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Kanti FS, Gorak Savard R, Bergeron F, Zomahoun HTV, Netter A, Maheux-Lacroix S. Transvaginal ultrasound and magnetic resonance imaging in the diagnosis of endometrioma: a systematic review and meta-analysis of diagnostic test accuracy studies. J OBSTET GYNAECOL 2024; 44:2311664. [PMID: 38348799 DOI: 10.1080/01443615.2024.2311664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/22/2024] [Indexed: 02/15/2024]
Abstract
INTRODUCTION The diagnosis of endometriomas in patients with endometriosis is of primary importance because it influences the management and prognosis of infertility and pain. Imaging techniques are evolving constantly. This study aimed to systematically assess the diagnostic accuracy of transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) in detecting endometrioma using the surgical visualisation of lesions with or without histopathological confirmation as reference standards in patients of reproductive age with suspected endometriosis. METHODS PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature and ClinicalTrials.gov databases were searched from their inception to 12 October 2022, using a manual search for additional articles. Two authors independently performed title, abstract and full-text screening of the identified records, extracted study details and quantitative data and assessed the quality of the studies using the 'Quality Assessment of Diagnostic Accuracy Study 2' tool. Bivariate random-effects models were used to determine the pooled sensitivity and specificity, compare the two imaging modalities and evaluate the sources of heterogeneity. RESULTS Sixteen prospective studies (10 assessing TVUS, 4 assessing MRI and 2 assessing both TVUS and MRI) were included, representing 1976 participants. Pooled TVUS and MRI sensitivities for endometrioma were 0.89 (95% confidence interval 'CI', 0.86-0.92) and 0.94 (95% CI, 0.74-0.99), respectively (indirect comparison p-value of 0.47). Pooled TVUS and MRI specificities for endometrioma were 0.95 (95% CI, 0.92-0.97) and 0.94 (95% CI, 0.89-0.97), respectively (indirect comparison p-value of 0.51). These studies had a high or unclear risk of bias. A direct comparison (all participants undergoing TVUS and MRI) of the modalities was available in only two studies. CONCLUSION TVUS and MRI have high accuracy for diagnosing endometriomas; however, high-quality studies comparing the two modalities are lacking.
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Affiliation(s)
- Fleur Serge Kanti
- Centre de recherche du CHU de Québec - Université Laval, Quebec City, Canada
| | - Rose Gorak Savard
- Centre de recherche du CHU de Québec - Université Laval, Quebec City, Canada
| | | | - Hervé Tchala Vignon Zomahoun
- Centre de recherche sur les soins et les services de première ligne (CERSSPL) - Université Laval, Quebec City, Canada
| | - Antoine Netter
- Department of Gynecology-Obstetrics and Reproductive Medicine, AP-HM, La Conception Hospital, Marseille, France
- Institut méditerranéen de biodiversité et d'écologie marine et continentale (IMBE), Aix Marseille University, CNRS, IRD, Marseille, France
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2
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Daoud E, Archer DF, Parazzini F, Herranz-Blanco B. Validation of an In Vitro Diagnostic Test for Endometriosis: Impact of Confounding Medical Conditions and Lesion Location. Int J Mol Sci 2024; 25:7667. [PMID: 39062909 PMCID: PMC11277503 DOI: 10.3390/ijms25147667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 07/01/2024] [Accepted: 07/04/2024] [Indexed: 07/28/2024] Open
Abstract
With the aim to shorten the time for diagnosis and accelerate access to correct management, a non-invasive diagnostic test for endometriosis was developed and validated. The IVD test combines an ELISA test kit to quantify CA125 and BDNF concentrations in serum and a data treatment algorithm hosted in medical software processing results from the ELISA test and responses to six clinical variables. Serum samples and clinical variables extracted from psychometric questionnaires from 77 patients were collected from the Oxford Endometriosis CaRe Centre biobank (UK). Case/control classification was performed based on laparoscopy and histological verification of the excised lesions. Biomarkers serum concentrations and clinical variables were introduced to the software, which generates the qualitative diagnostic result ("positive" or "negative"). This test allowed the detection of 32% of cases with superficial endometriosis, which is an added value given the limited efficacy of existing imaging techniques. Even in the presence of various confounding medical conditions, the test maintained a specificity of 100%, supporting its suitability for use in patients with underlying medical conditions.
