\r\n\tAn update on clinical manifestations, their assessment, monitoring, and imagiology, including peripheral arthritis, enthesopathy, and extra-articular findings, and, the differential diagnosis with other diseases which evolves with axial and peripheral calcifications will be provided.
\r\n
\r\n\t \r\n\tAn important component of this book must be dedicated to the more recent treatments namely with biologic therapies but focusing also on new small molecule inhibitors and experimental therapies.
",isbn:"978-1-80356-267-4",printIsbn:"978-1-80356-266-7",pdfIsbn:"978-1-80356-268-1",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,hash:"d13ec1a1832b3d86803555ea2d5f9759",bookSignature:"Dr. Serdar Küçük",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11455.jpg",keywords:"Robot Manipulator, Serial Manipulator, Parallel Manipulator, Hybrid Manipulator, Kinematics, Dynamics, Simulation Tool, Structural Design, Robotic Technology, Robotic Structure, Optimization, Control",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 10th 2022",dateEndSecondStepPublish:"April 14th 2022",dateEndThirdStepPublish:"June 13th 2022",dateEndFourthStepPublish:"September 1st 2022",dateEndFifthStepPublish:"October 31st 2022",remainingDaysToSecondStep:"a month",secondStepPassed:!0,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Dr. Serdar Küçük does research in kinematics and dynamics of serial and parallel robotic manipulators, as well as in the design of electrically controlled, above-knee prosthetics and hand–wrist rehabilitation robots, surgical robots, and biomedical robotic devices.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"5424",title:"Dr.",name:"Serdar",middleName:null,surname:"Küçük",slug:"serdar-kucuk",fullName:"Serdar Küçük",profilePictureURL:"https://mts.intechopen.com/storage/users/5424/images/system/5424.jpeg",biography:"Serdar Küçük received a BA and MSc from Marmara University, Istanbul, Turkey, in 1995 and 1998, respectively. He received a Ph.D. from Kocaeli University, Turkey, in 2004, where he is currently a full professor at the Department of Biomedical Engineering. He has several scientific publications to his credit, including international conference papers, journal papers, books, and book chapters. He serves as a reviewer for several well-known robotic journals. He is also an editor of scientific books. His research interests include optimization, control, and kinematics and dynamics modelling of serial and parallel robotic manipulators. 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From chapter submission and review to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"18358",title:"Laparoscopy for Diagnosis and Treatment of Endometriosis",doi:"10.5772/16733",slug:"laparoscopy-for-diagnosis-and-treatment-of-endometriosis",body:'\n\t\t
\n\t\t\t
1. Introduction
\n\t\t\t
Endometriosis is defined as the presence of endometrial like stroma and glands outside the uterine cavity (Giudice and Kao, 2004). Laparoscopy has been recognized as the gold standard for endometriosis diagnosis and has been used for the surgical treatment of endometriosis. Diagnosis of endometriosis is currently made following laparoscopic inspection of the pelvis, preferably with histological biopsy confirmation (Mettler et al., 2003), although the correlation of biopsy with visual inspection depends on the experience of the endoscopist, inter-observer variability, the technique of excision and the care and experience of the pathologist (Poncelet and Ducarme, 2007). In one recent study, only 67% of lesions identified at laparoscopy as possible endometriosis proved to have the histological features of endometriosis (Stratton et al., 2003). Moreover, visual inspection of the pelvis also has its own limitations, particularly for the diagnosis of atypical and non-peritoneal endometriosis.
\n\t\t\t
Endometriotic lesions can vary in colour, mostly non-black, red, white or like burned powder. In clinical observation the age of a lesion can be estimated from the colour of these lesions. It appears that clear papules are limited to a younger age group (17-31 years), than the red (16-43 years) and black (20-52 years) lesions (Redwine, 1987).
\n\t\t\t
Many studies have clearly shown that there is a substantial delay in endometriosis diagnosis which inevitably has negative effect on quality of life of endometriosis patients (Matsuzaki et al., 2006, Hadfield et al., 1996, Zrubek et al., 1999, Ballard et al., 2006, Stratton, 2006). Ballard et al. demonstrate that the definitive diagnosis of endometriosis is frequently delayed for many years (2006). In a series of patients from southeastern England the mean delay from onset of symptoms to definitive diagnosis was 102 months (9.5 years). Delays usually occurred at every stage in the diagnostic process. An average patient waited for 18 months before been seen by a family doctor. The general practitioner subsequently waited 3 years before referring the patient for a specialized opinion by a gynaecologist, and it takes a further 9 months before the diagnosis is made. This delay is even longer in cases with deep infiltrating endometriosis and advanced endometriosis stage IV (Matsuzaki et al., 2006).
\n\t\t\t
The review by Wykes, C. B showed that there are very few good quality studies in the literature regarding the role of laparoscopy in the diagnosis of endometriosis (Wykes et al., 2004). A negative laparoscopy for endometriosis is helpful and women can be adequately reassured without the need for further testing, while a positive laparoscopy is less informative without histological confirmation. A false positive laparoscopy can hugely affect the woman’s quality of life, perception of her own health, fertility and even sexual life.
\n\t\t\t
The aim of surgical management is to remove visible areas of endometriosis and restore anatomy by division of adhesions. Yet, treatment frequently must be individualized. However, distinguishing patients who need no treatment from patients who need intermediate or extensive treatment can be difficult. There are three recognized types of endometriosis:peritoneal endometriosis, ovarian endometriomas and deep adenomyotic nodules of the rectovaginal septum (Nisolle and Donnez, 1997).
\n\t\t\t
Few principles have to be considered regarding the surgical management of endometriosis:
\n\t\t\t
Severe disease must be treated differently from mild to moderate disease.
Patients with pain symptoms associated with endometriosis must be approached differently from patients seeking fertility.
Clinicians and patients should be aware that the expected benefit is depending on operator skills (Vercellini et al., 2009).
\n\t\t\t
Jansen and Russell have shown that peritoneum which looks completely normal does not contain histological features of endometriosis, therefore excision of all abnormally looking peritoneum, deep nodules and ovarian lesions should remove the disease (1986). Yet a downside of this approach is the risk for future adhesion formation.
\n\t\t
\n\t\t
\n\t\t\t
2. Background
\n\t\t\t
Endometriosis is a common and frequently chronic disease, characterized by the presence of endometrial like-glands and stroma outside the uterine cavity. Endometriosis is still an enigmatic disease as it is still represent itself as a big challenge for patients to coup with the disease and for medical professionals dealing with this category of patients. The challenge is primarily in the diagnostic process of endometriosis as it’s clinical features may cross with the clinical features of other conditions such as adenomyosis, interstitial cystitis and irritable bowel syndrome. Another problem with endometriosis diagnosis is the general normalization of pain symptoms by. Moreover, there yet no diagnostic tool with significantly enough specificity and sensitivity for the diagnosis. may be difficult to diagnose, yet may cause considerable distress with pelvic pain and infertility. However, some women will be completely asymptomatic although, having severe stage of the disease incidentally found during laparoscopy for other reasons. Laparoscopy with or without histological confirmation is the gold standard for endometriosis diagnosis. However, there is often a considerable delay in diagnosis of endometriosis, partly because there is no simple tool for effective diagnosis. For many decades, surgical removal of endometriotic lesions was the primary basis for the management of endometriosis and radical removal of ectopic lesions is still the preferred way for most surgeons when dealing with endometriosis (Redwine et al., 2000). However, there is no correlation between findings at laparoscopy and symptoms and prognosis in terms of fertility and recurrence rate (Vercellini et al., 2006). It seems to be that the patient’s own preference and plans for her fertility are becoming more important in controlling the management plans (Vercellini et al., 2003).
\n\t\t\t
Medical treatment for endometriosis is mainly for pain symptoms, while medical treatment for infertility purposes has no benefit or may even delay pregnancy, ‘more harm than good can be done by drug treatment, because of side effects and the lost opportunity to conceive’ (RCOG, 2000). It seems to be that a combined medical and conservative surgical approach is beneficial for most women with endometriosis associated pelvic pain (Davis and McMillan, 2003). Moreover, evidence showed that laparoscopic surgery in terms of excision and or ablation of mild to moderate disease can in fact enhance fertility (Marcoux et al., 1997, Olive and Pritts, 2002). However, an Italian RCT showed that ablation of endometriotic lesions did not markedly improves fertility rates (Parazzini, 1999).
\n\t\t
\n\t\t
\n\t\t\t
3. Anatomy of the anterior abdominal wall related to laparoscopic surgery for endometriosis
\n\t\t\t
Any surgeon intending to perform laparoscopic surgery for endometriosis must have a complete understanding and a thorough knowledge of the anterior abdominal wall vascular anatomy. This knowledge will reduce vascular complications associated with laparoscopy especially trocar placement. Of particular concern are the superior and inferior epigastric vessels. The superior epigastric artery, one of the terminal branches of the internal thoracic artery, enters the rectus sheath first and then the rectus muscle coursing near its lateral border. This artery and its adjacent vein often can be visualized by transillumination of the abdominal wall with the laparoscope.
\n\t\t\t
Visualization of the ventral abdominal wall laparoscopically will often locate the deep inferior epigastric vessels. The artery, a branch of the external iliac, and its accompanying vein course along the abdominal wall peritoneum just lateral to the rectus muscle until midway between the symphysis pubis and umbilicus, where it blends into the body of the rectus muscle. These vessels may be seen medial to the insertion of the round ligament at the deep inguinal ring. Therefore, placement of the trocar lateral to the deep inguinal ring and lateral border of the rectus muscle will avoid injury to these vessels.
\n\t\t\t
If placement of the trocar is too far laterally, branches of the superficial circumflex iliac vessels may be injured. Again, transillumination of the anterior abdominal wall by using the laparoscope will assist in avoiding these vessels.
\n\t\t\t
As a general guideline, the superficial and inferior epigastric vessels are located approximately 5.5 cm from the midline. The superficial circumflex iliac vessels are approximately 7 cm from the midline. Theoretically, a “safe area” would be 8 cm above the symphysis pubis and 8 cm from the midline. If transillumination is not effective due to a thick abdominal wall, the surgeon may consider insertion of a spinal needle through the abdominal wall at the selected trocar insertion site. If no bleeding is observed after removal of the needle, the location is likely safe for trocar placement.
