macroscopic tubal damage
due to tubal wall infiltration by endometriosis confirmed on histol-
ogy. All endometriotic implants or deep nodules, present on the sur-
face of the tube, which were removed without salpingectomy, were
not considered for this purpose.
The primary outcomes of the study were to evaluate incidence of
tubal endometriosis in patients with endometriosis-related infertility
and to analyze sensitivity and specificity of hydrosalpinx as an ultra-
sonographic marker of tubal endometriosis.
The secondary outcome was to analyze whether the addition of
other ultrasonographic markers such as ipsilateral endometrioma
and/or periadnexal adhesions may be useful to enhance the sensibil-
ity and specificity for the detection of tubal endometriosis.
IRB approval was not required as the clinical management rou-
tinely performed in our center was not influenced by the study.
Statistical analysis
Continuous variables were expressed as mean and standard devi-
ation or median and interquartile range for the asymmetric variables.
Categorical variables were expressed by their frequencies distribu-
tion.
For detection of tubal pathology, the overall pooled sensitivity,
specificity, positive predictive value (VPP) and negative predictive
value (VPN) of ultrasound was determined for different ultrasono-
graphic aspects like the presence of hydrosalpinx (which included
diagnosis of hydrosalpinx, sactosalpinx and hematosalpinx), ovarian
cyst or periadnexal adhesions on the preoperative ultrasound.
Receiver Operating Characteristic (ROC) curves and the related areas
under the curve were calculated. A p-value less than 5% was consid-
ered to be statistical significant.
Statistical analysis was performed by STATA vers.15 (StataCorp
LLC, 4905 Lakeway Drive, College Station, Texas 77845, USA).
Results
500 infertile women who underwent laparoscopic surgery for
endometriosis were analyzed.
The characteristics of patients are reported in Table 1. The mean
age in the group was 33 years old (range 22 to 42). The mean
Table 1
Characteristics of 500 patients included in the study and intraoperative findings dur-
ing laparoscopic surgery for endometriosis.
Age: mean (range) 33 years (range 22−42)
Duration of infertility: median (range) 31 months (range 14
to 100)
Previous surgery for endometriosis: 165 patients (33%), 75
number (percentage) cases in laparotomy
and 146 cases in
laparoscopy
More than one previous surgery for endometriosis 76 patients (15%)
(from 2 to 5 previous surgeries)
Severe dysmenorrhea (VAS score ≥7) 281 patients (56%)
Severe dyspareunia (VAS score ≥7) 110 patients (22%)
Severe dyschezia (VAS score ≥7) 99 patients (20%)
Severe chronic pelvic pain (VAS score ≥7) 82 patients (16%)
I stage r-ASRM (minimal endometriosis) 79 patients (16%)
II stage r-ASRM (mild endometriosis) 55 patients (11%)
III stage r-ASRM (moderate endometriosis) 100 patients (20%)
IV stage r-ASRM (severe endometriosis) 226 patients (45%)
Bowel endometriosis: number (percentage) 175 (35%)
Bladder endometriosis: number (percentage) 14 (3%)
Right ovary endometriomas: number (percentage) 172 (34%)
Left ovary endometriomas: number (percentage) 192 (38%)
Douglas nodule: number (percentage) 81 (16%)
Periadnexal adhesions: number (percentage) 180 (36%) on the right,
180 (36%) on the
left side
A.K. Stepniewska, R. Clarizia, P. De Mitri et al. Journal of Gynecology Obstetrics and Human Reproduction 50 (2021) 102208

Table 2
Tubal pathology in the study: previous surgery and intraoperative findings on the right and left tube in a population of 500 patients, preoperative ultrasound of adnexa in 42
patients who underwent salpingectomy and histological findings in 44 tubes removed during surgery.

Previous surgery and intraoperative aspects of adnexa in 500 women Right Side: N° (percentage) Left Side: N° (percentage) Together: N° (percentage)

Previous adnexectomy 10 (2%) 15 (3%) 25 (5%)

Previous salpingectomy 2 (<1%) 0 (0%) 2 (<1%)
Salpingectomy performed during surgery in the study 5 (1%) 39 (8%) 42 (8%) y
Tube with occlusion but apparently normal aspect 1 (<1%) 5 (1%) 6 (1%)
Completely retroperitoneal adnexa 8 (2%) 12 (2%) 20 (4%)
Tubes with suspected aspect on surgery, not removed 14 (3%) 10 (2%) 24 (5%)