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Affiliation(s)
| | - David F. Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA 23407, USA;
| | - Fabio Parazzini
- Department of Clinical Science and Community Medicine, University of Milan, 20122 Milan, Italy;
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Lerner V, Stuart AE, Baekalandt J. Vaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy Deconstructed: Expanding Minimally Invasive Gynecologic Surgeons' Toolbox. J Gynecol Surg 2024; 40:78-99. [PMID: 38690154 PMCID: PMC11057779 DOI: 10.1089/gyn.2023.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
Background The introduction of vaginal natural orifice transluminal endoscopic surgery (vNOTES) to the toolbox of gynecologic surgeons has the potential to reverse the trend of vaginal hysterectomy declines. Methods This review discusses nuances of the vNOTES technique applied to hysterectomy; describes vNOTES hysterectomy, step-by-step (including tips and tricks for low- and high-complexity cases for surgeons who may want to incorporate vNOTES hysterectomy into their surgical repertoires); and examines evidence and research trends in this field. Results The descriptions in the text, figures, tables, and videos all contribute to giving readers a clear understanding of vNOTES, its advantages, limitations, and research potentials. Conclusions vNOTES hysterectomy is a unique blend of vaginal, laparoscopic, and laparoendoscopic single-site surgery (LESS) techniques and is not a new procedure, but rather another tool to use in minimally invasive gynecologic surgery. (J GYNECOL SURG 40:78).
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Affiliation(s)
- Veronica Lerner
- Department of Obstetrics & Gynecology, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, New York, USA
| | - Andrea E Stuart
- Department of Obstetrics and Gynaecology, Institution of Clinical Sciences, Lund University, Lund, Sweden
- Department of Obstetrics and Gynaecology, Helsingborg Hospital, Sweden
| | - Jan Baekalandt
- Department of Gynaecologic Oncology, Imelda Hospital, Bonheiden, Belgium
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Dantkale KS, Agrawal M. A Comprehensive Review of the Diagnostic Landscape of Endometriosis: Assessing Tools, Uncovering Strengths, and Acknowledging Limitations. Cureus 2024; 16:e56978. [PMID: 38665720 PMCID: PMC11045176 DOI: 10.7759/cureus.56978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Endometriosis is a prevalent yet often underdiagnosed condition characterized by the presence of endometrial-like tissue outside the uterus, leading to significant morbidity and impaired quality of life. A timely and accurate diagnosis of endometriosis is essential for effective management and improved patient outcomes. This review provides a comprehensive overview of the current diagnostic landscape of endometriosis, including clinical evaluation, imaging modalities, biomarkers, and laparoscopy. The strengths and limitations of each diagnostic approach are critically evaluated, alongside challenges such as delayed diagnosis and misinterpretation of findings. The review emphasizes the importance of multidisciplinary collaboration, standardized diagnostic protocols, and ongoing research to enhance diagnostic accuracy and facilitate early intervention. By addressing these challenges and leveraging emerging technologies, healthcare professionals can improve the diagnosis and management of endometriosis, ultimately enhancing the well-being of affected individuals.
