Correlation Between Endometriosis Protocol MRI Findings and Endometriosis Symptoms, Including Infertility

INTRODUCTION: Endometriosis affects 10% of reproductive-aged women and can be associated with chronic pelvic pain (CPP), dysmenorrhea, dyspareunia, dyschezia, dysuria, and infertility. While the gold standard for diagnosis remains laparoscopy, ultrasound and MRI can assist non-surgical diagnosis. MRI is further improved by specific MRI protocols with vaginal and/or rectal gel and standardized reporting, which can aid in diagnosis and surgical planning. OBJECTIVE: This study sought to understand the utility of MRI in preoperative assessment by correlating MRI findings with endometriosis symptoms, including infertility. METHODS: This is a retrospective cohort of patients with surgically confirmed endometriosis and preoperative MRI with standardized reporting from 2021 to 2024. A convenience sample was utilized, and we compared MRI findings, symptoms, operative details, including surgical stage of endometriosis, and infertility. Chi-square and Fisher’s exact determined if there was a relationship between individual symptoms, MRI findings, and infertility. RESULTS: Of 123 patients with preoperative MRI and surgically diagnosed endometriosis, 81 (65.9%) were included for having MRI with both endometriosis protocol (with vaginal and rectal gel) and standardized reporting. Subjects were 34.1±6.8 years old with a BMI of 29.4±6.3. Chronic pelvic pain was the most common symptom (91.4%), while 65.4% had dyspareunia, 50.6% had bowel symptoms, 29.6% had bladder symptoms, and 19.8% experienced infertility. Infertility was more likely with MRI findings of deep infiltrating endometriosis of the bowel (60.0% vs 40.0%, p=0.050). Bowel symptoms (dyschezia and constipation) were more likely to occur with MRI detection of uterine adhesions to the bowel or posterior compartment (p=0.034). Increasing AAGL surgical stage of endometriosis was associated with infertility (stage I = 10.7%, stage II = 17.9%, stage III = 21.4%, stage IV = 50%, p=0.035), but surgical stage did not have a significant correlation to pain symptoms. CONCLUSIONS: Aside from bowel symptoms significantly associated with uterine adhesions to the bowel on MRI, most symptoms of endometriosis do not have significant association with specific MRI findings. Infertility was significantly associated with deep infiltrating bowel endometriosis. Our results confirm prior studies showing endometriosis symptoms do not correlate to MRI findings, even with implementation of specific endometriosis MRI protocols. However, MRI bowel endometriosis and a higher stage of disease are associated with infertility. These infertility findings raise an important question about whether addressing bowel endometriosis with surgical management can improve fertility in women suffering from endometriosis.Table 1Table 2