Search Results (255)

Background: Infertility is a common reproductive health disorder that affects roughly 10–15% of couples during their reproductive period. Hysterosalpingography (HSG) is a widely utilized imaging modality for assessing uterine cavity morphology and fallopian tube patency and continues to play a central role in infertility investigations. Nevertheless, the interpretation of HSG findings may vary according to the experience and expertise of the evaluator, potentially leading to inconsistencies in clinical decision-making. Although artificial intelligence (AI) has demonstrated considerable potential in medical image analysis across various specialties, evidence regarding its application in the interpretation of HSG examinations remains scarce. Therefore, this study aimed to evaluate the level of agreement among radiologists, gynecologists, and an AI-based system in the assessment of identical HSG images. Methods: In this retrospective study, a total of 1443 HSG images obtained from 414 women who underwent hysterosalpingography as part of an infertility evaluation between January 2021 and January 2025 were reviewed. Cases with incomplete clinical records or suboptimal image quality were excluded from the analysis. All examinations were independently assessed by an experienced radiologist, a gynecologist specializing in infertility management, and a multimodal artificial intelligence system based on ChatGPT-5, with each evaluator blinded to the assessments of the others and to the patients’ clinical information. Image interpretation included the evaluation of contrast distribution, peritoneal spill, uterine cavity findings, tubal patency, and overall HSG impression, which were categorized according to predefined diagnostic criteria. The primary outcome was the degree of interobserver agreement among the evaluators. Agreement analyses were performed using Cohen’s kappa (κ) and Gwet’s AC1 coefficients. Analyses were conducted using IBM SPSS Statistics (version 30.0; IBM Corp., Armonk, NY, USA) and R statistical software (version 4.4.0; R Foundation for Statistical Computing, Vienna, Austria). Statistical significance was set at p < 0.05 (two-sided). Results: A total of 1443 HSG images obtained from 414 women were included in the final analysis. The mean age of the study population was 30.97 ± 5.59 years, and primary infertility accounted for 87.9% of cases. The average number of images acquired per examination was 3.49 ± 1.05. According to Cohen’s kappa analysis, the highest levels of agreement were observed for the assessment of image artifacts and contrast medium distribution. Agreement between the AI system and the radiologist was particularly strong for contrast medium distribution (κ = 0.757). For the overall interpretation of HSG findings, AI demonstrated substantial agreement with the radiologist (κ = 0.637), exceeding the level of agreement observed between the radiologist and the gynecologist (κ = 0.363). In contrast, concordance involving AI was lower for the evaluation of uterine abnormalities, intrauterine filling defects, and tubal patency. When agreement was reassessed using Gwet’s AC1 statistic, concordance coefficients were consistently higher than the corresponding kappa values across all evaluator pairs. Near-perfect agreement between AI and the radiologist was identified for contrast medium distribution (AC1 = 0.954), peritoneal spill (AC1 = 0.893), and patterns of peritoneal contrast passage (AC1 = 0.841). Procedures performed under local anesthesia yielded a significantly greater number of images than those conducted under general anesthesia (3.86 ± 0.86 vs. 3.08 ± 1.10, p < 0.001). No significant associations were detected between abnormal HSG findings and either infertility type or anesthetic technique. In multivariable analysis, the use of general anesthesia was independently associated with a lower image count, whereas the presence of tubal pathology emerged as an independent predictor of acquiring a greater number of images during the examination. Conclusions: Our findings indicate that AI-assisted interpretation of HSG images has the potential to complement expert assessment, showing substantial concordance in several key diagnostic domains. While the technology appears promising as a decision-support tool in infertility evaluation, further research and refinement are warranted, particularly regarding the assessment of tubal and uterine pathologies. Full article

Ciliary-driven flow refers to the movement of fluid by the rhythmic and coordinated beating cilia and finds applications in the respiratory tract, fallopian tube, embryonic node, brain ventricles, paranasal sinuses, and understanding flows in the auditory tube. Previous research on cilia-driven flow has demonstrated forced convective flow with no-slip boundary conditions, which is crucial in mucus clearance and is not firmly stuck to the periciliary layer. This paper develops the mixed convective flow of Ellis fluid near the periciliary layer with a lubricated surface. The partial slip boundary condition provides reduced friction near the periciliary layer for the Ellis fluid flow. The momentum and energy equations are simplified by the lubrication approach, and the resulting problem is solved analytically. This research achieves the exact solutions for the temperature and velocity profiles for the consistency index 3. The findings show that the mucus flow along the lubricated surface is enhanced by the slip parameter and viscosity (shear-thinning fluid) parameter beta, but the flow across the trachea decays due to the slip and viscosity parameters. The mucus temperature rises due to the radiation and Prandtl number, which also help to reduce the frictional forces near the periciliary layer and facilitate faster mucociliary clearance. Full article