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Affiliation(s)
- Ketki S Dantkale
- Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Manjusha Agrawal
- Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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5
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Shenoy-Bhangle AS, Jha P. Transvaginal ultrasound: a reliable tool for detection and preoperative mapping of pelvic endometriosis. Fertil Steril 2024; 121:449-450. [PMID: 38163621 DOI: 10.1016/j.fertnstert.2023.12.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Affiliation(s)
| | - Priyanka Jha
- Department of Radiology, Stanford University Medical Center, Stanford, California
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6
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Tan S, Leonardi M, Lo G, Lee E. Role of ultrasonography in the diagnosis of endometriosis in infertile women: Ovarian endometrioma, deep endometriosis, and superficial endometriosis. Best Pract Res Clin Obstet Gynaecol 2024; 92:102450. [PMID: 38096645 DOI: 10.1016/j.bpobgyn.2023.102450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 11/22/2023] [Accepted: 11/24/2023] [Indexed: 02/06/2024]
Abstract
Endometriosis is a complex chronic inflammatory process characterised by the presence of endometrial-like glandular tissue outside the uterine cavity, typically within the pelvic structures. This condition affects up to 10-15 % of women and those assigned female at birth, and can result in chronic pelvic pain and in/subfertility. Treatment goals include medical, surgical options and alternative therapies. Transvaginal ultrasound (TVUS) is the currently recommended first line investigation for endometriosis with magnetic resonance imaging (MRI) reserved for those with equivocal ultrasound findings. In this paper, we aim to outline the commonly seen sonographic appearances of endometriosis divided into anterior, middle and posterior pelvic compartments. Limitations to ultrasound imaging include high operator dependence and patient factors. New imaging techniques and research into the utility of artificial intelligence (AI) into the detection of endometriosis is currently underway, with possibility of reduced diagnostic delay and better patient outcomes.
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Affiliation(s)
- Samantha Tan
- Fiona Stanley Hospital, Murdoch, Western Australia, Australia.
| | - Mathew Leonardi
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada; Robinson Research Institute, University of Adelaide, Adelaide, Australia.
| | - Glen Lo
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Curtin University Medical School, Perth, Western Australia, Australia; Western Ultrasound for Women, Perth, Western Australia, Australia.
| | - Emmeline Lee
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Western Ultrasound for Women, Perth, Western Australia, Australia.
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Signorile PG, Baldi A, Viceconte R, Ronchi A, Montella M. Pathogenesis of Endometriosis: Focus on Adenogenesis-related Factors. In Vivo 2023; 37:1922-1930. [PMID: 37652504 PMCID: PMC10500515 DOI: 10.21873/invivo.13288] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 09/02/2023]
Abstract
Endometriosis can be defined as the presence of the endometrium outside the uterine cavity. It affects approximately 10% of women of reproductive age and causes infertility, chronic pain, and deterioration of the quality of life. Since the identification of the disease, various pathogenetic mechanisms have been proposed, such as retrograde menstruation, coelomic metaplasia, hormonal imbalance, stem cell involvement, and alterations in epigenetic regulation. However, the underlying pathogenesis of endometriosis remains inadequately understood. Elucidation of the precise mechanism of the development and progression of endometriosis is crucial for effective treatment. This review presents the major pathogenetic theories of endometriosis based on current research studies with a major focus on the potential role of uterine factors.
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Affiliation(s)
| | - Alfonso Baldi
- Italian Endometriosis Foundation, Rome, Italy;
- Department of Environmental, Biological and Pharmaceutical Sciences and Technologies, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | | | - Andrea Ronchi
- Pathology Unit, Department of Mental Health and Physic and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marco Montella
- Pathology Unit, Department of Mental Health and Physic and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
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Maciel C, Ferreira H, Djokovic D, Kyaw Tun J, Keckstein J, Rizzo S, Manganaro L. MRI of endometriosis in correlation with the #Enzian classification: applicability and structured report. Insights Imaging 2023; 14:120. [PMID: 37405519 DOI: 10.1186/s13244-023-01466-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/14/2023] [Indexed: 07/06/2023] Open
Abstract
Endometriosis represents one of the most common causes of life-impacting chronic pelvic pain and female infertility. Magnetic resonance imaging (MRI) plays an increasing role in the diagnosis and mapping of endometriosis, while diagnostic laparoscopy currently tends to be reserved for the patients with negative imaging results. The #Enzian, published in 2021, proposes a new comprehensive classification system of endometriosis, combining a complete staging of deep infiltrative endometriosis with the evaluation of peritoneal/ovarian/tubal localizations and the presence of adenomyosis. This article addresses in detail the applicability of the #Enzian classification, primarily based on surgical findings, to the MRI evaluation of the endometriosis. Overall, there is a significant matching between MRI features and the #Enzian classification criteria, two different perspectives of endometriosis mapping, with different goals and levels of detail. The main discrepancy lies in the evaluation of tubo-ovarian condition, which is not fully assessable by MRI. Furthermore, as endometriosis is a complex disease, usually multifocal, that can present with a myriad of imaging findings, MRI reporting should be clear and well organized. The authors group, both radiologists and gynecologists, propose a structured MRI report of endometriosis in correlation with the #Enzian classification, merging the detailed anatomical and pre-operative information provided by the MRI with the benefits of a comprehensive classification system of endometriosis in the clinical practice and research field.Critical relevance statement This article addresses in detail the applicability of the #Enzian classification, primarily based on surgical findings, to the MRI evaluation of the endometriosis and proposes a #Enzian-based structured MRI report.
