Validação externa do Endometriosis Fertility Index (EFI) após ressecção cirúrgica de endometriose moderada e grave em uma população brasileira

Abstract

Endometriosis is an enigmatic disease that presents a complex correlation with infertility. Its incidence in the general population varies between 6% and 10%. Until now the most used staging system is the revised index of American Society for Reproductive Medicine which has severe limitations, including the incapacity of effectively predict the clinical results of surgical treatment and pregnancy rates in infertile patients. The endometriosis fertility index (EFI) is a new clinical staging system of to predict spontaneous pregnancy outcomes in patients with endometriosis. OBJECTIVE the main purpose is to validate the Endometriosis Fertility Index (EFI) in symptomatic patients, submitted to laparoscopy for moderate and severe endometriosis associated to infertility in a Brazilian population. Secondly, to evaluate the cumulative pregnancy rates (PR), in spontaneous pregnancy and ART, for 36 months; evaluate the correlation between the EFI and live birth rates (LBR) and to correlate surgical findings and pregnancy rates. METHODOLOGY:This was a retrospective coorte study carried out at the Biocor Hospital with patients undergoing laparoscopy resection of stage III – IV endometriosis from May 2007 to March 2017.A total of 202 surgeries were performed and 77 symptomatic women with infertility and endometriosis who attempted pregnancy after surgery were selected. Out of the 77 patients, 53 tried spontaneous conception and 24 were directed to ART. EFI was calculated for each patient and correlated to cumulative spontaneous PR, PR after ART, and LBR. The significance level used was of 0,05 and the softwares used to the statistical analysis were SPSS version 20.0 and Stata 9.1. RESULTS: out of the 77 patients, 53 (68,8%) tried spontaneous conception and 24 (31,2%) were directly to ART. Out of the 53 who attempted tried spontaneous conception, 29 got pregnant (54,7%) and 28 had live birth (52,8%). The majority of the patients (82,7%) got pregnant in the first 12 months after surgery and 75% of the patients who became spontaneously pregnant had EFI≥7. Out of the 24 patients referred to ART (FIV), 13 became pregnant (54,1%) and 10 had live birth (41,7%), the majority of the pregnancies (69,2%) happening in the first 12 months. The majority of pregnancies (61,6%) after FIV was from patients with 5 and 6 EFIs. The infertility gap higher than 36 months and the presence of endometrioma increases the probability of having EFI≤5 (p<0,05). The least function score (LF) had a significant association with spontaneous pregnancy in patients presenting severe and moderate endometriosis (p< 0,0014). The accumulated percentage of live birth with EFI 0-4 was 13% and with EFI- 6-9 was 80% rater-p<0,0001. CONCLUSION: The EFI validation in symptomatic patients with moderate and severe endometriosis in a Brazilian population was demonstrated possible, being useful to guide patients and manage treatment. An EFI>5 favor spontaneous pregnancy mainly in the 12 first months after laparoscopy. The least function score is a predictor of spontaneous pregnancy. Duration of infertility higher than 36 months and endometrioma presence are unfavourable to spontaneous pregnancy. The higher the EFI score in patients with moderate and severe endometriosis, the higher the percentage of pregnancy and live birth.