\n\t\t
\n\t\t
\n\t\t\t
4. Delay in diagnosis of endometriosis
\n\t\t\t
Many studies have clearly shown that there is a substantial delay in endometriosis diagnosis which inevitably has negative effect on quality of life of endometriosis patients (Matsuzaki et al., 2006, Hadfield et al., 1996, Zrubek et al., 1999, Ballard et al., 2006, Stratton, 2006). Ballard et al. demonstrate that the definitive diagnosis of endometriosis is frequently delayed for many years (2006). In a series of patients from southeastern England the mean delay from onset of symptoms to definitive diagnosis was 102 months (9.5 years). Delays usually occurred at every stage in the diagnostic process. An average patient waited for 18 months before been seen by a family doctor. The general practitioner subsequently waited 3 years before referring the patient for a specialized opinion by a gynaecologist, and it takes a further 9 months before the diagnosis is made. This delay is even longer in cases with deep infiltrating endometriosis and advanced endometriosis stage IV (Matsuzaki et al., 2006).
\n\t\t\t
The fundamental question about such delays is whether they matter. The work of Ballard et al. suggests that they do. The absence of a specific diagnosis left patients fearful of what was wrong with them and unable to communicate about their problems to others, particularly their employers. Learning of the correct diagnosis was associated with positive experiences in terms of reassurance about the absence of more sinister problems and in improving access to social support and accurately tailored treatment.
\n\t\t\t
An open, mutually understanding relationship between doctor and patient is necessary if the diagnosis is to be made without undue delay (Kennedy, 1991) thus improving the chances of getting better results in treatment and compliance.
\n\t\t
\n\t\t
\n\t\t\t
5. Laparoscopy as the gold standard for the diagnosis of endometriosis
\n\t\t\t
\n\t\t\t\t
5.1. Laparoscopy as gold standard
\n\t\t\t\t
Laparoscopy (figure 2) in endometriosis is based on the visualization of superficial implants, endometriomas, adhesion distribution, bowel disease and ureteric disease. In doubtful cases, biopsies showing glands and stroma have been the basis of the diagnosis. Endometriotic lesions can vary in colour, mostly non-black, red, white or like burned powder. In clinical observation the age of a lesion can be estimated from the colour. It appears that clear papules are limited to a younger age group (17-31 years), than the red (16-43 years) and black (20-52 years) lesions (Redwine, 1987).
\n\t\t\t\t
Figure 1.
Laparosocpy
\n\t\t\t\t
In some cases asymptomatic women endometrial implants have been found in biopsies from normal peritoneum, resulting in the suggestion that mild endometriosis is not a disease and that all women have this mild form of endometriosis (Koninckx, 1994, Evers, 1994).
\n\t\t\t\t
In the years 1994–1996 378,100 women with pelvic/abdominal pain underwent ambulatory diagnostic laparoscopy for pelvic pain. This figure excluded women undergoing laparoscopy as an in-patient procedure and represents 34% of the 1.1 million diagnostic laparoscopies performed in the U.S. during that period (Natuzzi et al., 1993).
\n\t\t\t\t
One-third of all diagnostic laparoscopies revealed endometriosis, one-third revealed no visible pathology, and the remaining one-third demonstrated a variety of other gynecologic conditions (Howard, 1993). Thus, two-thirds of all patients who undergo this invasive diagnostic procedure will not have endometriosis. To avoid false negative endometriotic lesion biopsy a multiple biopsy approach was proposed (Kazanegra et al., 2008).
\n\t\t\t\t
The review by Wykes, C. B showed that there are very few good quality studies in the literature regarding the role of laparoscopy in the diagnosis of endometriosis (Wykes et al., 2004). A negative laparoscopy for endometriosis is helpful and women can be adequately reassured without the need for further testing, while a positive laparoscopy is less informative without histological confirmation (Wykes et al., 2004). A false positive laparoscopy can hugely affect the woman’s quality of life, perception of her own health, fertility and even sexual life. Recently other diagnostic tools been proposed for the diagnosis of endometriosis such as blood markers and most recently an endometrial biopsy looking for nerve fibres in the functional layers been proposed (Al-Jefout et al., 2007, Al-Jefout et al., 2009), however, more studies are needed for further confirmation.
\n\t\t\t
\n\t\t\t
\n\t\t\t\t
5.2. Risks of laparoscopy
\n\t\t\t\t
As an invasive surgical procedure, laparoscopy still carries occasional risks of injuring vessels, ureter or intestine. An estimated risk of death of 0.1/1000 mainly due to vascular injuries and the risk of injury to bowel, bladder, or blood vessel of 2.4%, of whom two-thirds will require a laparotomy and this concern is still a significant contributor to the delay in diagnosis (Hadfield et al., 1996, Arruda et al., 2003, Brosens et al., 2003, Ballard et al., 2006, Schenken, 2006).
\n\t\t\t
\n\t\t\t
\n\t\t\t\t
5.3. Laparoscopic conscious pain mapping
\n\t\t\t\t
Laparoscopic conscious pain mapping was first described when it was used for laparoscopic evaluation of the appendix(Almeida et al., 1998). Pelvic pain mapping during laparoscopy performed under conscious sedation can provide useful information about visceral and somatic sources of chronic pelvic pain (Steege, 1998). Conscious laparoscopic pain mapping has been proposed as a way to improve information derived from laparoscopic evaluations in gynaecology even in an office set up (Howard, 2000, Almeida and Val-Gallas, 1998, Howard, 2003). Conscious pain mapping can be done with reasonable success in women with prior surgical evaluations and treatments for chronic pelvic pain. Chronic visceral pain syndrome, adhesions, and endometriosis were the most common diagnoses (Howard et al., 2000) Although, long term results needs to be verified in larger scale studies(Tytherleigh et al., 2004).
\n\t\t\t
\n\t\t\t
\n\t\t\t\t
5.4. Transvaginal hydrolaparoscopy (THL)
\n\t\t\t\t
In order to avoid the risks accompanied with laparoscopy a new diagnostic procedure trans-vaginal hydro-laparoscopy (Figure 2) has been proposed as an office based procedure (Gordts et al., 2000, Campo et al., 1999). Because it is done under local anaesthetic; the risks of general anaesthesia are avoided. The use of saline for visualization gives surgeons more sensitivity for identifying adhesions (Brosens et al., 1999). Use of this technology resulted in a 50% increase in finding peri-ovarian adhesions in comparison with conventional laparoscopy. THL also gives the surgeons and the patients more options in planning future treatment plans.
\n\t\t\t\t
Figure 2.
Hydrolaparosocpy
\n\t\t\t
\n\t\t
\n\t\t
\n\t\t\t
6. Laparoscopy for the staging of endometriosis
\n\t\t\t
\n\t\t\t\t
6.1. Historical background of endometriosis classification
\n\t\t\t\t
Wicks and Larson proposed the first classification of endometriosis (1949) which was based on pathological and histological examination of the endometriotic lesions. The next step was a proposed system based on macroscopic evidence of the disease (Huffman, 1951). However, this staging system did not include adhesions. The next staging system included the adhesions and for the first time guidelines were proposed to determine which patients should be treated medically and which ones surgically (Riva et al., 1962). Beecham suggested a new classification which recorded the medical data of patients(1966). It was not until 1973 that the first acceptable classification appeared and was known as the Acosta classification (Acosta et al., 1973). It was the first classification to take into account the size of the lesions, scarring and fibrosis around the implants, as well as all adhesions. However, this system did not clarifys if the lesions were uni- or bilateral and did not provide any prognosis about recurrence.
\n\t\t\t
\n\t\t\t
\n\t\t\t\t
6.2. The perfect classification, is there such a thing?
\n\t\t\t\t
Endometriosis is one of the most studied diseases in gynaecology, yet the mechanisms underlying the development of endometriosis are not understood. Nor is there understanding of the relationship between the clinical picture in terms of infertility and pain symptoms with the extent of the disease. Despite numerous clinical studies and intensive research, there are still no convincing answers to these questions and probably will not be for many years to come. The perfect classification should give clinicians the ability to correctly anticipate the prognosis for conception, relief of pelvic pain and the risk of recurrence. A perfect classification should also use common medical terminology, which clinicians from all over the world can interpret in the same way.
\n\t\t\t
\n\t\t
\n\t\t
\n\t\t\t
7. The reivised american society of reproductive medicine (rASRM) previously (rAFS)
\n\t\t\t
The American fertility Society proposed a new classification which was at that time simple and the most informative (1979). Now a widely used classification of endometriosis (renamed as the revised American Society for Reproductive Medicine (rASRM) (Figure 1)includes number, size and location of endometrial implants, endometriomas and if present adhesions. It is based
\n\t\t\t
on the appearance, size, and depth of peritoneal and ovarian implants;
on the presence, extent and type of lesions: red (red, red-pink, and clear), white (white, yellow-brown, and peritoneal defects) and black (black and blue);
on the presence, extent, and type of adnexal adhesions and the degree of cul-de-sac obliteration.
\n\t\t\t
This helped to establish the stage of the disease as Stage I( minimal disease), Stage II ( Mild disease), Stage III ( Moderate disease) and Stage IV (Severe disease.
\n\t\t\t
In a following meeting of the AFS this classification was revised after some comments from many experts and now it is widely for in the diagnosisof endometriosis (1985).
\n\t\t\t
Figure 3.
Revised classification of endometriosis according to American Society for Reproductive Medicine.
\n\t\t\t
\n\t\t\t\t
7.1. Advantages of rASRM
\n\t\t\t\t
The rASRM requires thorough description of the lesions and their extent, so in order to complete the classification form clinicians need to be thorough in their inspection of the abdominal cavity, thus enabling them to decrease false positive results at laparoscopies. Finally, this system can be used electronically to analyse the data later on
\n\t\t\t
\n\t\t\t
\n\t\t\t\t
7.2. Disadvantages of rASRM
\n\t\t\t\t
The American Fertility Society classification does not reflect the intensity of endometriosis-associated symptoms, probably underestimating the most active forms of this disease, and does not facilitate tracking the likely natural progression of the disease (Marana et al., 1991).
\n\t\t\t\t
\n\t\t\t\t\t
7.2.1. The ENZIAN-Score
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German Authors tried to substitute the rASRM by the ENZIAN-Score which was proposed as a new system to stage and classify deep infiltrating endometriosis. The endometriotic nodules are assigned to different subgroups depending on their localization and expansion. The authors of this system claimed that the still used r ASRM (rAFS)-score is of no clinical significance especially in patients with severe intestinal endometriosis (Tuttlies et al., 2005).