Background: The COVID-19 pandemic substantially disrupted healthcare systems worldwide, raising concerns regarding delays in diagnosis, alterations in treatment pathways, and oncological outcomes for women with advanced ovarian cancer (AOC). This study evaluated the impact of the pandemic on the management and survival of patients with AOC treated at a high-volume ESGO-accredited tertiary gynaecological oncology centre. Methods: A retrospective cohort study was conducted using a prospectively maintained database of consecutive women diagnosed with FIGO stage III–IV epithelial ovarian, fallopian tube or primary peritoneal cancer between January 2017 and December 2022. Patients were divided into pre-pandemic and pandemic cohorts. Demographic characteristics, FIGO stage, treatment pathways, surgical outcomes, and overall survival were compared. Survival was analysed using Kaplan–Meier methodology and multivariable Cox proportional hazards regression was performed to evaluate the independent association between the pandemic period and overall survival after adjustment for age, FIGO stage, ECOG performance status and treatment modality. Results: A total of 700 patients were included, 406 patients treated before the pandemic and 294 during the pandemic. Patients diagnosed during the pandemic had a better ECOG performance status, but 51.3% presented with FIGO stage IV disease. Overall treatment rates were maintained (84.4% vs. 87.4% pre-pandemic), although treatment strategies shifted towards increased use of neoadjuvant chemotherapy (55% vs. 42.4%, p < 001), with a greater proportion of patients subsequently undergoing interval debulking surgery. Complete cytoreduction following interval debulking surgery was preserved throughout the study period, despite more advanced disease at presentation. One-year overall survival was similar between cohorts (69% vs. 72.2% pre-pandemic), whereas three-year overall survival was significantly lower among patients treated during the pandemic (36.1% vs. 45.1%). On multivariable Cox regression analysis, treatment during the pandemic remained independently associated with poorer overall survival after adjustment for clinically relevant baseline factors. Conclusions: Despite unprecedented disruption to healthcare services, specialist gynaecological oncology care has maintained access to multimodality treatment and preserved maximal effort cytoreductive surgery. Nevertheless, patients diagnosed during the pandemic experienced inferior long-term survival independent of baseline disease characteristics and treatment allocation, highlighting the broader indirect consequences of the pandemic on cancer outcomes. These findings emphasise the importance of protecting diagnostic pathways, multidisciplinary cancer services and surgical capacity during future healthcare crises. Full article

Background/Objectives: Given the potential for achieving high concentrations at the target site while limiting systemic exposure, delivering drugs directly to the female reproductive tract (FRT) is emerging as a promising strategy for enhancing women’s reproductive health. However, quantitative data describing matrix-specific solubility, matrix-specific binding, and permeability across FRT tissues remain limited, constraining development of physiologically based pharmacokinetic (PBPK) models for intravaginal and intrauterine therapies. Methods: Our work was conducted to help fill this critical gap, evaluating four model drugs with diverse physicochemical and transporter profiles, dapivirine (DPV), levonorgestrel (LNG), MK-2048, and 4′-ethynyl-2-fluoro-2′-deoxyadenosine (EFdA; also known as islatravir or MK-8591) in in vitro and ex vivo human models. Plasma solubility, matrix-specific binding in plasma, cervicovaginal fluid, and FRT tissues, and bidirectional permeability across FRT tissues were quantified. Results: Our results demonstrated that the plasma solubility varied markedly across compounds, following lipophilicity trends, with DPV (34.14 ± 1.04 µg/mL) and EFdA (1808.02 ± 67.36 µg/mL) exhibiting the lowest and highest solubility, respectively. Hydrophobicity-dependent solubility enhancement by plasma proteins (~2× to >30× higher comparing to aqueous solubility in the literature) was observed for all four model drugs. Apparent binding in plasma, cervicovaginal fluid, and FRT tissues was highly correlated with the model compounds’ lipophilicity, with DPV having the most highly matrix-specific binding (97–99%) and EFdA having the least matrix-specific binding with the greatest variability (15–62%). Regional permeability differed significantly across FRT tissues: the human ectocervix, myometrium, endometrium, and fallopian tubes demonstrated distinct transport patterns consistent with epithelial architecture and the transporter-substrate status of the model compounds. Efflux transporter involvement was evident for MK-2048 and EFdA in Caco-2 models (efflux ratios 2.59 and 7.14, respectively), but was less pronounced in the 3D vaginal model and ex vivo tissues. Across all datasets, permeability and binding were strongly influenced by drug lipophilicity and ionization characteristics. Conclusions: Collectively, these findings demonstrate the interplay among solubility, matrix-specific binding, and tissue permeability in governing local drug distribution within the FRT. The experimentally derived parameters provide quantitative inputs for FRT PBPK model development, and are expected to inform design of safe and effective localized therapies for women’s reproductive health. Full article

