Association between kissing and retropositioned ovaries and severity of endometriosis: MR imaging evaluation

  • Jamie C. Williams
  • Tatnai L. Burnett
  • Tiffanny Jones
  • Sudhakar K. Venkatesh
  • Wendaline M. VanBurenEmail author
Special Section: Endometriosis



To retrospectively investigate the relationship between ovarian positioning on pre-operative MR imaging and intra-operative staging of endometriosis.

Materials and methods

Sixty-five women with suspected endometriosis who underwent pre-operative MRI and subsequent intra-operative staging of endometriosis formed the study group. A trained senior radiology resident and a board-certified staff radiologist experienced in endometriosis reviewed MR images for ovarian positioning and the presence of an endometrioma. The position of the ovaries was classified as (a) kissing when they were posterior to the uterus and in contact, (b) retropositioned when they were posterior to the uterus but not in contact, or (c) normal. Intra-operative staging of endometriosis (stage 0 to IV) was determined using the revised American Society for Reproductive Medicine classification system (rASRM) by a surgeon with expertise in endometriosis surgery. Correlation between ovarian positioning and endometriosis stage was evaluated with a logistical regression analysis. Sensitivity, specificity, and accuracy were calculated.


MR images revealed kissing ovaries in 12 women, retropositioned ovaries in 17 women, and normally positioned ovaries in 36 women. At surgery, endometriosis stages 0, I, II, III, and IV were found in 13, 15, 6, 9, and 22 patients, respectively. The odds of stage IV endometriosis were eight times higher given kissing or retropositioned compared to normal ovaries, regardless of the presence of an endometrioma (p =0.01). Kissing and retropositioned ovaries had an accuracy of 82% for stage IV endometriosis, with 86% sensitivity and 79% specificity. All cases with kissing ovaries had stage III/IV endometriosis.


Kissing and retropositioned ovaries on pre-operative MR images are associated with higher intra-operative rASRM stages of endometriosis.


Endometriosis Kissing ovaries MRI Endometriosis staging deep endometriosis 



The authors acknowledge the assistance of Desiree Lanzino, PhD, and Sonia Watson, PhD, in editing and submission of the manuscript.


Internal departmental funding was utilized without commercial sponsorship or support.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The institutional review board approval was obtained with waiver of written consent for this retrospective review.


  1. 1.
    Giudice LC, Kao LC (2004) Endometriosis. Lancet 364:1789-1799. CrossRefPubMedGoogle Scholar
  2. 2.
    Bulun SE (2009) Endometriosis. N Engl J Med 360:268-279. CrossRefPubMedGoogle Scholar
  3. 3.
    Coutinho A, Jr., Bittencourt LK, Pires CE, Junqueira F, Lima CM, Coutinho E, Domingues MA, Domingues RC, Marchiori E (2011) MR imaging in deep pelvic endometriosis: a pictorial essay. Radiographics 31:549-567. CrossRefPubMedGoogle Scholar
  4. 4.
    Woodward PJ, Sohaey R, Mezzetti TP, Jr. (2001) Endometriosis: radiologic-pathologic correlation. Radiographics 21:193-216; questionnaire 288-194.
  5. 5.
    Johnson NP, Hummelshoj L, Adamson GD, Keckstein J, Taylor HS, Abrao MS, Bush D, Kiesel L, Tamimi R, Sharpe-Timms KL, Rombauts L, Giudice LC, for the World Endometriosis Society Sao Paulo C (2017) World Endometriosis Society consensus on the classification of endometriosis. Hum Reprod 32:315-324. CrossRefGoogle Scholar
  6. 6.
    Revised American Society for Reproductive Medicine classification of endometriosis: 1996 (1997). Fertil Steril 67:817-821Google Scholar
  7. 7.
    Practice bulletin no. 114: management of endometriosis (2010). Obstet Gynecol 116:223-236. CrossRefGoogle Scholar
  8. 8.
    Hottat N, Larrousse C, Anaf V, Noel JC, Matos C, Absil J, Metens T (2009) Endometriosis: contribution of 3.0-T pelvic MR imaging in preoperative assessment--initial results. Radiology 253:126-134. CrossRefPubMedGoogle Scholar
  9. 9.
    Bazot M, Darai E, Hourani R, Thomassin I, Cortez A, Uzan S, Buy JN (2004) Deep pelvic endometriosis: MR imaging for diagnosis and prediction of extension of disease. Radiology 232:379-389. CrossRefPubMedGoogle Scholar
  10. 10.
    Saksouk FA, Johnson SC (2004) Recognition of the ovaries and ovarian origin of pelvic masses with CT. Radiographics 24 Suppl 1:S133-146. CrossRefPubMedGoogle Scholar
  11. 11.
    Ghezzi F, Raio L, Cromi A, Duwe DG, Beretta P, Buttarelli M, Mueller MD (2005) “Kissing ovaries”: a sonographic sign of moderate to severe endometriosis. Fertil Steril 83:143-147. CrossRefPubMedGoogle Scholar
  12. 12.
    Lebovic DI, Mueller MD, Taylor RN (2001) Immunobiology of endometriosis. Fertil Steril 75:1-10CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Jamie C. Williams
    • 1
  • Tatnai L. Burnett
    • 2
  • Tiffanny Jones
    • 2
  • Sudhakar K. Venkatesh
    • 1
  • Wendaline M. VanBuren
    • 1
    Email author
  1. 1.Department of RadiologyMayo Clinic, School of MedicineRochesterUSA
  2. 2.Department of Obstetrics and GynecologyMayo Clinic, School of MedicineRochesterUSA

Personalised recommendations