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Affiliation(s)
- Cristina Maciel
- Serviço de Radiologia, Centro Hospitalar Universitário São João, Porto, Portugal.
- Departamento de Medicina, Faculdade de Medicina, Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Hélder Ferreira
- Serviço de Ginecologia, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, 4099-001, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua de Jorge Viterbo Ferreira, 228, 4050-313, Porto, Portugal
| | - Dusan Djokovic
- Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário Lisboa Central (CHULC), Lisbon, Portugal
- Department of Obstetrics and Gynecology, NOVA Medical School - Faculdade de Ciências Médicas, NOVA University of Lisbon, Lisbon, Portugal
- Department of Obstetrics and Gynecology, Hospital CUF Descobertas, Lisbon, Portugal
| | - Jimmy Kyaw Tun
- Department of Interventional Radiology, The Royal London Hospital, Barts Health NHS Trust, London, E1 1BB, UK
| | - Jörg Keckstein
- Scientific Endometriosis Foundation (Stiftung Endometrioseforschung/SEF), Westerstede, Germany
- Endometriosis Clinic Dres. Keckstein, Villach, Austria
- University of Ulm, Ulm, Germany
| | - Stefania Rizzo
- Service of Radiology, Imaging Institute of Southern Switzerland, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Via G. Buffi 13, 6900, Lugano, Switzerland
| | - Lucia Manganaro
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
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Ichikawa M, Shiraishi T, Okuda N, Nakao K, Shirai Y, Kaseki H, Akira S, Toyoshima M, Kuwabara Y, Suzuki S. Clinical Significance of a Pain Scoring System for Deep Endometriosis by Pelvic Examination: Pain Score. Diagnostics (Basel) 2023; 13:diagnostics13101774. [PMID: 37238258 DOI: 10.3390/diagnostics13101774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/09/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
Endometriosis-associated pain is an essential factor in deciding surgical indications of endometriosis. However, there is no quantitative method to diagnose the intensity of local pain in endometriosis (especially deep endometriosis). This study aims to examine the clinical significance of the pain score, a preoperative diagnostic scoring system for endometriotic pain that can be performed only with pelvic examination, devised for the above purpose. The data from 131 patients from a previous study were included and evaluated using the pain score. This score measures the pain intensity in each of the seven areas of the uterus and its surroundings via a pelvic examination using a numeric rating scale (NRS) which contains 10 points. The maximum value was then defined as the max pain score. This study investigated the relationship between the pain score and clinical symptoms of endometriosis or endometriotic lesions related to deep endometriosis. The preoperative max pain score was 5.93 ± 2.6, which significantly decreased to 3.08 ± 2.0 postoperatively (p = 7.70 × 10-20). Regarding preoperative pain scores for each area, those of the uterine cervix, pouch of Douglas, and left and right uterosacral ligament areas were high (4.52, 4.04, 3.75, and 3.63, respectively). All scores decreased significantly after surgery (2.02, 1.88, 1.75, and 1.75, respectively). The correlations between the max pain score and dysmenorrhea, dyspareunia, perimenstrual dyschezia (pain with defecation), and chronic pelvic pain were 0.329, 0.453, 0.253, and 0.239, respectively, and were strongest with dyspareunia. Regarding the pain score of each area, the combination of the pain score of the pouch of Douglas area and the VAS score of dyspareunia showed the strongest correlation (0.379). The max pain score in the group with deep endometriosis (endometrial nodules) was 7.07 ± 2.4, which was significantly higher than the 4.97 ± 2.3 score obtained in the group without (p = 1.71 × 10-6). The pain score can indicate the intensity of endometriotic pain, especially dyspareunia. A local high value of this score could suggest the presence of deep endometriosis, depicted as endometriotic nodules at that site. Therefore, this method could help develop surgical strategies for deep endometriosis.