Advances in microelectronics have driven the miniaturization of endoscopic systems, leading to increasingly compact devices with enhanced optical and electronic performance. However, the current state-of-the-art commercial endoscopes—typically ranging from several millimeters to over 1 cm in diameter—still face significant limitations when accessing delicate anatomical structures such as the Fallopian tubes, urethra, and other narrow cavities. In this paper, we introduce an ultracompact endoscope based on the use of a CMOS image sensor from ams OSRAM (NanEyeM) and a single micro-LED (LTW-FC03DCD5). We achieved a total diameter of 1.8 mm, compatible with ultra-narrow cavities of the human body. Optically, a minimal correlated color temperature of 10,343 K and a maximal color rendering index of 73.6 were achieved. These values allow for the detection of structures of small dimensions by morphological and vascular contrast. The optical system demonstrated the ability to resolve up to 83 lp/mm, with a diagonal field-of-view of 115.0° ± 2.4°, measured at different working distances, suitable for working distances encountered in narrow anatomical cavities. This work represents a first prototype for direct visual imaging in human organs not previously accessible by endoscopy, assisting healthcare professionals in clinical assessment and supporting the diagnosis of diseases. Full article

Ovarian cancer (OC) is typically treated with cytoreductive surgery (CRS). Hyperspectral imaging (HSI) is an emerging non-invasive, label-free technique that enables whole-area scanning, making it a promising tool for real-time tumour recognition. However, developing tumour recognition algorithms requires a foundational understanding of spectral variability in normal tissues. This study focusses on the in vivo spectral profiles of key abdominal and pelvic organs encountered during CRS, including the uterus, ovaries, intestines, mesentery, omentum, peritoneum, and fallopian tubes, and evaluates the potential for organ recognition using HSI data. Intraoperative HSI data were from healthy patients. Two machine learning models, a support vector machine (SVM) and a 3D convolutional neural network (3DCNN), were trained to classify the organs based on their spectral signatures. In total, 15 patients were included in the dataset. The 3DCNN slightly outperformed the SVM in terms of the average accuracy (0.889 vs. 0.878), sensitivity (0.648 vs. 0.604), specificity (0.936 vs. 0.930), and Dice Similarity Coefficient (0.595 vs. 0.569). This study demonstrates the feasibility of using HSI for organ differentiation in the clinical setting, although in some cases separability remains a challenge, especially when organs have similar spectra. This is a critical step towards a generalizable in vivo abdominal tumour recognition algorithm, by carefully investigating spectral fingerprints of abdominal tissues. Full article