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7.3. Peritoneal endometriosis surgical management
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7.3.1. Minimal or mild disease
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The severity of pain symptoms in minimal disease are found not to be correlated with findings at laparoscopy (Chene et al., 2008). Surgical approaches like resection of peritoneal endometriosis; or monopolar electrocoagulation/ablation may be used. In the early stages, surgical treatment seems to reduce pain symptoms as effective as by drug therapy (Boing and Kimmig, 2007, Golfier and Sabra, 2007, Frishman and Salak, 2006). In the resection technique the peritoneum is incised near the lesion using a monopolar electrode and is dissected bluntly, separating healthy tissue from endometriotic tissue. Resection seems to be more efficient than diathermy coagulation, yet, it is more difficult, increases the time of the operation, and the cost (Martin and O\'Conner, 2003). Monopolar electrocoagulation is done by applying a monopolar electrode to the visible endometriotic lesion. Extra care must be taken when treating the lateral pelvic side wall to avoid thermal damage to the ureter. To minimize this thermal effect, the peritoneum on the pelvic side wall could be opened and dissected to allow visualization of the ureter. Alternatively, ‘hydroprotection’ can be used. This involves injection of 0.9% saline under the diseased peritoneum, which elevates the peritoneum, allowing safe vaporization or diathermy.
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For peritoneal endometriotic implants, a power setting of 40–50 W (laser CO2) is usually used using a continuous firing mode (Donnez et al., 2004). To date, only one double-blind, RCT has been reported that examined the effect of laparoscopic treatment of endometriosis on pain (Sutton et al., 1994). This study has shown that laser excision of endometriosis significantly improves pain symptoms.However, this study has been criticized because the investigators performed semaltenously laparoscopic uterine nerve ablation and laser excision of the endometriosis and hence we cannot know which treatment has resulted in the pain relief. Sutton et al (1997) in a follow up study reported that 90% of responders had a pain relief for 1 year after laser excision, while 29% of patients had progressive disease and the same percentage (29%) had spontaneous regression. Finally, pain symptoms reported to be improved with the use of Helica TC (thermal coagulator) in women with stages I and II endometriosis. However, this approach requires further evaluation as part of randomized controlled trials (Nardo et al., 2005).
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Laparoscopic uterine nerve ablation (LUNA) and presacral neurectomy were also suggested as a treatment of pain symptoms. LUNA was found beneficial for dysmenorrhoea not associated with endometriosis (Johnson et al., 2004), while presacral neurectomy was found to reduce pain symptoms in endometriosis without significant side effects (Garcia Leon et al., 2003, Zullo et al., 2004).
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7.3.2. Ovarian endometriomas
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Surgical laparoscopic management of ovarian endometriomas can involve stripping of the cyst lining or laser vaporization of the internal wall of the cyst. If laser used, the depth of this vaporization may be superficial and only the glandular epithelium and the adjacent stroma have to be vaporized (Brosens et al., 1996).
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Operative laparoscopy should be the first choice for management of ovarian endometrioma whenever possible (Ruhlmann et al., 1996) and seems to be effective in alleviating pain associated with ovarian endometriomas (Yoshida et al., 2002). Medical therapy alone has not generally been effective in reducing endometrioma size and formed adhesions (Donnez and Nisolle, 1991).
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7.3.3. Deep infiltrating endometriosis (DIE)
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Deep endometriosis has been defined as endometriosis infiltrating deeper than 5 mm under the peritoneum (Koninckx and Martin, 1994). Unfortunately, the current classification of endometriosis is unsuccessful in predicting the major clinical outcomes, including pain symptoms (Vercellini et al., 2006).
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In a retrospective study on 225 women with pelvic pain symptoms and DIE the anatomic locations of DIE implants and specific pain symptoms were recorded (including severe dysmenorrhoea, deep dyspareunia, non-cyclical chronic pelvic pain, painful defecation during menstruation, urinary tract symptoms, and gastrointestinal symptoms)(Fauconnier et al., 2002). There was an association between the frequency of severe dysmenorrhoea and DIE in the Douglas pouch adhesions, between the frequency of dyspareunia and DIE of uterosacral ligaments. The frequency of non-cyclical chronic pelvic pain was higher when it involved the bowel. The frequency of painful defecation during menstruation was higher when DIE involved the vagina; lower urinary tract symptoms were more frequent when DIE involved the bladder. The authors concluded that the types of pelvic pain can be broadly related to the anatomic location of DIE. Although, this study was retrospective, yet it gave good evidence of the correlation between locations of DIE and pain symptoms. Deep lesions need to be excised rather than vaporized (Koninckx and Martin, 1994). Coagulation, bipolar electrosurgery, argon laser, Potassium-Titanyl-Phosphate, (KTP) laser are also inadequate for management of lesions larger than 2 mm.
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Operative laparoscopy in terms of complete excision of the disease is efficient for the treatment of painful symptoms related to deep endometriosis infiltrating uterosacral ligaments (Chopin et al., 2005). The segments of the rectum involved in the disease must be freed, leaving the deep endometriotic nodule attached to the posterior wall of the vagina. Resection of the whole lesion requires the posterior wall of the vagina to be resected and the vagina is usually opened (Chapron et al., 2001), whereas ureterolysis is often unnecessary.
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Because laparoscopic excision of deep bowel lesions has been associated with a residual of pelvic pain, laparotomy may sometimes be needed. Moreover, a new combined vaginal-laparoscopic-abdominal approach was compared with laparoscopy, laparotomy and laparoscopy followed by laparotomy for bowel resection or laparoscopy followed by vaginal bowel resection for rectovaginal endometriosis. The new approach allows intra-operative digital bowel palpation to assess bowel infiltration and reduce unnecessary bowel resections and found to minimize complication rate, re-hospitalization rate, and hospitalization time (Zanetti-Dallenbach et al., 2008).
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Surgeons have been treating endometriosis using several approaches; either by laparoscopic excision, ablation or removal of endometriomata and endometriosis associated adhesions.
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The laparoscopic approach seems to have more favorable outcome than open approach in terms of quality of surgery and patients acceptance. Laparoscopic surgical management is now recognized as the best approach for endometriosis associated infertility treatment followed by assisted reproductive techniques. However, for endometriosis associated pain symptoms there is no general consensus regarding the best way of dealing with these symptoms. The problems of comorbidity and recurrence is still a problem and under great debate.
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7.4. Infertility and endometriosis
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Infertility is common in endometriosis sufferers and is generally manifested as a reduced monthly chance of conceiving (reduced fecundability). Nevertheless, even in severe cases of endometriosis spontaneous successful conception and delivery of a healthy baby often occur. Despite enormous studies about the relationship between endometriosis and subfertility, this relationship still controversial issue. The main problems in those studies, that they don’t have a defined patient population, clinical features arising from different endometriosis types are not well defined and the fact that scientists investigating endometriosis are lacking enough clinical data about patients they are studying. They just deal with tissues blindly.
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However, an association between endometriosis and infertility has repeatedly been reported in the literature, but an absolute cause-and-effect relationship has yet to be confirmed (Mahutte and Arici, 2002). Many mechanisms have been proposed to cause fertility problems in endometriosis. These include altered folliculogenesis (Doody et al., 1988), leading to ovulatory dysfunction and low quality oocytes, as well as luteal phase defects (Grant, 1966), impaired fertilization (Wardle et al., 1985), and abnormal embryogenesis (Garrido et al., 2002), abnormalities in peritoneal fluid (Minici et al., 2008), eutopic endometrium and immunological abnormalities (Akoum et al., 2006).
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It seems that not one mechanism is responsible for the reduced fecundability in endometriosis it is rather a complex of several mechanisms rather than one mechanism. The problem of conflicting results in different studies about infertility in endometriosis may be due to the lack of proper characterization of patient population, the defects imbedded in the current classification of endometriosis and the difficulty of elimination of other factors that affect fertility such as sperm quality and different interpretation by different laboratories.
