Contrast-enhanced sonography
the therapeutic role of oil soluble contrast media at hysterosalpingography:
a surprising result? Fertil. Steril., 61, 470477.
Jeffrey M.Goldberg1, Tommaso Falcone and Marjan Attaran
Department of Gynecology,
The Cleveland Clinic Foundation,
9500 Euclid Avenue, Cleveland, Ohio, USA
1To whom correspondence should be addressed
Previous abortions and risk of pelvic endometriosis
Dear sir,
Epidemiological studies have suggested that reproductive
history is associated with the risk of pelvic endometriosis
(Houston, 1984; Cramer et al., 1986; Parazzini et al.,
1989, 1995; Sangi-Haghpeykar and Poindexter, 1995) and
adenomyosis (Parazzini et al., 1997). Nulliparous women
were at increased risk of endometriosis in case-control
studies conducted in Italy and the US (Cramer et al., 1986;
Parazzini et al., 1989, 1995). Less clear, however, is the
relationship between a history of spontaneous and induced
abortion and the risk of endometriosis.
To re-analyse the association between spontaneous and
induced abortion and the risk of pelvic endometriosis and
reduce the potential difference in selective mechanisms
between cases with the disease and the comparison group,
we considered women with and without endometriosis who
underwent laparoscopy for infertility or pelvic pain in a
network of hospitals co-operating in the Gruppo Italiano
per lo Studio dellEndometriosi.
Women with primary or secondary infertility or pelvic
pain requiring laparoscopy were eligible for the study, and
were consecutively observed between September 1995 and
January 1996 in 15 obstetric and gynaecology departments
in Italy. Women with a previous diagnosis of endometriosis
were specifically excluded.
A total of 817 women were included in the study. Of
these, 393 women (median age 32 years, range 1843) were
included for infertility (an active effort at pregnancy for 2
years or more) and 424 women with a median age of 31
years (range 1853) for cyclic or acyclic pelvic pain lasting
Table I. Distribution and odds ratio (OR) of cases of endometriosis and controls, according to indications for surgery and a history of spontaneous and
induced abortions (Italy 19951996)
Pelvic pain
Endometriosis No endometriosis
(n) (n)
Spontaneous abortions
0 204 181
1 6 33
Induced abortions
0 197 172
1 13 42
aMultivariate estimate including terms for age, parity, centre
bReference category for the computation of odds ratio.
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6 months or more and with severity of 5 or more, on a
10-point linear analogue scale in which 0 indicates the
absence of pain and 10 unbearable pain. Out of the 424
women included for pelvic pain and the 393 included for
infertility, 210 (49.5%) and 135 (34.4%) respectively, had
a diagnosis of endometriosis.
For women with infertility, the median age in women
with endometriosis was 31 years (range 1841) and 32
years (range 2143) in women without endometriosis. For
women with pelvic pain, the corresponding ages were 30
years (1852) and 31 years (1953). Education was unrelated
to the frequency of endometriosis the mean number of years
of schooling was 13 (range 522) and 13 (224) respectively
in women with or without endometriosis.
Using women who had reported no spontaneous abortions
as comparison group, the estimated odds ratio (OR) of
endometriosis was 0.3 [95% confidence interval (CI) 0.2
0.7] in those who reported at least one miscarriage (Table
I). Likewise, using as comparison group women reporting
no induced abortions, the OR of endometriosis was 0.3
(95% CI 0.20.7) in women who had undergone one or
more induced abortions. This finding was consistent in both
the indications for laparoscopy.
In this study we included women with and without endo-
metriosis undergoing laparoscopy with a specific indication of
pelvic pain or infertility. Thus the results cannot be generalized
across the whole population. This selected control group
may be a cause of bias. Otherwise, in consideration of the
impossibility in population-based studies of obtaining controls
who had undergone a specific work-up (i.e. laparoscopy or
laparotomy) to exclude endometriosis, the design of this
analysis may offer the opportunity of identifying a comparison
group with a documented lack of endometriosis.
The observation of a reduced risk of endometriosis in
women reporting a history of induced abortion can probably
be explained by the higher fertility of women reporting induced
abortions. This suggests that infertility, more than pregnancy
itself, may be associated with a risk of the disease. In addition,
we found no relationship between a history of miscarriage and
the risk of endometriosis, suggesting that endometriosis is not
associated with spontaneous abortion.
Infertility OR (95% confidence interval)
Endometriosis No endometriosis Totala Pelvic pain Infertility
(n) (n)
126 218 1b 1b 1b
9 40 0.3 (0.20.5) 0.2 (0.10.5) 0.4 (0.20.8)
132 240 1b 1b 1b
3 18 0.3 (0.20.7) 0.3 (0.20.7) 0.3 (0.11.0)
plus, in turn, the above listed variables and indications for surgery when indicated.
3283
 Letters to the Editor

