This letter is in response to the letter by M. Leonardi and G. Condous who in response to our article [1], highlighted the vital role of ultrasound in the assessment of endometriosis and “kissing ovaries”. The points addressed by the authors are valid and noteworthy, however, several portions of the discussion require further clarification. In particular, ultrasound when performed with a dedicated protocol such as those suggested in this edition [2, 3] and a skilled operator may achieve excellent results. Routine pelvic ultrasound which is not targeted for endometriosis may underperform when compared to MRI for disease detection [4] for a variety of reasons, but certainly non-dedicated protocols, operator/interpreter inexperience and limited field of view may contribute.

While “kissing ovaries” themselves are a surgical descriptor of characteristic morphologic changes related to endometriosis, until this configuration is identifiable via other modalities it remains a presumption. Both our paper and your letter reference the study which validates this configuration on ultrasound [5]. While not surprising, our study goes on to validate this characteristic positioning at MRI, however, also shows that ovarian positioning has increased disease severity independent of the presence or absence of an endometrioma and shows an increased risk of deep infiltrative endometriosis.

Our paper highlights the increased disease severity of endometriosis seen in association with “kissing ovaries” and should prompt a thorough search pattern to optimize future possible operative management.