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Affiliation(s)
- Masao Ichikawa
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo, Tokyo 113-8602, Japan
| | - Tatunori Shiraishi
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo, Tokyo 113-8602, Japan
| | - Naofumi Okuda
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo, Tokyo 113-8602, Japan
| | - Kimihiko Nakao
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo, Tokyo 113-8602, Japan
| | - Yuka Shirai
- Department of Obstetrics and Gynecology, Nippon Medical School, Chibe Hokuso Hospital, 1715 Kamagari, Inzai 270-1694, Chiba, Japan
| | - Hanako Kaseki
- Department of Obstetrics and Gynecology, Nippon Medical School, Chibe Hokuso Hospital, 1715 Kamagari, Inzai 270-1694, Chiba, Japan
| | - Shigeo Akira
- Meirikai Tokyo Yamato Hospital, 36-3 Honcho Itabashi, Tokyo 173-0001, Japan
| | - Masafumi Toyoshima
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo, Tokyo 113-8602, Japan
| | - Yoshimitu Kuwabara
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo, Tokyo 113-8602, Japan
| | - Shunji Suzuki
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo, Tokyo 113-8602, Japan
- Department of Obstetrics and Gynecology, Nippon Medical School, Musashikosugi Hospital, 1-383 Kosugicho, Nakahara, Kawasaki 211-8533, Kanagawa, Japan
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Kitaya K, Yasuo T. Commonalities and Disparities between Endometriosis and Chronic Endometritis: Therapeutic Potential of Novel Antibiotic Treatment Strategy against Ectopic Endometrium. Int J Mol Sci 2023; 24:ijms24032059. [PMID: 36768381 PMCID: PMC9916512 DOI: 10.3390/ijms24032059] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023] Open
Abstract
Chronic endometritis (CE) is a local mucosal inflammatory disorder of the uterine lining, which is histopathologically recognized as the unusual infiltration of CD138(+) plasmacytes into the endometrial stromal compartment. Accumulating body of research documented that CE is associated with female infertility and several obstetric/neonatal complications. The major cause of CE is thought to be intrauterine infection represented by common bacteria (Escherichia coli, Enterococcus faecalis, Streptococcus, and Staphylococcus), Mycoplasma/Ureaplasma, and Mycobacterium. Additionally, local dysbiosis in the female reproductive tract may be involved in the onset and development of CE. Antibiotic treatments against these microorganisms are effective in the elimination of endometrial stromal plasmacytes in the affected patients. Meanwhile, endometriosis is a common female reproductive tract disease characterized by endometriotic tissues (ectopic endometrium) growing outside the uterus and potentially causes chronic pelvic symptoms (dysmenorrhea, dyspareunia, dyschezia, and dysuria), infertility, and ovarian cancers. Endometriosis involves endocrinological, genetic, and epigenetic factors in its etiology and pathogenesis. Recent studies focus on immunological, inflammatory, and infectious aspects of endometriosis and demonstrate several common characteristics between endometriosis and CE. This review aimed to better understand the immunological and microbial backgrounds underlying endometriosis and CE and look into the therapeutic potential of the novel antibiotic treatment strategy against endometriosis in light of endometrial infectious disease.
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Affiliation(s)
- Kotaro Kitaya
- Infertility Center, Kouseikai Mihara Hospital/Katsura Mihara Clinic, 6-8, Kamikatsura Miyanogo-cho, Nishikyo-ku, Kyoto 615-8227, Japan
- Correspondence: ; Tel.: +81-75-392-3111
| | - Tadahiro Yasuo
- Department of Obstetrics and Gynecology, Otsu City Hospital, Otsu 520-0804, Japan
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