References
Cramer, D.W., Wilson, E., Stillman, R.J. et al. (1986) The relation of
endometriosis to menstrual characteristics, smoking, and exercise. J. Am.
Med. Assoc., 255, 19041908.
Erratum
Houston, D.E. (1984) Evidence for the risk of pelvic endometriosis by age, The effects of antioxidant supplementation during Percoll
race and socioeconomic status. Epidemiol. Rev., 6, 167191. preparation on human sperm DNA integrity
Parazzini, F., La Vecchia, C., Franceschi, S. et al. (1989) Risk factors for
endometrioid, mucinous and serous benign ovarian cysts. Int. J. Epidemiol.,
18, 108112. by Ciara M.Hughes, Sheena E.M.Lewis,
Parazzini, F., Ferraroni, M., Fedele, L. et al. (1995) Pelvic endometriosis: Valerie J.McKelvey-Martin and W.Thompson
reproductive and menstrual risk factors at different stages in Lombardy,
Northern Italy. J. Epidemiol. Comm. Health, 49, 6164.
Parazzini, F., Vercellini, P., Panazza, S. et al. (1995) Risk factors for
Hum. Reprod., 13, 12401247, 1998
adenomyosis. Hum. Reprod., 12, 12751279.
Sangi-Haghpeykar, H. and Poindexter III, A.N. (1995) Epidemiology of The following acknowledgements were omitted from the
endometriosis among parous women. Obstet. Gynecol., 85, 983992. above publication.

Gruppo Italiano per lo Studio dellEndometriosi*

Acknowledgement
*Co-ordination and data analysis The study was supported by Wellcome Trust Project Grant No:
1
Fabio Parazzini , Elisabetta Di Cintio, Liliane Chatenoud, 049993/Z/97/Z. The skilful technical assistance of Mrs M.Kennedy
Carmela Mezzanotte, Pier Giorgio Crosignani is also gratefully acknowledged.
Istituto di Ricerche Farmacologiche Mario Negri and Prima
Clinica Ostetrico Ginecologica, Universita di Milano
1To whom correspondence should be addressed
The following clinicians are the co-authors of this letter to
the editor:
Benevento (Italo Ardovino, Elisario Struzziero); Bologna
(Ettore Zanardi, Daniele Pungetti); Cagliari (Valerio Mais,
Silvio Ajossa); Catania (Giovanni Mignemi, Luciano Di
Leo); Ferrara (Albino Bianchi, Carlo Campobasso); Firenze
2nd Clinic (Gian Franco Scarselli) Firenzi 1st Clinic
(Gianluca Bracco); Milano M.Melloni (Piero Capetta,
Carlo Bertullessi); Milano Mangiagalli (Simona Moroni,
Patrizia Mazza, Paolo Vercellini); Parma (Alfio Bacchi
Modena); Roma (Alessandro Casa); Torino Mauriziano
(Marco Massobrio, Cristina Ansaldi); Torino S.Laigi (Gian
Franco Trossarelli); Treviso (Maria Teresa Gervasi, Vittorio
Marsoni); Trieste (Secondo Guaschino, Luigi-Troiano,
Giuseppe Ricci); Varese (Paolo Beretta, Massimo Franchi)

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