WERF EPHect Standard Surgical Form (EPHect SSF) Supplemental Appendix I

Surgeon ID: ______Patient ID: ______Date: __ __/__ __/______

DD MM YYYY

I. Menses:LMP:__ __/__ __/______Cycle day: __ __ Currently bleeding? No Yes

DD MM YYYY

II. Current hormonal treatment:NoDo not knowYes

COCP POPDepot progestin

GnRH agonist GnRH antagonistIUCD

 Other ______

Last application: __ __/__ __/______

DD MM YYYY

III. Previous surgical diagnosis of endometriosis:NoDo not knowYes

If Yes:1) Hospital? ______When? __ __/__ __ /______Procedure(s)? ______

DD MM YYYY

2) Hospital? ______When? __ __/__ __/______Procedure(s)? ______

DD MM YYYY

3) Hospital? ______When? __ __/__ __/______Procedure(s)? ______

DD MM YYYY

IV. Imaging prior to surgery:NoYes

UltrasoundDates:__ __/__ __/______

DD MM YYYY

MRIDates: __ __ /__ __ /______

DD MMYYYY

Findings:

Cyst(s) left size:1. __ __cm2. __ __cm3. __ __cm

Cyst(s) right size:1. __ __cm2. __ __cm3. __ __cm Rectovaginal nodule

Bladder nodule

Ureter involvement

Left

Right

Uterine anomalies

Fibroids

Polyps

Adenomyosis

Other: ______

V.Procedures:Total surgical time: ______min.

Uterine cavity surgeryHysteroscopy before laparoscopy:NoYes

Hysteroscopy after laparoscopy:NoYes

Findings: Normal

Abnormal: ______

 Diagnostic Hysteroscopy

Polypectomy

Resection of fibroid

Resection of endometrium

Resection of septum/adhesions

 Other ______

Ovarian surgerySurface:Excision Left Right Both:  Laser Monopolar  Bipolar

Ablation Left Right Both: LaserMonopolarBipolar

Fulguration Left Right Both

Ovariolysis Left Right Both

Temporary suspension Left Right Both

Oophorectomy Left Right Both

Ovarian cystectomy Left Right Both

 Ovarian reconstruction Left Right Both

Cyst aspiration/drainage Left Right Both

Cyst ablation Left Right Both

Tubal surgery Fimbrioplasty Left Right Both

Tuboplasty Left Right Both

Lysis of adhesions (salpingolysis) Left Right Both

Salpingectomy  Left Right Both

Peritoneum surgery Destruction of endometriosis, specify:

Electrosurgery (monopolar)Electrosurgery (bipolar)  Lasertype: ______

Other: ______

 Excision of endometriosis, specify:

 ScissorsHarmonic scalpel Lasertype: ______

Other: ______

Number of specimens: ______Other ______

Peritoneal fluid volume: ______mlPeritoneal Fluid:ClearBloody

Bladder surgeryViscera enteredNoYesSpecify: ______

Ureter surgeryNoYes

LeftRightBoth

Ureterolysis left

Mucosa enteredNoYesSpecify: ______

 Primary repair Segmental resection  Psoas hitch Specify: ______

Ureterolysis right

Mucosa enteredNoYesSpecify: ______

 Primary repair Segmental resection  Psoas hitch Specify: ______

Bowel surgeryNoYes

Mucosa enteredNoYes Specify:______

Nodule removed

 Discectomy

 Bowel resection

 Appendectomy

 Other: ______

Uterine surgeryNoYes

 Hysterectomy

TotalSubtotalLAVH

Other ______

 Myomectomy

Other procedures______

VI. At conclusion of surgery:Residual peritonealendometriosis?NoYesLocation(s)______

Residual adhesions? NoYesLocation(s)______

Residual endometriomas?NoYesLocation(s)______

Residual nodules?NoYesLocation(s)______

VII. Intraoperative complications:NoYes

 Type(s):______

 Treatment(s):______

VIII. Any pathology observed during surgery:NoYesIf no: end of questionnaire

Visual diagnosis of endometriosis:NoYesIf no: go to question XII

Peritoneal

Ovarian

Deeply infiltrative

Perito-neum / Endometriosis / <1cm / 1-3cm / >3cm
superficial / 1 / 2  / 4
deep / 2  / 4  / 6
ovary / Left superficial / 1 / 2  / 4
deep / 4 / 16  / 20 
Right superficial / 1 / 2  / 4
deep / 4 / 16  / 20 
Pouch of Douglasobliteration / Partial / Complete
4  / 40 
ovary / Adhesions / <1/3 enclosure / 1/3 – 2/3 / >2/3 enclosure
Left filmy / 1 / 2 / 4
dense / 4 / 8 / 16 
Right filmy / 1 / 2 / 4
dense / 4 / 8 / 16 
tube / Left filmy / 1 / 2 / 4
dense / 4* / 8* / 16
Right filmy / 1 / 2 / 4
dense / 4* / 8* / 16