Preoperative ultrasound in 42 patients who underwent salpingectomyy

Ultrasonographic aspect of adnexa on the side of the tube removed Number (percentage)y

Endometrioma on the same side 17 (40%)

Endometrioma and suspect of adhesions 8 (19%)
Periadnexal adhesions 4 (10%)
Hydrosalpinx (in 2 patients bilateral) 8 (19%)
Not suspected 5 (12%)

Histology in 44 tubes removed y

Histology of the fallopian tube Number (percentage)

Total number of tubes infiltrated by endometriosis 40 (91%)

Endometriosis of the left tube only 33 (75%)
Endometriosis of the right tube only 3 (7%)
Endometriosis of both tubes y 2 (5%)
Chronic inflammation 2 (5%)
Salpingitis isthmica nodosa 2 (5%)
y
in two patients a bilateral salpingectomy was performed.

duration of preoperative infertility was 31 months (range 14 to 100 (involving more than 1/3 of ovary or the tube) in our group was 36%
months). 165 of the included women, already underwent prior sur- for both sides (180 cases), endometriomas were present in 38% of
gery for endometriosis. Among them, 75 women underwent more patients (192) on the left ovary, and in 34% (172) on the right.
than one surgery in the past (range 2 to 5 previous surgeries).
More than half of women involved in the study (56%, 281
patients) reported severe dysmenorrea (VAS score ≥7), while severe Ultrasonographic findings
dyspareunia (VAS score ≥7) and severe dyschezia (VAS score ≥7)
were recorded in 110 (22%) and 99 (20%) patients, respectively. Among 42 women who underwent salpingectomy, only eight
25 (5%) women underwent adnexectomy during previous surgery (19% of all women who underwent salpingectomy, 50% of 16 women
(10 on the right side, 15 on the left side), 2 women (<1%) underwent with hydrosalpinx or hematosalpinx), presented an image which was
a salpingectomy in the past, both on the right side (Table 2). suspected for hydrosalpinx (2 patients) or hematosalpinx (6 patients)
on the preoperative ultrasound (Table 2), in two of them the pathol-
Intraoperative findings ogy was present in both tubes.
In 25 (60% of 42 patients who underwent salpingectomy) cases, an
On the day of surgery, 82 women presented menstrual bleeding, endometriotic cyst was present on the side of the affected tube, mak-
so they did not undergo the dye test. Among the remaining 418 ing the diagnosis more difficult. In eight patients (19% of 42 women),
women, 289 (69%) presented bilateral tubal patency, only one tube pericystic adhesions were suspected on the ultrasound. In four
was open in 98 (23%) of them and bilateral tubal occlusion or absence patients (10%), the adhesions were the only suspect of adnexal
of tubes was reported in 31 (7%) patients. Salpingectomy was per-
formed in 42 (8%) patients, two of them underwent a bilateral salpin-
gectomy.
Among 42 of our patients who underwent salpingectomy, the
removed tube had the clear intraoperative aspect of hydrosalpinx
(Fig. 1) in eight cases (in two of them-bilateral) and a monolateral
hematosalpinx in six cases. In 28 patients, the fallopian tube after
removal of adhesions presented a significant thickening of the tubal
wall (Fig. 2) and absence of the fimbrial tract with the impression of
important organ damage, even if the tube was not completely
occluded or dilated by fluid accumulated inside of it. On palpation
with laparoscopic forceps, a hard consistence of the tubal wall was
noticed, and the color was whitened like some other infiltrating
endometriosis nodules, giving the impression of tubal wall infiltra-
tion by endometriotic or fibrotic tissue and low functional capacity of
the organ. Other sites of endometriosis present during surgery, and
those confirmed on histology, are reported in Table 1.
Fig. 1. Intraoperative findings of bilateral tubal endometriosis before salpingectomy.
In the study population, bowel endometriosis was present in 175 Bilateral hydrosalpinges with severe adhesions, irregular and thick wall, dilated and
(35%) women. While the incidence of periadnexal adhesions tortuous salpinges with distal occlusion.

3
A.K. Stepniewska, R. Clarizia, P. De Mitri et al. Journal of Gynecology Obstetrics and Human Reproduction 50 (2021) 102208

were present causing the thickening of the tubal wall. The macro-
scopic aspect did not allow for distinction of which layer of the tube
was infiltrated by endometriosis.
For the analysis of tubal endometriosis in the present study we
did not consider superficial endometriosis on tubal sierosa treated by
coagulation or endometriotic peritubaric nodules of endometriosis
removed during surgery without tubal damage.