Background/Objectives: Chlamydia trachomatis (CT) is a prevalent sexually transmitted pathogen associated with pelvic inflammatory disease, infertility, and has been proposed as a potential contributor to carcinogenesis through chronic inflammation and tissue remodeling. The molecular mechanisms triggered by CT infection in fallopian tube cellular contexts and their relevance to ovarian cancer transcriptomes remain incompletely understood. Methods: We analyzed GSE109428, profiling primary human fallopian tube mesenchymal cells infected with CT, to identify differentially expressed genes and characterize affected pathways using g:Profiler and STRING protein–protein association networks (confidence ≥ 0.7). To provide translational context, we computed ssGSEA scores in TCGA-OV for four signatures capturing IFN/ISG, TNF/NF-κB, NOD/innate immunity, and ECM programs, and evaluated inter-signature correlations and exploratory associations with overall survival (OS) and progression-free interval (PFI). Results: CT infection induced sustained inflammatory and interferon-associated transcriptional programs, with STRING networks highlighting cytokine hubs and a densely connected ISG module. Genes downregulated at 48 h post-infection (48-hpi) showed coherent enrichment for ECM organization and adhesion pathways. In TCGA-OV (n = 307), inflammatory and innate immune signatures co-occurred across tumors, with moderate correlations between TNF/NF-κB and NOD/innate (ρ = 0.591) and IFN/ISG and NOD/innate (ρ = 0.534). Exploratory survival analyses showed no significant associations with OS or PFI in Kaplan–Meier analyses or multivariable Cox models, including clinically adjusted and tumor microenvironment-adjusted specifications. Conclusions: CT infection induces sustained inflammatory and interferon-linked programs and coordinated repression of ECM networks in fallopian tube mesenchymal cells. Analogous immune transcriptional states co-occur in ovarian tumors, though the signatures evaluated did not yield robust prognostic signals in TCGA-OV. As this is an entirely in silico study without experimental validation, these findings should be treated as hypothesis-generating; thus, further mechanistic and experimental studies are warranted to clarify how CT infection-associated pathways may intersect with female tumorigenesis. Full article

Background: Ectopic pregnancy remains a significant cause of maternal morbidity in early pregnancy. While most ectopic pregnancies happen within the fallopian tube, implantation may rarely occur in atypical locations such as the ovary or abdominal cavity. These rare forms often present with nonspecific clinical findings and may represent a considerable diagnostic challenge. Methods: We report a case series of three rare ectopic pregnancies managed at a tertiary referral center. Two cases involved ovarian pregnancy, and one case represented an exceptionally rare hepatic ectopic pregnancy. Clinical presentation, diagnostic pathway, surgical management, and outcomes were analyzed and compared with available literature. Results: In the first two cases, ovarian pregnancy was confirmed intraoperatively and treated surgically, with ovarian preservation in one patient and adnexectomy in the other due to active bleeding. The third case had an unusual course: initial surgery was performed for hemoperitoneum caused by a ruptured corpus luteum cyst, while persistent β-hCG elevation later led to identification of hepatic ectopic pregnancy, confirmed by imaging and surgery. All patients recovered favorably, with complete β-hCG negativization. Conclusions: Rare ectopic implantation sites may mimic acute abdominal conditions and remain difficult to diagnose preoperatively. High clinical suspicion, serial β-hCG monitoring, and appropriate imaging are essential. Surgical management remains central, particularly in life-threatening bleeding. Standard algorithms for tubal ectopic pregnancy may not be fully applicable and should be adapted to the clinical context. Full article

Background and Objectives: Robotic-assisted tubal reanastomosis (RATR) remains a clinically relevant option for selected women seeking fertility after sterilization. In the era of IVF, surgical reversal continues to be discussed because it may restore the possibility of spontaneous conception rather than offering only cycle-dependent treatment. However, the available evidence on RATR is heterogeneous and derives predominantly from observational studies. The aim of this narrative review with a structured literature search was to synthesize the published evidence on the operative, reproductive, and economic outcomes of RATR and to contextualize its role in contemporary fertility counseling. Materials and Methods: A structured literature search of PubMed/MEDLINE, Scopus, and Google Scholar was performed from database inception to 20 December 2025. Data were synthesized descriptively without meta-analysis. Primary robotic clinical studies were interpreted separately from secondary and contextual publications. Results: In total, 16 studies were included in our study. The evidence base comprised predominantly retrospective cohorts and case series; no randomized controlled trials were identified. Reported tubal patency endpoints in robotic cohorts ranged from 81.0% to 94.1%, although denominators differed across studies and were reported either per patient or per tube. Reported pregnancy outcomes ranged from 25% to 80%, reflecting substantial heterogeneity in patient selection, follow-up duration, and outcome definitions. When woman-level delivery or live-birth outcomes were explicitly reported, they were generally encouraging in selected series, although not uniformly defined. Estimated blood loss was usually minimal when reported, and conversion to laparotomy was uncommon. Any comparison with IVF was indirect because no contemporary head-to-head comparative studies were identified. Economic data were sparse, institution-specific, and methodologically heterogeneous. Conclusions: Available observational evidence suggests that RATR is a feasible minimally invasive option for fertility restoration in carefully selected women after sterilization. However, the evidence base remains limited by retrospective design, small cohorts, heterogeneous outcome reporting, variable follow-up, and indirect comparison with IVF. RATR should be considered within individualized fertility counseling rather than as a universal alternative to IVF. Prospective comparative studies with standardized outcome definitions, transparent reporting of prognostic factors, and robust economic evaluation are needed. Full article