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\n\t\n',keywords:null,chapterPDFUrl:"https://cdn.intechopen.com/pdfs/18358.pdf",chapterXML:"https://mts.intechopen.com/source/xml/18358.xml",downloadPdfUrl:"/chapter/pdf-download/18358",previewPdfUrl:"/chapter/pdf-preview/18358",totalDownloads:3818,totalViews:511,totalCrossrefCites:1,totalDimensionsCites:2,totalAltmetricsMentions:0,impactScore:1,impactScorePercentile:59,impactScoreQuartile:3,hasAltmetrics:0,dateSubmitted:"October 14th 2010",dateReviewed:"May 18th 2011",datePrePublished:null,datePublished:"August 23rd 2011",dateFinished:null,readingETA:"0",abstract:null,reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/18358",risUrl:"/chapter/ris/18358",book:{id:"916",slug:"advanced-gynecologic-endoscopy"},signatures:"Moamar Al-Jefout",authors:[{id:"26163",title:"Dr",name:"Moamar",middleName:null,surname:"Al-Jefout",fullName:"Moamar Al-Jefout",slug:"moamar-al-jefout",email:"drmoamar@yahoo.co.uk",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Background",level:"1"},{id:"sec_3",title:"3. Anatomy of the anterior abdominal wall related to laparoscopic surgery for endometriosis",level:"1"},{id:"sec_4",title:"4. Delay in diagnosis of endometriosis",level:"1"},{id:"sec_5",title:"5. Laparoscopy as the gold standard for the diagnosis of endometriosis",level:"1"},{id:"sec_5_2",title:"5.1. Laparoscopy as gold standard",level:"2"},{id:"sec_6_2",title:"5.2. Risks of laparoscopy",level:"2"},{id:"sec_7_2",title:"5.3. Laparoscopic conscious pain mapping",level:"2"},{id:"sec_8_2",title:"5.4. Transvaginal hydrolaparoscopy (THL)",level:"2"},{id:"sec_10",title:"6. Laparoscopy for the staging of endometriosis",level:"1"},{id:"sec_10_2",title:"6.1. Historical background of endometriosis classification",level:"2"},{id:"sec_11_2",title:"6.2. The perfect classification, is there such a thing?",level:"2"},{id:"sec_13",title:"7. The reivised american society of reproductive medicine (rASRM) previously (rAFS)",level:"1"},{id:"sec_13_2",title:"7.1. Advantages of rASRM",level:"2"},{id:"sec_14_2",title:"7.2. Disadvantages of rASRM",level:"2"},{id:"sec_14_3",title:"7.2.1. The ENZIAN-Score",level:"3"},{id:"sec_16_2",title:"7.3. Peritoneal endometriosis surgical management",level:"2"},{id:"sec_16_3",title:"7.3.1. Minimal or mild disease",level:"3"},{id:"sec_17_3",title:"7.3.2. Ovarian endometriomas",level:"3"},{id:"sec_18_3",title:"7.3.3. Deep infiltrating endometriosis (DIE)",level:"3"},{id:"sec_20_2",title:"7.4. Infertility and endometriosis",level:"2"}],chapterReferences:[{id:"B1",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAcosta\n\t\t\t\t\t\t\tA. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tButtram\n\t\t\t\t\t\t\tV. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJr \n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBesch\n\t\t\t\t\t\t\tP. 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T.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1966Classification of endometriosis. Obstet Gynecol, 28, 437 EOF\n\t\t\t\t\n\t\t\t'},{id:"B10",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBoing\n\t\t\t\t\t\t\tC.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKimmig\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2007Surgical management of endometriosis--an overview]. Gynakol Geburtshilfliche Rundsch,\n\t\t\t\t\t47\n\t\t\t\t\t124\n\t\t\t\t\t31\n\t\t\t\t\n\t\t\t'},{id:"B11",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBrosens\n\t\t\t\t\t\t\tI.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCampo\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGordts\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1999Office hydrolaparoscopy for the diagnosis of endometriosis and tubal infertility. 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Fertil Steril,\n\t\t\t\t\t66\n\t\t\t\t\t517\n\t\t\t\t\t21\n\t\t\t\t\n\t\t\t'},{id:"B13",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBrosens\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTimmerman\n\t\t\t\t\t\t\tD.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tStarzinski-Powitz\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBrosens\n\t\t\t\t\t\t\tI.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2003Noninvasive diagnosis of endometriosis: the role of imaging and markers. Obstet Gynecol Clin North Am,\n\t\t\t\t\t30\n\t\t\t\t\t95\n\t\t\t\t\t114viii-ix.\n\t\t\t'},{id:"B14",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCampo\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGordts\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRombauts\n\t\t\t\t\t\t\tL.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBrosens\n\t\t\t\t\t\t\tI.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1999Diagnostic accuracy of transvaginal hydrolaparoscopy in infertility. Fertil Steril,\n\t\t\t\t\t71\n\t\t\t\t\t1157\n\t\t\t\t\t60\n\t\t\t\t\n\t\t\t'},{id:"B15",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tChapron\n\t\t\t\t\t\t\tC.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJacob\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDubuisson\n\t\t\t\t\t\t\tJ. B.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tVieira\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLiaras\n\t\t\t\t\t\t\tE.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFauconnier\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2001Laparoscopically assisted vaginal management of deep endometriosis infiltrating the rectovaginal septum. Acta Obstet Gynecol Scand,\n\t\t\t\t\t80\n\t\t\t\t\t349\n\t\t\t\t\t54\n\t\t\t\t\n\t\t\t'},{id:"B16",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tChene\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJaffeux\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLasnier\n\t\t\t\t\t\t\tC.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAublet-Cuvelier\n\t\t\t\t\t\t\tB.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMatsuzaki\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJardon\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMage\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPouly\n\t\t\t\t\t\t\tJ. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCanis\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2008Are there anatomical and clinical correlations between minimal and deep endometriosis? First results of Auvergne’s Registry of Endometriosis]. Gynecol Obstet Fertil,\n\t\t\t\t\t36\n\t\t\t\t\t17\n\t\t\t\t\t22\n\t\t\t\t\n\t\t\t'},{id:"B17",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tChopin\n\t\t\t\t\t\t\tN.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tVieira\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBorghese\n\t\t\t\t\t\t\tB.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFoulot\n\t\t\t\t\t\t\tH.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDousset\n\t\t\t\t\t\t\tB.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCoste\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMignon\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFauconnier\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tChapron\n\t\t\t\t\t\t\tC.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2005Operative management of deeply infiltrating endometriosis: results on pelvic pain symptoms according to a surgical classification. J Minim Invasive Gynecol,\n\t\t\t\t\t12\n\t\t\t\t\t106\n\t\t\t\t\t12\n\t\t\t\t\n\t\t\t'},{id:"B18",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDavis\n\t\t\t\t\t\t\tC. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMcmillan\n\t\t\t\t\t\t\tL.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2003Pain in endometriosis: effectiveness of medical and surgical management. Curr Opin Obstet Gynecol,\n\t\t\t\t\t15\n\t\t\t\t\t507\n\t\t\t\t\t12\n\t\t\t\t\n\t\t\t'},{id:"B19",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDonnez\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNisolle\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1991Laparoscopic management of large ovarian endometrial cyst: use of fibrin sealant. J Gynecol Surg,\n\t\t\t\t\t7\n\t\t\t\t\t163\n\t\t\t\t\t6\n\t\t\t\t\n\t\t\t'},{id:"B20",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDonnez\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPirard\n\t\t\t\t\t\t\tC.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSmets\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJadoul\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSquifflet\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2004Surgical management of endometriosis. Best Pract Res Clin Obstet Gynaecol,\n\t\t\t\t\t18\n\t\t\t\t\t329\n\t\t\t\t\t48\n\t\t\t\t\n\t\t\t'},{id:"B21",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDoody\n\t\t\t\t\t\t\tM. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGibbons\n\t\t\t\t\t\t\tW. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tButtram\n\t\t\t\t\t\t\tV. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJr \n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1988Linear regression analysis of ultrasound follicular growth series: evidence for an abnormality of follicular growth in endometriosis patients. Fertil Steril,\n\t\t\t\t\t49\n\t\t\t\t\t47\n\t\t\t\t\t51\n\t\t\t\t\n\t\t\t'},{id:"B22",body:'\n\t\t\t\tEvers, J. L. (1994) Endometriosis does not exist; all women have endometriosis. Hum Reprod, 9\n\t\t\t\t\t2206\n\t\t\t\t\t9\n\t\t\t\t\n\t\t\t'},{id:"B23",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFauconnier\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tChapron\n\t\t\t\t\t\t\tC.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDubuisson\n\t\t\t\t\t\t\tJ. B.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tVieira\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDousset\n\t\t\t\t\t\t\tB.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBreart\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2002Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis. Fertil Steril,\n\t\t\t\t\t78\n\t\t\t\t\t719\n\t\t\t\t\t26\n\t\t\t\t\n\t\t\t'},{id:"B24",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFrishman\n\t\t\t\t\t\t\tG. N.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSalak\n\t\t\t\t\t\t\tJ. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2006Conservative surgical management of endometriosis in women with pelvic pain. J Minim Invasive Gynecol,\n\t\t\t\t\t13\n\t\t\t\t\t546\n\t\t\t\t\t58\n\t\t\t\t\n\t\t\t'},{id:"B25",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGarcia\n\t\t\t\t\t\t\tLeon. F.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tOviedo\n\t\t\t\t\t\t\tOrtega. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tReyes\n\t\t\t\t\t\t\tCuervo. H.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tIbarrola\n\t\t\t\t\t\t\tBuenabad. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tVon Der\n\t\t\t\t\t\t\tMeden. W.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2003Presacral neurectomy and uterine nerve ablation in chronic pelvic pain. Laparoscopic management. A comparative study.]. Ginecol Obstet Mex,\n\t\t\t\t\t71\n\t\t\t\t\t137\n\t\t\t\t\t42\n\t\t\t\t\n\t\t\t'},{id:"B26",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGarrido\n\t\t\t\t\t\t\tN.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNavarro\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGarcia-Velasco\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRemoh\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPellice\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSimon\n\t\t\t\t\t\t\tC.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2002The endometrium versus embryonic quality in endometriosis-related infertility. Hum Reprod Update,\n\t\t\t\t\t8\n\t\t\t\t\t95\n\t\t\t\t\t103\n\t\t\t\t\n\t\t\t'},{id:"B27",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGiudice\n\t\t\t\t\t\t\tL. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKao\n\t\t\t\t\t\t\tL. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2004Endometriosis. Lancet,\n\t\t\t\t\t364\n\t\t\t\t\t1789\n\t\t\t\t\t99\n\t\t\t\t\n\t\t\t'},{id:"B28",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGolfier\n\t\t\t\t\t\t\tF.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSabra\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2007Surgical management of endometriosis]. J Gynecol Obstet Biol Reprod (Paris),\n\t\t\t\t\t36\n\t\t\t\t\t162\n\t\t\t\t\t72\n\t\t\t\t\n\t\t\t'},{id:"B29",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGordts\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCampo\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBrosens\n\t\t\t\t\t\t\tI.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2000Office transvaginal hydrolaparoscopy for early diagnosis of pelvic endometriosis and adhesions. J Am Assoc Gynecol Laparosc,\n\t\t\t\t\t7\n\t\t\t\t\t45\n\t\t\t\t\t9\n\t\t\t\t\n\t\t\t'},{id:"B30",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGrant\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1966Additional sterility factors in endometriosis. Fertil Steril,\n\t\t\t\t\t17\n\t\t\t\t\t514\n\t\t\t\t\t9\n\t\t\t\t\n\t\t\t'},{id:"B31",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHadfield\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMardon\n\t\t\t\t\t\t\tH.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBarlow\n\t\t\t\t\t\t\tD.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKennedy\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1996aDelay in the diagnosis of endometriosis: a survey of women from the USA and the UK. Hum Reprod,\n\t\t\t\t\t11\n\t\t\t\t\t878\n\t\t\t\t\t80\n\t\t\t\t\n\t\t\t'},{id:"B32",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHoward\n\t\t\t\t\t\t\tF. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1993The role of laparoscopy in chronic pelvic pain: promise and pitfalls. Obstet Gynecol Surv,\n\t\t\t\t\t48\n\t\t\t\t\t357\n\t\t\t\t\t87\n\t\t\t\t\n\t\t\t'},{id:"B33",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHoward\n\t\t\t\t\t\t\tF. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2000The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol,\n\t\t\t\t\t14\n\t\t\t\t\t467\n\t\t\t\t\t94\n\t\t\t\t\n\t\t\t'},{id:"B34",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHoward\n\t\t\t\t\t\t\tF. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2003Chronic pelvic pain. Obstet Gynecol,\n\t\t\t\t\t101\n\t\t\t\t\t594\n\t\t\t\t\t611\n\t\t\t\t\n\t\t\t'},{id:"B35",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHoward\n\t\t\t\t\t\t\tF. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t-M\n\t\t\t\t\t\t\tE. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\tI. N. A. W. I. A. 