Ms. A, a 34-year-old nulligravida, presented to the gynecology clinic with a chief complaint of severe pelvic pain and difficulty conceiving for the past two years. The pain was cyclical, worsening during menstruation, and associated with dyspareunia. A pelvic MRI revealed deep infiltrating endometriosis and the presence of the "cloverleaf sign."

Discussion

Endometriosis is a chronic disease affecting around 10% of reproductive-age women and is defined by the presence of endometrial tissue outside the uterine cavity, causing severe pelvic pain and infertility. Deep infiltrating endometriosis is defined as subperitoneal invasion that exceeds 5 mm in depth. The diagnosis of endometriosis was based on laparoscopy and biopsy for decades, but nowadays, MRI allows non-invasive and accurate staging of DIE [1].

The cloverleaf sign in deep infiltrating endometriosis is a recently described MRI sign that is highly suggestive of a more complex surgery, a greater risk of bowel resection, and blood loss. It is detectable on T2W sequences in sagittal, coronal, and axial planes. The cloverleaf is formed by at least three organs brought closer by constrictive adhesions and detectable T2-weighted hypointense deep infiltrating endometriosis. Therefore, its presence should call for better preoperative planning [2].