Discussion

Ultrasound has been shown as a useful diagnostic tool in the sus-

Fig. 2. Intraoperative findings of the left tube endometriosis (confirmed on histological
examination and not suspected on preoperative study). After adhesiolysis, thickening
of the tubal wall in the proximal tract is evident.
pathology on the ultrasound, and in five (12%) cases, no adnexal
pathology was detected in the preoperative study. For the detection
of tubal alteration in endometriosis-associated infertility in the over-
all pooled, sensitivity and specificity of TVU were 12% (95%CI, 5−23%)
and 99% (95%CI, 98−100%), respectively, using the presence of hydro-
salpinx as a parameter. The overall pooled sensibility, specificity, VPP
and VPN of different ultrasonographic parameters like the presence
of hydrosalpinx, ovarian cyst, periadnexal adhesions, for the detec-
tion of tubal alterations are reported in the Table 3. If the presence of
at least one ultrasonographic parameter (adnexal alterations) like
hydrosalpinx or periadnexal adhesions or ovarian cyst was consid-
ered as a ultrasonographic sign of possible tubal involvement, a sen-
sitivity equal to 94% (95% IC, 85−98%) and VPN equal to 97% (95%IC,
93−99%) were obtained. Specificity and VPP for the presence of any
ultrasonographic parameter (adnexal alterations) were 31% (95%CI,
27−36%) and 17% (95%CI, 13−21%), respectively, with a ROC area of
62%.
Histologic aspects
In the study group, in most cases (91%) histological examination
reported tubal infiltration by endometriosis (Fig. 3), in 40 of 44 tubes
removed (Table 2). Other histologic findings on the removed speci-
mens were chronic inflammation (2 cases, 5%) and salpingitis isth-
mica nodosa (other 2 cases, 5%). Most frequently, the left tube was
infiltrated by endometriosis (35 cases, 83% versus five cases, 11%,
p<0.05). In 24 (60%) of 40 tubes with endometriosis, the disease infil-
trated the muscularis layer, in four cases (10%) it infiltrated serosa
and fimbrial tract, and 12 (30%) cases, multiple localizations on serosa
pect of tubal endometriosis, with a high specificity, VPP and VPN for
detection of hydrosalpinx; however this marker was characterized
by low sensibility. Its’ sensibility could be improved with the simulta-
neous consideration of an endometrioma or pelvic adhesions or both.
The population of patients included in our study was affected by a
recurrent and aggressive disease, as one-third of them (165 women,
33%) have already been operated on for endometriosis in the past,
and 76 (15%) underwent already more than one operation. Infact, 27
women already underwent salpingectomy or adnexectomy during a
previous surgery. If we exclude them from analysis, the percentage of
tubal endometriosis in our population was 8%. In some cases, how-
ever, the patient did not give the informed consent for salpingec-
tomy. In fact, in 24 (5%) cases, even if its’ aspect was questionable, the
tube was not removed. If we consider the same incidence of tubal
infiltration by endometriosis in these cases, as in other tubes
removed, the possible incidence of tubal endometriosis in the ana-
lyzed population could be as high as 13%. In the present study, super-
ficial endometriosis on tubal sierosa and nodules of endometriosis
removed during surgery without tubal damage were excluded from
the analysis of tubal endometriosis.
Tubes may be affected by endometriosis in two main ways:
serose-subserose (from the outside) and intraluminal (from the
inside) [17-21]. In our series, tubal endometriosis was present in 8%
of infertile patients with endometriosis. The affected tube may pres-
ent as hydro or hematosalpinx and may take part of a complex mass
together with endometriotic cysts or peritoneal nodules (Figs. 1, 2, 3).
In fact, only in 15% of our cases the tubal damage evidenced during
surgery was related to the image of hydro or hematosalpinx evi-
denced on the preoperative ultrasound. In some cases, there was evi-
dence of adjacent ovarian endometrioma or suspect of adhesions,
while in 29 cases (43% of study group) of 68 tubes with intraoperative
aspect with significant damage (together 44 tubes removed and 24
not removed), the preoperative ultrasonographic study was not sus-
pected for tubal pathology. However, when the fallopian tube was
damaged on macroscopic intraoperative inspection, the main reason
for the alteration in our study was endometriotic infiltration on his-
tology (40 of 44 tubes, 91%), and in most cases (60%) it involved the
muscularis layer and this may be related to the possible serose-sub-
serose way of tubal infiltration.
The diagnosis of “tubal endometriosis” on pathology is complex as
different inflammatory and reactive changes may influence the

Table 3
Different ultrasonographic aspects of adnexa as a preoperative marker of tubal involvement by endometriosis: sensibility, specificity, positive and negative predictive value.