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JSLS,\n\t\t\t\t\t7\n\t\t\t\t\t15\n\t\t\t\t\t8\n\t\t\t\t\n\t\t\t'},{id:"B49",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMinici\n\t\t\t\t\t\t\tF.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTiberi\n\t\t\t\t\t\t\tF.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTropea\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tOrlando\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGangale\n\t\t\t\t\t\t\tM. F.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRomani\n\t\t\t\t\t\t\tF.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCampo\n\t\t\t\t\t\t\t. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBompiani\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLanzone\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tApa\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2008Endometriosis and human infertility: a new investigation into the role of eutopic endometrium. Hum Reprod,\n\t\t\t\t\t23\n\t\t\t\t\t530\n\t\t\t\t\t7\n\t\t\t\t\n\t\t\t'},{id:"B50",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNardo\n\t\t\t\t\t\t\tL. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMoustafa\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGareth\n\t\t\t\t\t\t\tBeynon. D. W.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2005Laparoscopic treatment of pelvic pain associated with minimal and mild endometriosis with use of the Helica Thermal Coagulator. Fertil Steril,\n\t\t\t\t\t83\n\t\t\t\t\t735\n\t\t\t\t\t8\n\t\t\t\t\n\t\t\t'},{id:"B51",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNatuzzi\n\t\t\t\t\t\t\tE. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tUrsell\n\t\t\t\t\t\t\tP. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHarrison\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBuscher\n\t\t\t\t\t\t\tC.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRiemer\n\t\t\t\t\t\t\tR. K.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1993Nitric oxide synthase activity in the pregnant uterus decreases at parturition. Biochem Biophys Res Commun,\n\t\t\t\t\t194\n\t\t\t\t\t1\n\t\t\t\t\t8\n\t\t\t\t\n\t\t\t'},{id:"B52",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNisolle\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDonnez\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1997Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities. Fertil Steril,\n\t\t\t\t\t68\n\t\t\t\t\t585\n\t\t\t\t\t96\n\t\t\t\t\n\t\t\t'},{id:"B53",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tOlive\n\t\t\t\t\t\t\tD. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPritts\n\t\t\t\t\t\t\tE. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2002The treatment of endometriosis: a review of the evidence. 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Fertil Steril,\n\t\t\t\t\t32\n\t\t\t\t\t633\n\t\t\t\t\t4\n\t\t\t\t\n\t\t\t'},{id:"B57",body:'\n\t\t\t\t\n\t\t\t\t\tRcog\n\t\t\t\t\t2000The investigation and management of endometrioisis. Giudelines. London, RCOG Press\n\t\t\t'},{id:"B58",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRedwine\n\t\t\t\t\t\t\tD.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMann\n\t\t\t\t\t\t\tC. H.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWright\n\t\t\t\t\t\t\tJ. T.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2000Evidence on endometriosis. Elitism about randomised controlled trials is inappropriate. BMJ,\n\t\t\t\t\t321\n\t\t\t\t\t1077\n\t\t\t\t\t8\n\t\t\t\t\n\t\t\t'},{id:"B59",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRedwine\n\t\t\t\t\t\t\tD. B.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1987aAge-related evolution in color appearance of endometriosis. 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F.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1998Superior hypogastric block during microlaparoscopic pain mapping. J Am Assoc Gynecol Laparosc,\n\t\t\t\t\t5\n\t\t\t\t\t265\n\t\t\t\t\t7\n\t\t\t\t\n\t\t\t'},{id:"B65",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tStratton\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2006aThe tangled web of reasons for the delay in diagnosis of endometriosis in women with chronic pelvic pain: will the suffering end? Fertil Steril,\n\t\t\t\t\t86\n\t\t\t\t\t1302\n\t\t\t\t\t4discussion 1317.\n\t\t\t'},{id:"B66",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tStratton\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWinkel\n\t\t\t\t\t\t\tC.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPremkumar\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tChow\n\t\t\t\t\t\t\tC.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWilson\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHearns-Stokes\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHeo\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMerino\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNieman\n\t\t\t\t\t\t\tL. K.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2003Diagnostic accuracy of laparoscopy, magnetic resonance imaging, and histopathologic examination for the detection of endometriosis. Fertil Steril,\n\t\t\t\t\t79\n\t\t\t\t\t1078\n\t\t\t\t\t85\n\t\t\t\t\n\t\t\t'},{id:"B67",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSutton\n\t\t\t\t\t\t\tC. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tEwen\n\t\t\t\t\t\t\tS. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWhitelaw\n\t\t\t\t\t\t\tN.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHaines\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1994Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertil Steril,\n\t\t\t\t\t62\n\t\t\t\t\t696\n\t\t\t\t\t700\n\t\t\t\t\n\t\t\t'},{id:"B68",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSutton\n\t\t\t\t\t\t\tC. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPooley\n\t\t\t\t\t\t\tA. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tEwen\n\t\t\t\t\t\t\tS. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHaines\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1997Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis. Fertil Steril,\n\t\t\t\t\t68\n\t\t\t\t\t1070\n\t\t\t\t\t4\n\t\t\t\t\n\t\t\t'},{id:"B69",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTuttlies\n\t\t\t\t\t\t\tF.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKeckstein\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tUlrich\n\t\t\t\t\t\t\tU.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPossover\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSchweppe\n\t\t\t\t\t\t\tK. W.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWustlich\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBuchweitz\n\t\t\t\t\t\t\tO.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGreb\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKandolf\n\t\t\t\t\t\t\tO.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMangold\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMasetti\n\t\t\t\t\t\t\tW.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNeis\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRauter\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tReeka\n\t\t\t\t\t\t\tN.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRichter\n\t\t\t\t\t\t\tO.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSchindler\n\t\t\t\t\t\t\tA. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSillem\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTerruhn\n\t\t\t\t\t\t\tV.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTinneberg\n\t\t\t\t\t\t\tH. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2005ENZIAN-score, a classification of deep infiltrating endometriosis]. Zentralbl Gynakol,\n\t\t\t\t\t127\n\t\t\t\t\t275\n\t\t\t\t\t81\n\t\t\t\t\n\t\t\t'},{id:"B70",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTytherleigh\n\t\t\t\t\t\t\tM. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFell\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGordon\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2004Diagnostic conscious pain mapping using laparoscopy under local anaesthetic and sedation in general surgical patients. Surgeon,\n\t\t\t\t\t2\n\t\t\t\t\t157\n\t\t\t\t\t60\n\t\t\t\t\n\t\t\t'},{id:"B71",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tVercellini\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCrosignani\n\t\t\t\t\t\t\tP. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAbbiati\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSomigliana\n\t\t\t\t\t\t\tE.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tVigano\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFedele\n\t\t\t\t\t\t\tL.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2009The effect of surgery for symptomatic endometriosis: the other side of the story. Hum Reprod Update,\n\t\t\t\t\t15\n\t\t\t\t\t177\n\t\t\t\t\t88\n\t\t\t\t\n\t\t\t'},{id:"B72",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tVercellini\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFedele\n\t\t\t\t\t\t\tL.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAimi\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDe Giorgi\n\t\t\t\t\t\t\tO.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tConsonni\n\t\t\t\t\t\t\tD.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCrosignani\n\t\t\t\t\t\t\tP. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2006aReproductive performance, pain recurrence and disease relapse after conservative surgical treatment for endometriosis: the predictive value of the current classification system. Hum Reprod,\n\t\t\t\t\t21\n\t\t\t\t\t2679\n\t\t\t\t\t85\n\t\t\t\t\n\t\t\t'},{id:"B73",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tVercellini\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFedele\n\t\t\t\t\t\t\tL.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPietropaolo\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFrontino\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSomigliana\n\t\t\t\t\t\t\tE.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCrosignani\n\t\t\t\t\t\t\tP. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2003Progestogens for endometriosis: forward to the past. Hum Reprod Update,\n\t\t\t\t\t9\n\t\t\t\t\t387\n\t\t\t\t\t96\n\t\t\t\t\n\t\t\t'},{id:"B74",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWardle\n\t\t\t\t\t\t\tP. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMitchell\n\t\t\t\t\t\t\tJ. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMclaughlin\n\t\t\t\t\t\t\tE. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRay\n\t\t\t\t\t\t\tB. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMcdermott\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHull\n\t\t\t\t\t\t\tM. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1985Endometriosis and ovulatory disorder: reduced fertilisation in vitro compared with tubal and unexplained infertility. Lancet,\n\t\t\t\t\t2\n\t\t\t\t\t236\n\t\t\t\t\t9\n\t\t\t\t\n\t\t\t'},{id:"B75",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWicks\n\t\t\t\t\t\t\tM. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLarson\n\t\t\t\t\t\t\tC. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1949Histologic criteria for evaluating endometriosis. Northwest Med,\n\t\t\t\t\t48\n\t\t\t\t\t611\n\t\t\t\t\t3\n\t\t\t\t\n\t\t\t'},{id:"B76",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWykes\n\t\t\t\t\t\t\tC. B.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tClark\n\t\t\t\t\t\t\tT. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKhan\n\t\t\t\t\t\t\tK. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2004aAccuracy of laparoscopy in the diagnosis of endometriosis: a systematic quantitative review. Bjog,\n\t\t\t\t\t111\n\t\t\t\t\t1204\n\t\t\t\t\t12\n\t\t\t\t\n\t\t\t'},{id:"B77",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tYoshida\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHarada\n\t\t\t\t\t\t\tT.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tIwabe\n\t\t\t\t\t\t\tT.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTerakawa\n\t\t\t\t\t\t\tN.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2002Laparoscopic surgery for the management of ovarian endometrioma. 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Ginekol Pol,\n\t\t\t\t\t70\n\t\t\t\t\t264\n\t\t\t\t\t9\n\t\t\t\t\n\t\t\t'},{id:"B80",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tZullo\n\t\t\t\t\t\t\tF.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPalomba\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tZupi\n\t\t\t\t\t\t\tE.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRusso\n\t\t\t\t\t\t\tT.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMorelli\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSena\n\t\t\t\t\t\t\tT.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPellicano\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMastrantonio\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2004Long-term effectiveness of presacral neurectomy for the treatment of severe dysmenorrhea due to endometriosis. J Am Assoc Gynecol Laparosc,\n\t\t\t\t\t11\n\t\t\t\t\t23\n\t\t\t\t\t8\n\t\t\t\t\n\t\t\t'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Moamar Al-Jefout",address:null,affiliation:'
Department of Obstetrics & Gynecology, Mutah Medical Faculty, Mutah University, Jordan
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1. Introduction
Batteries are used as the power source in electric vehicles and take the critical role for driving milage improvement and transportation safety as well as cost control. Battery energy density is the important parameter related with the driving mileage. As battery material and technology development, energy density of lithium ion battery for electric vehicle has been increased to 300 Wh/kg at cell level, [1, 2] it has big progress compared with the lead acid battery at beginning period. Lithium ion battery is basically composed by cathode, anode, separator and electrolyte. Lithium ions move between cathode and anode to store and output energy through reversible chemical reaction. In present commercial lithium ion batteries, lithium ions are reserved in cathode side and the reversible lithium concentration in cathode mainly determine the battery energy density. Three type of cathodes have been widely utilized in commercial lithium ion batteries, layered oxide which has two-dimensional lithium ion diffusion pathway, spinel oxide that provides three-dimensional lithium ion transportation space, and olivine phosphate with one-dimensional lithium ion diffusion channels. Each of them has their merit and are servicing the specialized portable power source market.
