Are there any clinical signs and symptoms that are related to endometriosis in infertile women? Roberto Matorras, MD, PhD," Fernando Rodriguez, MD,"Jose Ignaeio Pijoan, MD, b Enrique Soto, MD, b Carlos P6rez, MD," Olga Ram6n, MD," and Francisco Rodriguez-Eseudero, MD, PhD a Baracaldo, Vizcaya, Spain OBJECTIVE: Our purpose was to assess the physical signs and clinical symptoms associated with endometriosis in infertile women. STUDY DESIGN: This case-control study was carried out in an academic tertiary hospital. There were 174 infertile women with endometriosis and 174 infertile women without endometriosis, all of them studied by laparoscopy. Before laparoscopy a standard interview and a standard physical examination were performed. RESULTS: Cul-de-sac nodularity was more frequent in infertile women with endometriosis than in infertile women without endometriosis (6.3% vs 0%). Although uterosacral tenderness was also more frequent in infertile women with endometriosis (7.5% vs 1.7%), uterosacral tenderness without nodularity was similar in both populations. Uterine retroversion and cul-de-sac obstruction frequencies were somewhat higher in the endometriosis group (p < 0.10). The remaining signs and symptoms analyzed, including pelvic pain and dysmenorrhea, were similarily frequent in both populations. Symptoms were similarily frequent in all American Fertility Society stages, although adnexal mass was higher in stage IV. CONCLUSION: Uterosacral nodularity was pathognomonic of endometriosis in infertile women. Uterosacral nodularity and uterosacral tenderness (associated with uterosacral nodularity) were the only symptoms or signs of value to indicate endometriosis in infertile patients. The remaining clinical signs, as well as the clinical symptoms, were of no value in diagnosing endometriosis in infertile women. (AM J OBsTET GYNECOL1996;174:620-3.) Key words: Endometriosis, infertility, symptoms, signs, dysmenorrhea, uterosacral nodularity, American Fertility Society stages There are a number of well-known clinical signs and symptoms that are presumed to be associated with en- dometriosis, such as dysmenorrhea, pelvic pain, dys- pareunia, retroverted uterus, nodular uterosacral liga- ments, and adnexal mass) -~ However, although epide- miologic studies clearly differentiate among the populations analyzed (infertile patients, patients under- going laparoscopy because of pelvic pain or tubal steril- ization, patients having abdominal or vaginal surgery), clinical studies usually either refer to endometriosis as a whole or lack adequate controls. Thus the true relation of the aforementioned symptoms with endometriosis associ- ated with infertility has not been tested. The purpose of this study is to investigate the utility of clinical signs that From the Department of Obstetrics and Gynecology a and the Clinical Epidemiology Unit,b Hospital of Cruces and Pals Vaseo University. Received for publication December 15, 1994; revised June 12, 1995; acceptedJune 21, 1995. Reprint requests: Roberto Matorras, MD, PhD, Maria Diaz de Haro 7, 6, 48013 Bilbao, Spain. Copyright © 1996 by Mosby-Year Book, Inc. 0002-9378/96 $5.00+ 0 6/1/67299 could lead us to suspect endometriosis in infertile women. Material and methods We studied 602 infertile women consecutively sub- jected to diagnostic laparoscopy at the Hospital of Cruces-Baracaldo (Vizcaya, Spain). All of them had a history of infertility >2 years and were prospectively sub- jected to a standard interview and a standard physical examination before the laparoscopy. Thus it was not known whether each patient was an endometriosis case or a control case. The following symptoms and physical signs were investigated at the first visit: dysmenorrhea, dys- pareunia, painful defecation, pelvic pain and hematuria, painful cervical mobilization, retroverted uterus, uterine lateralization, uterine fixation, limited uterine motility, painful ovarian palpation, uterosacral nodularity or pain, obstruction of Douglas pouch, and adnexal mass. In cases with normal results of pelvic examination, hysterosalpingography, and pelvic ultrasonography, lap- aroscopy was performed after failure to achieve preg- nancy in six ovarian stimulation cycles, whereas it was 620