Revised American Fertility Society Score

Mark the total area of endometriosis, possibly of multiple lesions, NOT just the largest lesion

Deeply infiltrative endometriosis (DIE)NoYes

Pelvic side wallLeft Right

UreterLeft Right

Posterior Cul-de-sac (Pouch of Douglas)

Rectum

Sigmoid

Bladder

Parametrium

Uterosacral ligament Left Right

Vagina

Other ______

IX.Location of endometriosis, number and appearance of lesions:

LEFT SIDE

Location of Endometriosis / Lesion Size (please circle)
A = <1cm B = 1 – 3 cm C = >3cm / Adhesions (please check)
Vascular / Clear / Yellow / Red / White / Blue/Black / Brown / Filmy / Web / Thin / Dense / Sac Like
Left pelvic sidewall  / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Left utero-sacral ligament / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Left ovary – serosa  / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Left tube – serosa  / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Others ______/ A B C / A B C / A B C / A B C / A B C / A B C / A B C
Others ______/ A B C / A B C / A B C / A B C / A B C / A B C / A B C

RIGHT SIDE

Location of Endometriosis / Lesion Size (please circle)
A = <1cm B = 1 – 3 cm C = >3cm / Adhesions (please check)
Vascular / Clear / Yellow / Red / White / Blue/Black / Brown / Filmy / Web / Thin / Dense / Sac Like
Right pelvic sidewall  / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Right utero-sacral ligament / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Right ovary – serosa  / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Right tube – serosa  / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Others ______/ A B C / A B C / A B C / A B C / A B C / A B C / A B C
Others ______/ A B C / A B C / A B C / A B C / A B C / A B C / A B C

CENTRAL AREA

Location of Endometriosis / Lesion Size (please circle)
A = <1cm B = 1 – 3 cm C = >3cm / Adhesions (please check)
Vascular / Clear / Yellow / Red / White / Blue/Black / Brown / Filmy / Web / Thin / Dense / Sac Like
Uterovesical pouch/
Anterior cul-de-sac  / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Pouch of Douglas/
Posterior cul-de-sac  / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Uterus – serosa  / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Bladder – deep infiltrating / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Bladder – serosa  / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Colon – deep infiltrating  / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Colon – serosa  / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Vagina  / A B C / A B C / A B C / A B C / A B C / A B C / A B C
Others ______/ A B C / A B C / A B C / A B C / A B C / A B C / A B C
Others ______/ A B C / A B C / A B C / A B C / A B C / A B C / A B C

Peritoneal pouches/pocketsNoYes

Location(s): ______

Depth: ______Diameter: ______

DiaphragmNoYes

LeftDescribe: ______

RightDescribe: ______

Biopsy taken:NoYes

Location(s): 1. ______2. ______3. ______

4. ______5. ______6. ______

Control biopsy taken:NoYes

Location(s): 1. ______2. ______3. ______

X. Endometrioma:NoYes

Left size(s):1. __ __cm2. __ __cm3. __ __cm

Right size(s):1. __ __cm2. __ __cm3. __ __cm

 Sent to histology

 Sample collected for research:  Left Right

XI. Endometriotic nodule:Pouch of DouglasNoYes Size* __ __ X __ __ X__ __ cm__ __ X __ __ X__ __ cm

VaginaNoYes Size* __ __ X __ __ X__ __ cm__ __ X __ __ X__ __ cm

BladderNoYes Size* __ __ X __ __ X__ __ cm__ __ X __ __ X__ __ cm

AppendixNoYes Size* __ __ X __ __ X__ __ cm__ __ X __ __ X__ __ cm

Small bowelNoYes Size* __ __ X __ __ X__ __ cm__ __ X __ __ X__ __ cm

Sigmoid colonNoYes Size* __ __ X __ __ X__ __ cm__ __ X __ __ X__ __ cm

RectumNoYes Size* __ __ X __ __ X__ __ cm__ __ X __ __ X__ __ cm

 Location:______

Full thickness:NoYesNoYes

Distance from anus (bowel nodule):______cm______cm

* Clinical estimate

XII. Additional findings:

Fibroids (Myoma)NoYes

SubmucousNumber ______ Size* __ __ cm __ __ cm

 Size* __ __ cm __ __ cm

IntramuralNumber ______ Size* __ __ cm __ __ cm

 Size* __ __ cm __ __ cm

SubserousNumber ______ Size* __ __ cm __ __ cm

 Size* __ __ cm __ __ cm

* Clinical estimate

Adhesions (w/o evidence of endometriosis)NoYesLocation(s)______

 Filmy

 Dense

 Co-apted

 Obstruction

Congenital anomalyNoYes If yes, type(s) ______

Non-endometriotic ovarian cystNoYes If yes, side:LeftSuspected type ______

RightSuspected type ______

Any other findings ______

Procedure was:more complex/difficult than expected

as complex/difficult as expected

less complicated/difficult than expected

XIII. Endometriosis Fertility Index (EFI):

© World Endometriosis Research Foundation | Version 3.0 | December 2014 / Page 1 of 6