Lithium ion battery utilized on electrical vehicles has high requirement on safety, long lifespan, high energy density, high power density as well as low cost. Olivine phosphate cathode has stable crystal structure and present advantage on safety, long cycling stability and cost effective. In this chapter, lithium iron phosphate, lithium manganese phosphate and related composite cathodes are reviewed to understand material technology development. Blend cathode demonstrates the possibility to tailor and balance the cathode property and performance. Binary and ternary blend cathodes using olivine phosphate are summarized and discussed.
2. Olivine phosphate cathode
Iron source is abundant in earth, it is inexpensive and less toxic than cobalt and nickel, using iron redox in cathode is promising to reduce cathode material cost. Inspired and encouraged by the successful development of LiCoO2 cathode, layered LiFeO2 prepared by ion-exchange from α-NaFeO2 presents iron redox activity [3]. But it is metastable and the performance was not attractive due to anion issues [4]. Comparing with other iron compounds, Fe3+/Fe2+ redox energy and potential can be adjusted by different anion groups. As consequence, polyanions were considered to build stable framework structure and improve redox stability. Due to Fe3+/Fe2+ redox potential is influenced by the corresponding anion group. A series of iron polyanion compounds were screened to search stable cathodes for lithium ion batteries [5]. In Figure 1a, Fe3+/Fe2+ redox energy is compared in different phosphates. The lower redox energy below Fermi level can achieve higher voltage compared with lithium. Fe3+/Fe2+ redox couple demonstrates the lower redox energy in LiFePO4 and higher redox potential at 3.5 V (vs. Li+/Li). This voltage matches with stable window of carbonate electrolytes very well and accelerate the development of lithium iron phosphate. It delivered 110 mAh/g capacity firstly reported by Nobel laureate J. B. Goodenough at 1997 and has been successfully commercialized with decades of research and development.
Figure 1.
(a) Iron redox energy and potential can be adjusted by polyanion groups [5]. (b) LiFePO4 crystal structure [6].
2.1 Lithium iron phosphate
The ordered olivine structure of LiFePO4 is constructed by P-O framework with space group Pnma. Oxygen atoms are hexagonal-close-packed stacking order. Phosphorus atoms occupy tetrahedral sites, iron and lithium atoms locate at octahedral 4a and 4c position in Pnma space group. PO4 tetrahedral share one edge with FeO6 octahedron and two edges are shared with LiO6 octahedron. The FeO6 octahedra are linked through corner in bc-plane and LiO6 octahedra form edge-sharing chains in b direction [6]. Li resides in chains of edge-shared octahedra and connecting as the Li diffusion channel. PO4 polyanion framework is very stable in thermal dynamics as P-O bonding energy is high. During heating up to 350°C in N2 or O2 atmosphere [7], LiFePO4 and delithiated FePO4 structure were not changed which contributes to the high safety performance.
Li diffusion pathway in olivine LiFePO4 is one dimensional channel along [010] direction due to LiO6 octahedra is only continuous along b-axis. Although theoretical intrinsic ionic diffusion coefficient is 10−8–10−7 cm2/s for both LiFePO4 and FePO4 [8, 9] the tested lithium ion diffusion coefficient is lower than 10−12 cm2/s. As structure defects existing, such as Li/Fe anti-site defect, stacking fault and impurities, one-dimensional channels would be block and the ionic diffusion coefficient will be dramatically decreased [10]. In ordered olivine structure, corner-shared FeO6 does not form a continuous 3D network, and transition metal-d-oxygen-p hybridization in phosphate is weak [11]. Accordingly, the electronic conductivity of LiFePO4 at room temperature is only ~10−10 S/cm [12], which is usually thought as semiconductor [13]. Slow kinetics of lithium ion diffusion and low electronic conductivity lead to the poor rate capability of LiFePO4. Thus, numerous works have been devoted to overcome this drawback. Such as reducing particle size, element substitution, surface coating et al.
2.2 Reaction mechanism
Phase transformation mechanism in cathode during delithiation and lithiation is critical for electrochemical performance in lithium ion battery. When lithium ion extracting from LiFePO4, olivine LiFePO4 host will transform to FePO4 which have same structure. Even all active lithium ions are extracted out from LiFePO4, lattice volume only vary 6.5–6.8%, which demonstrate high crystal structure stability. Although the two phases reaction mechanism in lithiation/delithiation is widely accepted, the specific transformation route is reported as several models, which are highly related with material morphology, particle size, even experimental conditions [14, 15].
Core-shell (shrinking-core) model was proposed when LiFePO4 was initial reported by J. B. Goodenough at 1997 [7]. In lithiation process, lithium ions will be reserved from surface to particle core in FePO4 phase, two-phase boundary moves accordingly. In delithiation process, phase boundary will move reversibly from core to surface. In order to have deep and clear understanding on reaction mechanism, advanced operando/ex-situ characterization technologies are involved to study the structure changes furtherly. Beside two phases coexistence phenomenon (two phases distribution may be different), lithium deficient Li1-xFePO4 was seizing especially in nano size particle and high rate tests. Solid solution mechanism is reported to support the fast lithium transportation [16].
No matter phase transformation would undergo which mechanism in detail, the rigid P-O tetrahedral in structure provides rigid framework and contributes to highly reversible and stable delithiation/lithiation.
2.3 Carbon coating
Limited by the intrinsic low electronic conductivity, lithium utilization ratio in LiFePO4 is low (~0.6) and decays fast. Carbon coating was developed to improve material conductivity. This approach can be achieved through simple process by mixing carbon precursors with active materials followed by calcination. However, the electrochemical performance is influenced by the carbon coating quality. Numerous works were reported to study and optimize carbon coating for LiFePO4 from different carbon sources, coating methods, carbon structure and carbon composite [17]. Beside enhancement of electronic conductivity, carbon coating can also be used to control LiFePO4 particle growth in calcination.
Beside conventional carbon coating, advanced carbon materials such as carbon nanotube, graphene and carbon fibers are introduced to form composite for pursuing high performance. Benefitting by excellent electronic conductivity from carbon coating layer and carbon composite, LiFePO4 material can be prepared into thick electrode without sacrifice performance [18].
2.4 Lithium manganese phosphate
Encouraged by well development of LiFePO4, pure phase of lithium manganese olivine is expected to improve energy density due to the high redox potential (4.1 V vs. Li+/Li) of Mn3+/Mn2+ couple. However, lithium ion diffusion kinetics and electronic conductivity in LiMnPO4 is even worse than LiFePO4 and hard to prepare the pure phase with high performance [19, 20]. Morphology control and particle size reduction are effective solutions to improve the sluggish kinetics property referencing from LiFePO4 development [21]. A facile polyol synthesis approach is developed to prepare well-crystallized LiMnPO4 with ~30 nm thick nanoplates (as shown in Figure 2) [22]. High ratio of (020) plane which orientated in a-c plane and has short length along b-axis provides morphology to optimize kinetics property. Pure phase LiMnPO4 prepared by polyol method can deliver 159 mAh/g reversible capacity at 50°C, and retained 95% over 200 cycles. Elemental substitution was applied on LiMnPO4 to modify the olivine structure. Fe, Ni and Mg substitution made contribution to improve electronic conductivity, but only Fe substitution presents the positive function on electrochemical performance enhancement [24]. Poly synthesis method was further developed and cheap solvent DMSO was used to replace polyhydric alcohols in co-precipitation reaction. 50–100 nm Fe substituted LiMn0.8Fe0.2PO4 presents promising capability and cycling stability as presented in Figure 2 [23, 25]. Considering kinetics of LiFePO4 is better than LiMnPO4, a core-shell structure of LiMn0.8Fe0.2PO4/C which has Fe rich on surface is prepared by adjusting co-precipitation process. LiFePO4 is controlled to grow on LiMnPO4 shell [26]. Comparing with LiMn0.8Fe0.2PO4 solid solution cathode, lithium ion diffusion kinetics is further enhanced due to the lower charge transfer resistance is achieved in this structure modification.
Figure 2.
(a) (020) Oriented LiMnPO4 prepared by polyhydric alcohols approach [22]. (b) Developed co-precipitation method for synthesis of Fe substituted LiMnPO4 [23].
2.5 Composite cathode
Although the Mn doped LiFe1-xMnxPO4 can deliver higher energy density contributed by the higher redox potential of Mn3+/Mn2+, rate performance is geared down when increasing manganese ratio. NASICON structured phosphate Li3V2(PO4)3 has open lattice framework which guarantee the fast Li ion transportation in cathode bulk phase [27]. As consequence, high rate NISICON cathode is integrated with olivine phosphate to improve Li diffusion kinetics [28]. In LiMnPO4-LVP composite cathode prepared by solid state approach, both the NISSCON and olivine phase diffraction peaks and plateau character could be identified even LVP ratio is below 3% [29]. As the composite LVP ratio is higher than 20%, the capacity contributed from Mn2+/Mn3+ plateau is increased and indicates that LVP composite can improve activity of Mn redox in olivine phase. Checking the lattice paraments, olivine phase LiMnPO4 is substituted by a small amount of vanadium [30]. The composite cathode presents enhanced rate capacity (Figure 3).
Figure 3.
(a) XRD patterns of the LMP and LVP sample prepared by different ratios. (b) Influence of LVP amount on reversible capacity of LMP-LVP composite [29]. (c) XRD pattern of LMFP and LVP composite cathode [30]. (d) Rate capability of LMP and LVP composite cathodes [29].