Background/Objectives: With the ongoing efforts in supporting the discovery of novel targeted drug delivery systems for the upper region of the female reproductive tract (FRT), it is imperative to understand the local drug disposition pathways. We aim to obtain a comprehensive profile of the drug transporters and drug-metabolizing enzymes in the human ectocervix, uterus, and fallopian tubes, as these factors may substantially influence mucosal penetration, tissue exposure, drug disposition, and the risk of drug–drug interactions. Methods: Gene expression of 12 drug transporters and 21 drug-metabolizing enzymes was quantified using RT-qPCR. Protein expression of highly expressed transporters was assessed using immunohistochemistry (IHC). Results: Among the 12 transporters analyzed, the efflux transporters P-gp, BCRP, and MRP4 exhibited the highest expression across the ectocervix, endometrium, myometrium, and fallopian tubes, with P-gp consistently showing the greatest abundance in all evaluated FRT tissues. Expression of these transporters was significantly higher (6–17×) in myometrium compared with ectocervix. IHC demonstrated strong localization of P-gp, BCRP, and MRP4 to epithelial layers facing the lumen, as well as to stromal and vascular endothelial cells. For drug-metabolizing enzymes, all 21 phase I and II enzymes were detectable across the FRT, and 15 were expressed at comparatively higher levels across all tissue types. These included CYP1A1, CYP1B1, CYP2B6, CYP2C8, CYP2C19, CYP3A4, UGT1A1, UGT1A3, UGT1A4, UGT1A7, UGT1A8, UGT1A10, UGT2B4, UGT2B15, and UGT2B17. Conclusions: The gene expression and localization data obtained from this work may improve our understanding of drug disposition in the FRT, which will inform selection, design, and optimization of drugs intended for targeted delivery within the FRT. Full article

Ovarian cancer remains the most lethal gynecologic malignancy, with the majority of patients presenting at advanced stages and exhibiting poor long-term survival. High-grade serous carcinoma (HGSC), the predominant subtype, likely originates from fallopian tube epithelial cells (FTECs), whose biology is strongly influenced by hormonal signaling. Progesterone receptor (PR) expression, particularly of the PR-B isoform, is associated with improved prognosis in HGSC; however, the isoform-specific molecular mechanisms in precancerous FTECs remain unclear. This study investigated the distinct biological and transcriptomic effects of PR-A and PR-B in p53- and Rb-defective FE25 FTEC-derived cells. Stable overexpression of PR-A suppressed cell proliferation, enhanced apoptosis, and induced robust senescence, whereas PR-B promoted proliferation and activated JNK/c-Jun signaling. Upon progesterone (P4) treatment, both isoforms mediated cell-cycle arrest and apoptosis, with PR-A exhibiting stronger Sub-G1 induction. PR-A and PR-B differentially regulated cell-cycle inhibitors, senescence markers, and downstream pathways, including the PI3K–Akt and MAPK pathways, while RNA sequencing analyses revealed broader P4-induced transcriptomic changes in PR-B than in PR-A, involving immune, angiogenic, and proliferative programs. Collectively, these findings demonstrate that PR-A and PR-B exert distinct yet complementary regulatory roles in FTEC biology and progesterone responsiveness. The observed PR isoform-dependent effects in FE25 cells should be interpreted as context-specific mechanistic insights rather than direct predictors of clinical prognosis or treatment response. Full article

