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Objective  Uterine hyperperistalsis and dysperistalsis are common phenomena in endometriosis and may be responsible for reduced fertility in cases of minimal or mild extent of disease. Since a high prevalence of adenomyosis uteri has been well documented in association with endometriosis, we designed a study to examine whether hyperperistalsis and dysperistalsis are caused by the endometriosis itself or by the adenomyotic component of the disease. Design  A prospective observational study. Setting  University hospital, Department of Obstetrics and Gynaecology, Division of Reproductive Medicine and Gynaecologic Endocrinology with 300 in vitro fertilisation/intracytoplasmatic sperm injection cycles and 350 intrauterine insemination cycles/year. Population  Forty‐one subjects with infertility and with laparoscopically proven endometriosis and patent fallopian tubes. Thirty‐five subjects (85%) additionally showed signs of adenomyosis. Methods  All subjects underwent T2‐weighed magnetic resonance imaging (MRI) and hysterosalpingoscintigraphy (HSSG) during the subsequent menstrual cycle. MRI revealed the extent of the adenomyotic component of the disease and the integrity of uterotubal transport capacity was evaluated by HSSG. Main outcome measures  Influence of adenomyosis on uterotubal transport capacity in endometriosis. Results  In 35 of the 41 subjects (85%) with endometriosis, signs of adenomyosis were detected using T2‐weighed MRI. Two of six (33%) subjects with no adenomyosis (group I) showed dysperistalsis and hyperperistalsis, compared with 14 of 24 (58%) women with focal adenomyosis (group II) and 10 of 11 (91%) women with diffuse adenomyosis (seven showed a failure in transport capacity and two contralateral transport). Conclusions  Our data suggest that endometriosis is associated with impeded hyperperistaltic and dysperistaltic uterotubal transport capacity. However, adenomyosis is of even more importance, especially when diffuse adenomyosis is detected. Both forms of adenomyosis are commonly found in subjects with mild to moderate endometriosis. We suggest that the extent of the adenomyotic component in subjects with endometriosis explains much of the reduced fertility in subjects with intact tubo‐ovarian anatomy.

Detection of disseminated tumor cells (DTCs) in bone marrow is an independent prognostic factor in primary breast cancer. Here, we conducted a proof-of-principle study to evaluate whether this tumor cell spread occurs already in patients with ductal carcinoma in situ (DCIS). After preoperative screening by stereotactic core biopsy, 30 consecutive women with DCIS were included. Bone marrow aspirates, taken at the time of primary surgery, were subjected to DTC detection by a standardized immunoassay using the established monoclonal anti-cytokeratin antibodies A45-B/B3 and AE1/AE3. DTCs were detected in 4 of 19 cases of pure DCIS (21.1%) and in four of seven cases of DCIS with microinvasion (57.1%). After a median follow-up time of 22 months, two initially DTC-positive patients suffered from contralateral carcinoma and contralateral DCIS at months 12 and 30, respectively, whereas the remaining patients were relapse free. Thus, hematogenous tumor cell dissemination into bone marrow is an early event in breast cancer development.Breast cancer is the most common malignant disease in women. According to a meta-analysis including 4,703 Stage I-III breast cancer patients, the detection of disseminated tumor cells (DTCs) in bone marrow is associated with poor prognosis.1,2 Interestingly, DTC detection is seen in small primary carcinomas and is not only a predictor for metastatic relapse in bone and other organs but also for local relapse, 2 supporting recent experimental data that breast tumor cells may recirculate from bone marrow back to the primary site where they might contribute to local relapse and even primary tumor growth.3 Thus, bone marrow might be a reservoir for breast tumor cells in which they may survive for an extended period of time. 4,5 Thus far, the time point of the onset of breast tumor cell spread is unclear. A DCIS is a nonobligate precursor of invasive breast cancer. However, 1-2% of all primary DCIS patients present positive axillary lymph node metastases. 6 Indeed, classification of DCIS is based on histopathological criteria and on the growth dimensions. 7,8 Remarkably, DCIS patients may relapse with invasive breast cancer, whereas patients with large, high-grade DCIS with necrosis are at higher risk of developing recurrence. Furthermore, DCIS patients with poorly differentiated histological types are associated with higher rates of distant metastases and death within a long follow-up period. 9 The rate of metastases increases after invasive local recurrence.10 Free surgical margins and postoperative radiotherapy are the most important and significant prognostic factors for local disease control, 11 but none of them can reliably predict the risk of invasive recurrence. 12,13 Material and MethodsOur proof-of-principle investigation focused on the search for DTC in bone marrow aspirates from 30 patients who were treated with the suspicion of DCIS at the Goethe-University hospital and the Diakonie Medical Center, Frankfurt, Germany. Written informed consent was provided by all patients, and the stud...

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The uterus is composed of different smooth muscle layers that serve various functions. First, menstrual debris is expulsed at the time of the menses. Second, sperm is transported in the preovulatory phase to maximize fertility, and third, the human embryo is placed in an adequate setting during implantation. Endometriosis is a gynecologic disorder leading to severe pain symptoms such as severe pain during menstruation (dysmenorrhea), chronic pelvic pain, pain during sexual intercourse (dyspareunia), and abnormal uterine bleeding. Besides, endometriosis is often associated with female infertility and exhibits a massive impairment in the physiology of uterine contractility that can be documented by the in vivo examination method of hysterosalpingoscintigraphy (HSSG). In addition, endometriosis is associated in 80-90% of subjects with adenomyosis and our data clearly indicate that sperm transport is disturbed by hyperperistalsis when at least one focus of adenomyosis can be detected via magnetic resonance imaging (MRI) and turns into dysperistalsis (a complete failure in sperm transport capacity) when diffuse adenomyosis affecting all myometrial uterine muscle layers is detected. Hence, dysperistalsis is significantly associated with reduced spontaneous pregnancy rates. We therefore recommend MRI and HSSG in every sterility workup.

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