3. Blend cathodes
The present commercial cathode layered oxide, spinel oxide and olivine phosphate have their own advantage and have already been successfully utilized in different lithium ion battery designs according to the application scenarios. The blend of different cathode is a facile method to tailor the properties and performance of electrodes for lithium ion batteries.
3.1 Blend cathode – olivine phosphate and layered oxide
Layered structure oxide contained nickel cobalt manganese (NMC) has much higher theoretical capacity (~270 mAh/g) than olivine phosphate cathodes (~170 mAh/g). Limited by the delithiated structure stability at high voltage and electrolyte decomposition window [31, 32], only <0.8 Li in layered oxide cathode will participate in charge–discharge process. Although NMC cathode can be used to prepare high energy density lithium ion batteries for electric vehicles, the safety concerns arise comparing with the one using olivine phosphate cathodes [33, 34]. Blend cathode including both olivine and layered oxide cathode would a moderate strategy to integrate.
LiMn0.8Fe0.2PO4/C was mixed directly with LiNi0.88Co0.09Al0.03O2 (NCA) to improve the comprehensive performance. The reasonable ratio of LiMn0.8Fe0.2PO4/C can extend cycling life of Ni rich cathode without sacrificing capacity at electrode level [35]. Adding 1% and 2% LiMn0.8Fe0.2PO4/C, electrodes present similar discharge capacity. But the capacity retention ratio is increased from 77% using pristine NCA to 88% using 2% olivine addition. Using LiNi0.5Mn0.3Co0.2O2 (NMC532) and LiFe0.15Mn0.85PO4 blend cathode, cycling stability is enhanced when LFMP/C ratio in blend cathode is less than 10% [36].
LiCoO2 presents more stable structure stability with adding LiFePO4, both the particle cracking and irreversible phase transformation are inhabited even cycling at high cutoff voltage. Mixing with 12 wt% LiFePO4, discharge capacity of blend cathode is decreased to 177.9 mAh/g at 0.2C charging to 4.5 V (vs. Li+/Li). However, overpotential of cobalt redox is reduced and presents enhanced cycling stability [37].
Redox dynamics in LiFePO4 and LiCoO2 blend cathode is different with individual component. At low C-rate, each components of the blend cathode can independently present their redox reaction. When working at high C-rate, the effective C-rate for each constituent is higher than nominal value. However, the rate performance of blend cathode is significantly improved [38]. Buffer effect is proposed that the internal pathway would be constructed by component with fast reaction kinetics as shown in Figure 4. Lithium is redistributed among the constituents to reach an equilibrium potential during relaxation.
Figure 4.
a) Cyclic voltammetry of a blend electrode illustrating the contributions of LiFePO4 and LiCoO2. (scanning rate 25 μV/s). b) and c) potential profile and specific current during discharge and subsequent relaxation of a LiFePO4 and LiCoO2 blend at 0.2C and 5C [38].
Despite electrochemical performance is improved by blending, LiFePO4 and layered oxide cathode blend cathode may have heterogeneity issue as material property such as particle size and density are different. 3D X-ray tomography technology is used to check the composition distribution in prepared blend electrodes [39, 40]. Small NMC, nano sized LiFePO4 and carbon additives are enriched in layer close to current collector and large particle NMC is depleted in this region. Although electrode composition is close to design value above the NMC depleted layer, the mean NMC particle size presents gradient distribution toward top surface, as demonstrated in Figure 5. Beside local morphology heterogeneities, LiFePO4 agglomeration and cavities are observed in NMC rich zones. The heterogeneity issue may can be resolved by technique and equipment optimization, but the reported results reveal that materials properties differences should be considered to prepare uniform electrodes with high quality especially for blend cathodes.
Figure 5.
Schematic figure of typical features in a) NMC, b) LFP, and c) NMC/LFP blend electrodes [39].
3.2 Blend cathode – olivine phosphate and spinel oxide
Spinel oxide cathode has advantage of low cost, high thermal stability and high rate capability. However, spinel oxide suffers from fast capacity fading in long cycling test, especially at high temperature. Olivine phosphate has excellent cycling stability and could blend with spinel to pursue the comprehensive performance.
LiFexMn1-xPO4 (LFMP) and spinel oxide blend cathode demonstrates linear changing on tap density, reversible capacity, energy density and power density at low C-rate by adjusting blend ratio between two components. However, synergetic effect was observed in blend cathode at high C-rate [41]. Discharge curves of blend cathode at 3C presents lower polarization for Mn3+/Mn2+ plateau as shown in Figure 6. Structure change was studied by in-situ XRD characterization during 3C pulse discharge and the following relaxation. (004) diffraction peak of spinel cathode shifts toward lower angle during discharge and moves to high angle in relaxation period. This result indicates that spinel component is reoxidized in relaxation step. As lithium diffusion in LFMP is slower than spinel LiMn2O4, the higher delithiated state LFMP will provide lithium ions to spinel for reaching a common equibium potential state (demonstrated in Figure 6). This buffer effect reduce the electrode polarization and improves the power pulse capability. Energy density and power density at high C-rate are enhanced contributed by the reduction of electrode polarization by blend ratio optimization [42].
Figure 6.
(a) Discharge curve comparison of blend cathode and individual component [42]. (b) Schematic illustration of buffer effect in blend cathode during pulse power test [41].
Manganese dissolution is notorious for lithium ion batteries using spinel LiMn2O4 cathodes [43]. Dissolution mechanism is generally ascribed to the presence of HF generated by the reaction between hexafluorophosphate anion and water impurity. Dissolved manganese will be reduced/deposited on anode side and involved in SEI formation in graphite surface. Spinel cathode will loss reversible capacity by manganese dissolution and anode impedance will be dramatically increased by manganese migration and deposition, as result spinel cathode performance in lithium ion battery is poor, especially calendar life and cycling stability at high temperature. This issue can be alleviated by using blend cathode design. Layered structure cathodes such as LiCoO2 and NMC reported that can work as proton scavenger through Li ion and proton exchanging in blend cathodes [44]. In LFMP and spinel oxide cathodes, dissolved manganese may be precipitation on LFMP particle surface instead of migrating to anode side. This results is also approved in LiFe0.3Mn0.7PO4 and LiMn1.9Al0.1O4 blend cathode that manganese dissolution from spinel cathode is dramatically reduced [42].
3.3 Ternary blend cathodes
Based on the development of binary blend cathode, ternary blend cathode composited by olivine phosphate, layered oxide and spinel oxide are proposed to study. Mixing three components at even ratio (33% for each), the ternary blend electrode presents highest electronic conductivity when all the other electrode parameters are controlled at same level (as list in Table 1) [45]. Redox activities studies reveal that each components in blend cathode can work independently and contributes to reduce the over-potential [46]. This is consistent with other reports.
Label
NMC/LMFP/LMO [wt%]
Areal capacity [mAh cm−2]
Mass loading [mg cm−2]
Specific capacity [mAh gAM−1]
Porosity [%]
Density [g cm−3]
Conductivity [S cm−2]
100%NMC
100:0:0
2.51 ± 0.02
15.86 ± 0.07
170.14 ± 0.67
33 ± 2
2.83 ± 0.05
0.68 ± 0.11
100%LMFP
0:100:0
2.53 ± 0.04
17.89 ± 0.25
151.27 ± 0.30
32 ± 2
2.13 ± 0.03
1.16 ± 0.03
100%LMO
0:0:100
2.58 ± 0.02
26.25 ± 0.01
105.41 ± 0.08
31 ± 1
2.73 ± 0.02
0.39 ± 0.20
75%NMC
75:12.5:12.5
2.48 ± 0.01
16.07 ± 0.02
165.57 ± 0.12
32 ± 2
2.72 ± 0.04
1.84 ± 0.19
75%LFMP
12.5:75:12.5
2.46 ± 0.08
17.70 ± 0.55
149.25 ± 0.29
32 ± 2
2.27 ± 0.03
1.89 ± 0.19
75%LMO
12.5:12.5:75
2.59 ± 0.07
23.20 ± 0.28
118.49 ± 3.72
30 ± 2
2.70 ± 0.03
1.52 ± 0.19
33%each
33.3:33.3:33.3
2.41 ± 0.2
18.79 ± 0.65
136.45 ± 11.95
32 ± 2
2.54 ± 0.04
2.04 ± 0.20
Table 1.
Characteristic properties of electrodes with an aerial capacity of approximately 2.5 mAh cm−2 and a porosity of 30% calculated from the electrodes’ thickness. Mass loading includes active materials, binder, and conductive carbon. Specific capacity is based on 93% active material (AM) content. The proportions indicated in the second column are based on the total AM [45].
4. Safety
Along energy density of lithium ion battery increasing, safety concerns are serious raised. Safety performance and evaluation is one of the critical criteria for the practical utilization of novel battery materials/technologies. Although battery management systems (BMS) are equipped on electrical vehicles to monitor all the cells and ensure the safety operation, battery still has thermal runway risk and would cause disaster results. Many countries published the strict compulsory standards for battery safety tests before releasing to commercial utilization on EVs [47]. Therefore, it is important to pay attention on safety development as well as energy/power density improvement.
Lithium ion battery is a comprehensive system and sensitive to temperature. When battery temperature rising to the cathode decomposition triggering point, the exothermic reaction will abruptly release heat and accelerate thermal runaway which is the detrimental safety issue. Thermal studies of materials components in lithium ion batteries can be investigated by differential scanning calorimetry (DSC) or accelerating rate calorimetry (ARC) [48]. As cathode material property are different, the onset reaction temperature and released heat are varied. In brief, the onset temperature for cathodes follow the order: LiFePO4 > LiNixCoyMnzO2 > LiCoO2 as compared in Figure 7 [47]. Polyanionic phosphate cathodes have robust P-O covalent constructing stable three-dimensional framework, it reduces the reactivity between cathode and electrolyte.
Figure 7.
The energy release diagram of different cathode in lithium ion batteries [47].
Although spinel is reported that onset temperature is little higher than LiFePO4 [49], but the exothermic reaction enthalpy is higher than LiFePO4 and the peak shape is more sharp which means more heat will be generated in shorter time. Although electrochemical performance of layered oxide cathodes have been improved a lot by material modification [33, 50, 51], they are still hard to compete with LiFePO4 on safety performance evaluation. Blend cathode is a reasonable method to balance the comprehensive performance. By adding olivine phosphate cathode LiFe0.15Mn0.85PO4/C in NMC523 cathode, the exothermic reaction enthalpy is significantly decreased [36]. But there is no linearly relationship between LFMP adding ratio and thermal performance (Figure 8).