Background/Objectives: Accurate evaluation of fallopian tube patency is an essential step in infertility assessment. This study investigated the diagnostic capability of saline infusion sonography combined with color Doppler flow (SIS-CF), using laparoscopic chromopertubation as the comparator method. Methods: A prospective diagnostic accuracy study was conducted between January and November 2025 at the Infertility Unit, Chiang Mai University Hospital, Thailand. Women requiring laparoscopic assessment for infertility evaluation or preconception investigation were consecutively enrolled. Each participant underwent SIS-CF immediately before laparoscopic chromopertubation within the same operative session. Primary outcomes included diagnostic indices for tubal patency. Secondary outcomes included procedural duration and perioperative safety. Results: Forty-four women (88 fallopian tubes) were included. SIS-CF demonstrated sensitivity of 89.4% (95% CI 78.1–95.9) and specificity of 95.5% (95% CI 77.2–99.9). Positive and negative predictive values were 98.3% and 75.0%, respectively. Likelihood ratios were 19.65 (positive) and 0.11 (negative), with overall accuracy of 90.9% (95% CI 82.9–95.8). Median procedure duration was 5.7 min for SIS-CF and 3.0 min for laparoscopic chromopertubation. No adverse events were recorded. Conclusions: SIS-CF demonstrated favorable diagnostic characteristics for evaluation of tubal patency. The technique provided functional information regarding tubal status while maintaining a minimally invasive profile. Further investigation is warranted to determine its role within routine infertility workups. Full article

Objective: To compare real-world PFS between BEV and OLA as maintenance therapy for PSROC, with an exploratory evaluation of clinical outcomes after OLA dose reduction. Methods: This retrospective multicenter study included 101 patients with first platinum-sensitive recurrent ovarian, fallopian tube, or primary peritoneal cancer who achieved a response to platinum-based chemotherapy and then received maintenance therapy. Patients were classified into three groups: BEV (n = 34), standard-dose OLA (n = 31), and dose-reduced OLA (n = 36). The primary endpoint was PFS; secondary endpoints were OS and adverse events. Survival outcomes were evaluated using Kaplan–Meier methods and Cox proportional hazards models. Results: In the primary comparison of all OLA-treated patients versus BEV, OLA was associated with longer PFS (HR 0.48, 95% CI 0.29–0.77), with median PFS of 19 months versus 16 months, respectively. OS did not differ significantly between groups (HR 0.60, 95% CI 0.34–1.05). In exploratory subgroup analyses, patients who underwent OLA dose reduction had numerically longer PFS than those who remained on the full dose; however, this comparison is vulnerable to time-dependent and selection biases and should be interpreted cautiously. Grade ≥ 3 hematologic toxicities were more frequent in the OLA groups but were clinically manageable. Conclusions: In real-world practice, OLA was associated with longer PFS than BEV in PSROC. Clinically necessary dose reduction appeared feasible without an obvious loss of benefit, although this finding requires cautious interpretation. Full article

Background: Ectopic pregnancy occurs in about 1–2% of all pregnancies, with 95% implanting in the fallopian tubes. Hepatic implantation is one of the rarest and most dangerous forms of abdominal ectopic pregnancy. Its diagnosis is often delayed because of nonspecific symptoms, and it is also often difficult for routine ultrasound imaging to visualize ectopic pregnancy sites that are not in the pelvis. Since this type of pregnancy carries a risk of severe hemorrhage, early identification is crucial. Case: A 30-year-old woman, gravida 3 para 2, presented with a serum β-hCG of 66,408 mIU/mL, but no intrauterine pregnancy was detected on ultrasound imaging. At an outside facility, a laparoscopy was performed, which also failed to show a pelvic ectopic pregnancy. The patient then received her first dose of methotrexate and was subsequently transferred to a tertiary care center for further evaluation. MRI and liver ultrasound showed a 2.3 cm subcapsular lesion in segment 5 of the liver that was suspicious for a hepatic ectopic pregnancy. However, these imaging studies could not exclude a gestational trophoblastic disease or hepatic neoplasm. A dilation and curettage revealed no trophoblastic tissue. The patient next received two additional doses of methotrexate on hospital days 4 and 7 due to an inadequate decline in interval β-hCG; β-hCG levels declined gradually but steadily over several months until they became undetectable and indicated a successful medical treatment of her hepatic ectopic pregnancy. Conclusions: This case highlights the complex diagnostic and treatment challenges presented by a hepatic ectopic pregnancy. Multimodal imaging, serial monitoring of β-hCG levels, and the engagement of a multidisciplinary team were essential factors in achieving a safe, nonsurgical, and successful resolution of this condition. When a pregnancy of unknown location is suspected, extended imaging studies are critical tools for patient evaluation after initial imaging studies and laparoscopy are inconclusive. Full article