Endometriosis is a chronic gynecological condition in
which, endometrial tissue is found outside the uterine
cavity. It is a relatively common disorder among women
of reproductive-age and is associated with marked pain
and morbidity (
Endometriosis is considered one of the main underlying
causes of the development of adhesions unrelated to
a previous operation (
Local inflammation associated with endometriosis is
viewed as an important element in the formation of adhesions.
Adhesions may form as a result of endometrial
implants bleeding into the surrounding area and causing
an inflammatory reaction which leads to the formation of
a band between two organs. Adhesions correlated with
endometriosis have different types (i.e. thin, filmy and
transparent or thick, dense, and opaque). In severe cases,
adhesions found within the pelvis, could cause a fatal condition
called “frozen” pelvis (
There are many complications associated with endometriosis-
related adhesions such as dyspareunia, and rectal
constriction which leads to constipation. Also, in this sense,
adhesions correlated with endometriosis, are responsible for
infertility, chronic pelvic pain, and bowel obstruction (
Women with pelvic adhesions should be informed about
the risk associated with endometriosis-related adhesions
and instructed how to deal effectively with this condition
The study aimed to identify the impact of endometriosis- related adhesions on quality of life among infertile women.
The present descriptive study was conducted to identify the impact of adhesions associated with endometriosis on quality of life among infertile women. The study was performed at Endoscopic Unit, in Zagazig University Hospitals in Egypt. This research was conducted after getting permission from the director of Faculty of Nursing-Zagazig University and director of Endoscopy Unit.
These cases were chosen from more than 756 cases
from December 2016 to March 2018. Among 756 cases,
only 109 women were candidates for laparoscopy due
to infertility issues and were diagnosed with endometriosis.
According to the revised American Society for
Reproductive Medicine (r-ASRM) classification of endometriosis
i. Existence of adhesions due to other reasons such as pelvic inflammatory disease (PID) or myoma or adenomyosis, ii. Existence of chronic pelvic pain that defined as pelvic pain which is constant or cyclical in nature for 6 months or more, iii. Women with previous surgery in the abdomen or pelvis (cesarean section or appendectomy), and iv. Women with autoimmune and/or allergic disease.
Oral consent was taken from women who desired to participate in this research. All procedures involving human participants were in accordance with the ethical standards of the institutional and/or national research committee as well as the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Zagazig University-Faculty of Nursing Ethical Committee with the ethical code ZU.NUR/25/22-8-2016.
After revising the laparoscopic report details for recruited women (n=109), participants were grouped into group I (n=41) with subjects who had endometriosis with adhesions and group II (n=68) with subjects who had endometriosis without adhesions.
The tool used for data collection in this research was a structured interview form which was designed by the researchers in order to gather the following data: demographic characteristics as; age (years), body mass index (BMI) (Kg/m2), educational level and occupational status. Also, using this tool, the following variables were recorded: duration of the marriage (years), menarche age (years), contraception type and family history of endometriosis.
Adhesions detected during laparoscopy were divided regarding the locality into adenxal adhesion, anterior abdominal wall adhesion, vesico-uterine adhesion, uterus to abdominal wall adhesion, and frozen pelvis.
Adhesions were classified in terms of severity by grading
using adhesion scoring method of the American Fertility
Society (AFS) (
Validated language version of the Global Quality of
Life Scale (GQOL) was used to measure the quality of
life for women with adhesions related to endometriosis.
The Global Quality of Life Scale is a single scale that directly
evaluates the quality of life by patients themselves
by using a scale between 0 (='no quality of life') and 100
(='perfect quality of life'). Also, in this scale, each patient
was asked to describe her life quality by writing a number
between 0 and 100 (
Data were gathered and outcome measures were coded,
entered into and analyzed by Microsoft Excel program.
Statistical analysis was done with IBM SPSS Statistics V.
20 (SPSS Inc., Chicago, IL, USA). According to the type
of data, qualitative data were presented as number and
percentage, continues quantitative data were represented
as mean ± SD; also, the following tests were utilized to
test differences between groups; difference and association
of qualitative variables were tested by Chi-square test
(X2) and differences between quantitative independent
groups were assessed by t test. A P<0.05 was regarded as
statistically significant. Also, cases who received a score
=40 in global quality of life scale were considered the
cases whose quality of life was affected and cases with
a score = 45 in global quality of life scale, were considered
the cases whose quality of life was not affected. We
considered in our study score 40 or less to be impacted
on quality of life, according to classification suggested by
Hyland and Sodergren (
Demographic characteristics of women with and without endometriosis-related adhesions
|Variables||Group I(cases with endometriosis-related adhesions) (n =41)n (%) or (mean ± SD)||Group II (cases without endometriosis- related adhesions) (n=68)n (%) or (mean ± SD)||T test||P value|
|Age (Y)||32.1 ± 5.6||31.7 ± 5.8||0.34||0.7|
|Menarche age (Y)||12.2 ± 1.4||12.6 ± 1.3||1.2||0.1|
|Duration of marriage (Y)||5.8 ± 1.5||5.6 ± 1.7||0.48||0.5|
|BMI (Kg/m2)||30.2 ± 4.5||29.5 ± 4.8||0.737||0.4|
|Elementary education||12 (29.3)||19 (27.9)||0.18||0.9|
|Secondary education||12 (29.3)||18 (26.5)|
|College education or above||17 (41.4)||31 (45.6)|
|Worked||10 (24.4)||16 (23.5)||0.01||0.9|
|Not worked||31 (75.6)||52 (76.5)|
|Family history of endometriosis|
|No||12 (29.3)||21 (30.9)||0.03||0.8|
|Yes||29 (70.7)||47 (69.1)|
|None||31 (75.6)||40 (58.8)||3.8||0.1|
|Oral||6 (14.6)||21 (30.9)|
|IUD||4 (9.8)||7 (10.3)|
BMI; Body mass index, IUD; Intrauterine device, T test; Independent samples t test, MCP; P value based on Mont Carlo exact probability, and X2; Chi-square test.