Parameter ROC SENS IC95% - SENS SPEC IC95% - SPEC VP+ IC95% - VP+ VP- IC95% - VP-

hydrosalpinx 0,557 12,1 5,4 22,5 99,3 98,0 99,9 72,7 39,0 94,0 88,1 84,9 90,9
endometrioma 0,602 78,8 67,0 87,9 41,7 37,0 46,5 17,0 13,0 21,7 92,8 88,2 96,0
periadnexal adhesions 0,684 90,9 81,3 96,6 45,9 41,1 50,7 20,3 15,9 25,4 97,1 93,7 98,9
hydrosalpinx or adhesions 0,691 92,4 83,2 97,5 45,9 41,1 50,7 20,6 16,1 25,7 97,5 94,4 99,2
hydrosalpinx or adhesions 0,623 83,3 72,1 91,4 41,2 36,6 46,0 17,7 13,7 22,5 94,2 89,9 97,1
endometrioma or adhesions 0,617 95,5 87,3 99,1 27,9 23,7 32,4 16,8 13,1 20,9 97,6 93,1 99,5
any of above (adnexal alterations) 0,624 93,9 85,2 98,3 30,9 26,6 35,5 17,1 13,4 21,4 97,1 92,7 99,2

4
A.K. Stepniewska, R. Clarizia, P. De Mitri et al.
Fig. 3. A-cross section of the tube involved by endometriosis. Multiple foci are present involving the serosa and wall. B-C: H&E endometrial glands and stromal component are pres-
ent the latter one highlighted by CD10 immunostatin.
histologic aspect [22]. Therefore, all histologic findings in our study
may be compatible with endometriosis-induced tubal pathology.
A higher prevalence of the left-side tubal infiltration by endome-
triosis in our patients is in line with the data of other studies [19].
The prevalence of hydrosalpinx in tubal pathology among infertile
women, based on ultrasound, has been reported in the literature to
be about 15%, while the incidence based on tubal evaluation during
hysterosalpingography, laparoscopy or laparotomy is even as high as
30% [23,25].
Two meta-analyses [25,26] demonstrated that the presence of an
hydrosalpinx is associated with a lower implantation, pregnancy and
delivery rate, and a higher incidence of spontaneous miscarriage after
IVF. The possible mechanisms include embryo toxic proprieties of the
fluid, altered endometrial receptivity and mechanical hindrance
(with dysregulated epithelial barrier function and altered endome-
trial peristalsis) [27]. The meta-analysis of four surgical trials demon-
strated that the average pregnancy rate was 21,7% higher if
salpingectomy was performed prior to IVF [28]. Therefore, the pres-
ence of hydrosalpinx in women considering IVF treatment is an indi-
cation for surgical treatment [4].
It has been reported that the complete removal of all endometri-
otic lesions is related to a better outcome in terms of pain, lower
recurrence rate and better fertility outcome [14]. For this reason, it
may be important to remove a fallopian tube infiltrated by endome-
triosis for complete removal of the disease.
Tubal involvement is very difficult to diagnose because the pres-
ence of a hydrosalpinx as an ultrasonographic marker has a high
specificity but a low sensibility; the sensibility of ultrasound can be
improved by addition of other markers like ovarian endometrioma
and peri adnexal adherences or both. The difficulties in diagnosis of
tubal endometriosis can affect the radicality of surgery, when this
structure is not removed despite being affected by the disease
because of erroneous diagnosis with subsequent incorrect patient
counselling.
5
Journal of Gynecology Obstetrics and Human Reproduction 50 (2021) 102208
In conclusion, even if hydrosalpinx diagnosed on preoperative
ultrasound is actually considered the only indication for salpingec-
tomy, among women with endometriosis it is insufficient alone for
detection of all patients who present tubal infiltration by the disease.
Tubal endometriosis was not a frequent finding, however if intra-
operative aspect of the tube was suspected, histology confirmed
endometriotic infiltration in quite all cases.
Ultrasonographic signs suspected for tubal endometriosis should
include the presence of at least one of markers such as hydrosalpinx,
endometrioma or periadnexal adhesions, therefore infertile patients
who present any of them should be informed that during surgery
important tubal damage may be diagnosed and salpingectomy could
be indicated.
Declaration of Competing Interest
The authors declare that they wave no conflicts of interest and
nothing to disclose.
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