In this study, 109 cases with endometriosis were enrolled at the time of laparoscopy. Among them, 41 participants were found to have adhesions with endometriosis and 68 cases had no adhesions with endometriosis; thus, the prevalence of endometriosis-related adhesions was 37.6%.
The mean and the standard deviation (mean ± SD) of age, BMI, menarche age and duration of marriage of the women with and without endometriosis-related adhesions are presented in Table 1.There was no statistically significant difference in the afore-mentioned factors between the women with adhesions and the women without adhesions (P=0.7, 0.4, 0.1 and 0.5, respectively).
Also, based on data shown in Table 1, we found no correlations between the two groups regarding educational level, occupational status, family history of endometriosis and contraceptive type (P=0.9, 0.9, 0.8 and 0.1, respectively).
Table 2 reveals that the greater part of the studied women (51.2%) had adnexal adhesion followed by anterior abdominal wall adhesion 10 (24.4%) and vesico-uterine adhesion 5 (12.2%). Few patients (2.4%) had frozen pelvis. Concerning the severity of adhesions resulted from endometriosis, Table 2 indicates that almost all of the participated women had a moderate degree of severity 19 (46.3%) and only nine cases (22.0%) showed a severe degree of adhesions.
Locations and grading of pelvic adhesions (n=41)
|Locations of adhesion|
|Adnexal adhesion||21 (51.2)|
|Anterior abdominal wall adhesion||10 (24.4)|
|Vesico-uterine adhesion||5 (12.2)|
|Uterus to abdominal wall adhesion||4 (9.8)|
|Frozen pelvis||1 (2.4)|
|Grading of the pelvic adhesion|
Based on Table 3, it was found that the quality of life was significantly impacted by adhesions (P=0.002). Chi-square test (X2) showed a significant association between impacted quality of life and adhesions that were resulted from endometriosis as 34.1% of cases with adhesions had a negatively influenced life while only 10.3% of cases without adhesions reported a negatively impacted quality of life.
Association between adhesions related to endometriosis and quality of life (n=109)
|Variable||Group I(cases with adhesions related to endometriosis) (n=41)||Group II (cases without adhesions related to endometriosis) (n=68)||X2||P value|
|Quality of life|
|Not impacted||27 (65.9)||61 (89.7)||9.3||0.002*|
|Impacted||14 (34.1)||7 (10.3)|
Data are presented as n (%). X2; Chi-square test, MCData P; P value based on Mont Carlo exact probability, and *; P<0.05 (significant).
Endometriosis is a condition in which a multiple interplay
between the shed endometrial tissue, the peritoneal
environment, and the peritoneal lining occurs. When
the peritoneum cannot remove the endometrial tissue in
time, these tissues will have the chance to adhere to the
peritoneal lining which finally leads to this disease (
Adhesions and endometriosis are connected together because endometriosis is an adhesiogenic disease. The nature of recurrence of endometriosis means that repeated surgical operations are usually performed, which in turn increase the chance of adhesion formation. So, the current research was performed to understand the impact of adhesions with endometriosis on the women’s quality of life.
The prevalence of adhesion among women with endometriosis
in the current study, was 37.6%. While, the
study conducted by Parker et al. (
Concerning the demographic characteristics of patients, the two groups with and without adhesions were similar in age, occupational status, level of education and body mass index. Thus, these variables did not influence the frequency of adhesions in each group, nor the risk factors analyzed in the current study.
On the other hand, our study did not include any women
with an extremely high BMI; mean and the standard deviation
(mean ± SD) of BMI were 30.2 ± 4.5 in patients
with adhesions associated with endometriosis and 29.5 ±
4.8 in the group of women without adhesions. The above-
mentioned results were coinciding with those reported by
Stocker et al. (
The majority of studies to date, have reported that early
menarche (<11 years) increases the danger of endometriosis,
but our results did not find any significant difference
between the age of menarche and endome-triosis and the
formation of adhesion. Peterson et al. (
Use of contraception, as oral contraceptive pills (OCPs)
and intrauterine contraceptive device (IUD), is also known
to affect menstrual flow. If retrograde menstruation is involved
in induction of endometriosis, usage of IUD (a
common reason of menorrhagia) would be expected to
increase the risk of the disease. Hughes et al. (
Adnexal area, anterior abdominal wall, bladder and
uterus were the most common locations of adhesions in
our research. These findings are different from several
reports showing that adhesions are more often found in
the omentum (
In the current study, concerning the associations between
endometriosis-related adhesions and quality of life,
the results showed that the quality of life is significantly
impacted by adhesions. In our study, it was noticed that all
the cases with a severe degree of adhesions presented with
poor quality of life. This finding was consistent with previous
This research had some limitations such as a decrease in the number of participants and samples' readiness in participating. Pain was not discussed in the present study, although it might affect the quality of life as we focused on the adhesions in cases of endometriosis. No long-term follow-up was done in this research as many of patients did not return to the hospitals after doing the procedure of laparoscopy.
Based on the findings of the present study, it can be concluded that the prevalence of adhesions associated with endometriosis was 37.6%. Also, an association between adhesions related to endometriosis and quality of life among infertile women was found. Further researches might be conducted to study the same problems in larger populations of the women with long-term follow-up.