Figure 8.
(a–d) Schematic description of Li redistribution among the components induced by a temperature change [38]. (e) Thermal performance comparison in LFMP/C and NMC523 blend cathode [36]. (f) Differential scanning calorimetry of fully charged blend electrodes (red) comparing with individual cathode at different ratios [45].
5. Summary
Olivine phosphate has been successfully commercialized and used in lithium ion batteries to equip on electrical vehicles. Although energy density is not competitive comparing with using layered oxide cathode especially Ni rich cathode, olivine phosphate present excellent safety performance. Manganese substitution and composited with lithium vanadium phosphate is carried out to improve energy density and power density. Beside this, blend cathode is an effective strategy to improve energy density without sacrificing safety advantage. Binary and ternary blend cathode present the possibility to tailor cathode property and performance. Blend cathodes show synergetic effect on rate capability and thermal stability tests which is higher than nominal value. Structure and electrochemistry studies reveal that buffer effect in blended components is contributed to the improvement. This chapter provides opinions from material science and electrochemistry viewpoints to understand the requirement of lithium ion battery on cathode materials development.
Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"phosphate, phosphate composite, blend cathode, lithium ion battery, electric vehicles, stability, rate capability, safety",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/78388.pdf",chapterXML:"https://mts.intechopen.com/source/xml/78388.xml",downloadPdfUrl:"/chapter/pdf-download/78388",previewPdfUrl:"/chapter/pdf-preview/78388",totalDownloads:145,totalViews:0,totalCrossrefCites:0,dateSubmitted:"July 16th 2021",dateReviewed:"August 16th 2021",datePrePublished:"November 12th 2021",datePublished:"March 30th 2022",dateFinished:"September 1st 2021",readingETA:"0",abstract:"As electric vehicle market growing fast, lithium ion batteries demand is increasing rapidly. Sufficient battery materials supplies including cathode, anode, electrolyte, additives, et al. are required accordingly. Although layered cathode is welcome in high energy density batteries, it is challenging to balance the high energy density and safety beside cost. As consequence, olivine phosphate cathode is coming to the stage center again along with battery technology development. It is important and necessary to revisit the olivine phosphate cathode to understand and support the development of electric vehicles utilized lithium ion batteries. In addition, blend cathode is a good strategy to tailor and balance cathode property and performance. In this chapter, blend cathode using olivine phosphate cathode will be discussed as well as olivine phosphate cathode.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/78388",risUrl:"/chapter/ris/78388",signatures:"Yujing Bi and Deyu Wang",book:{id:"10969",type:"book",title:"New Perspectives on Electric Vehicles",subtitle:null,fullTitle:"New Perspectives on Electric Vehicles",slug:"new-perspectives-on-electric-vehicles",publishedDate:"March 30th 2022",bookSignature:"Marian Găiceanu",coverURL:"https://cdn.intechopen.com/books/images_new/10969.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-83969-615-2",printIsbn:"978-1-83969-614-5",pdfIsbn:"978-1-83969-616-9",isAvailableForWebshopOrdering:!0,editors:[{id:"169608",title:"Prof.",name:"Marian",middleName:null,surname:"Găiceanu",slug:"marian-gaiceanu",fullName:"Marian Găiceanu"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"353922",title:"Dr.",name:"Yujing",middleName:null,surname:"BI",fullName:"Yujing BI",slug:"yujing-bi",email:"biyujing15@hotmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"427192",title:"Prof.",name:"Deyu",middleName:null,surname:"Wang",fullName:"Deyu Wang",slug:"deyu-wang",email:"wangdeyu@jhun.edu.cn",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Jianghan University",institutionURL:null,country:{name:"China"}}}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Olivine phosphate cathode",level:"1"},{id:"sec_2_2",title:"2.1 Lithium iron phosphate",level:"2"},{id:"sec_3_2",title:"2.2 Reaction mechanism",level:"2"},{id:"sec_4_2",title:"2.3 Carbon coating",level:"2"},{id:"sec_5_2",title:"2.4 Lithium manganese phosphate",level:"2"},{id:"sec_6_2",title:"2.5 Composite cathode",level:"2"},{id:"sec_8",title:"3. Blend cathodes",level:"1"},{id:"sec_8_2",title:"3.1 Blend cathode – olivine phosphate and layered oxide",level:"2"},{id:"sec_9_2",title:"3.2 Blend cathode – olivine phosphate and spinel oxide",level:"2"},{id:"sec_10_2",title:"3.3 Ternary blend cathodes",level:"2"},{id:"sec_12",title:"4. Safety",level:"1"},{id:"sec_13",title:"5. Summary",level:"1"},{id:"sec_17",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Cao, W.Z., J.N. Zhang, and H. Li, Batteries with high theoretical energy densities. Energy Storage Materials, 2020. 26: p. 46-55'},{id:"B2",body:'Assat, G. and J.M. Tarascon, Fundamental understanding and practical challenges of anionic redox activity in Li-ion batteries. Nature Energy, 2018. 3(5): p. 373-386'},{id:"B3",body:'Nalbandyan, V.B. and I.L. Shukaev, New Modification of Lithium Monoferrite and the Morphotropic Series AFeO2. Russian Journal of Inorganic Chemistry, 1987. 32(3): p. 453-454'},{id:"B4",body:'YasuoTakeda, et al., Sodium deintercalation from sodium iron oxide. Materials Research Bulletin, 1994. 29(6): p. 659-666'},{id:"B5",body:'Padhi, A.K., et al., Effect of Structure on the Fe3+ /Fe2+ Redox Couple in Iron Phosphates. Journal of The Electrochemical Society, 1997. 144: p. 1609-1613'},{id:"B6",body:'Tarascon, J.M. and M. Armand, Issues and challenges facing rechargeable lithium batteries. Nature, 2001. 414(6861): p. 359-367'},{id:"B7",body:'Padhi, A.K., K.S. Nanjundaswamy, and J.B. Goodenough, Phospho-olivines as positive-electrode materials for rechargeable lithium batteries. Journal of the Electrochemical Society, 1997. 144(4): p. 1188-1194'},{id:"B8",body:'Ouyang, C.Y., et al., First-principles study of Li ion diffusion in LiFePO4. Physical Review B, 2004. 69(10)'},{id:"B9",body:'Shi, S.Q., et al., Enhancement of electronic conductivity of LiFePO4 by Cr doping and its identification by first-principles calculations. Physical Review B, 2003. 68(19)'},{id:"B10",body:'Yang, Z.G., et al., How to make lithium iron phosphate better: a review exploring classical modification approaches in-depth and proposing future optimization methods. Journal of Materials Chemistry A, 2016. 4(47): p. 18210-18222'},{id:"B11",body:'Zhou, F., et al., The electronic structure and band gap of LiFePO4 and LiMnPO4. Solid State Communications, 2004. 132(3-4): p. 181-186'},{id:"B12",body:'Chung, S.Y., J.T. Bloking, and Y.M. Chiang, Electronically conductive phospho-olivines as lithium storage electrodes. Nature Materials, 2002. 1(2): p. 123-128'},{id:"B13",body:'Guo, L.M., et al., Unlocking the energy capabilities of micron-sized LiFePO4. Nature Communications, 2015. 6'},{id:"B14",body:'Wang, J.J., et al., Visualization of anisotropic-isotropic phase transformation dynamics in battery electrode particles. Nature Communications, 2016. 7'},{id:"B15",body:'Wang, J.J., et al., Size-dependent surface phase change of lithium iron phosphate during carbon coating. Nature Communications, 2014. 5'},{id:"B16",body:'Liu, H., et al., Capturing metastable structures during high-rate cycling of LiFePO4 nanoparticle electrodes. Science, 2014. 344(6191)'},{id:"B17",body:'Wang, J.J. and X.L. Sun, Understanding and recent development of carbon coating on LiFePO4 cathode materials for lithium-ion batteries. Energy & Environmental Science, 2012. 5(1): p. 5163-5185'},{id:"B18",body:'Li, H., et al., Ultrahigh-Capacity and Fire-Resistant LiFePO4-Based Composite Cathodes for Advanced Lithium-Ion Batteries. Advanced Energy Materials, 2019. 9(10)'},{id:"B19",body:'Xiao, J., et al., Synthesis and Characterization of Lithium Manganese Phosphate by a Precipitation Method. Journal of the Electrochemical Society, 2010. 157(2): p. A142-A147'},{id:"B20",body:'Xiao, J., et al., Electrochemical performances of LiMnPO4 synthesized from non-stoichiometric Li/Mn ratio. Phys Chem Chem Phys, 2011. 13(40): p. 18099-18106'},{id:"B21",body:'Guo, H., et al., Performance Improvement of Lithium Manganese Phosphate by Controllable Morphology Tailoring with Acid-Engaged Nano Engineering. Inorganic Chemistry, 2015. 54(2): p. 667-674'},{id:"B22",body:'Wang, D., et al., High-performance, nano-structured LiMnPO4 synthesized via a polyol method. Journal of Power Sources, 2009. 189(1): p. 624-628'},{id:"B23",body:'Yang, W., et al., LiMn0.8Fe0.2PO4/C cathode material synthesized via co-precipitation method with superior high-rate and low-temperature performances for lithium-ion batteries. Journal of Power Sources, 2015. 275: p. 785-791'},{id:"B24",body:'Wang, D., et al., Improving the Electrochemical Activity of LiMnPO4 Via Mn-Site Substitution. Journal of The Electrochemical Society, 2010. 157(2): p. A225-A229'},{id:"B25",body:'Du, G., et al., Additives to disturb LiMn0.8Fe0.2PO4 growth and their influence on performance. Journal of Nanoparticle Research, 2015. 17(6)'},{id:"B26",body:'Xu, X., et al., Improvement of electrochemical activity of LiMnPO4-based cathode by surface iron enrichment. Journal of Power Sources, 2017. 341: p. 175-182'},{id:"B27",body:'Tang, Y., et al., Li2NaV2(PO4)3: A novel composite cathode material with high ratio of rhombohedral phase. Journal of Power Sources, 2013. 227: p. 199-203'},{id:"B28",body:'Rui, X.H., et al., Li3V2(PO4)(3) cathode materials for lithium-ion batteries: A review. Journal of Power Sources, 2014. 258: p. 19-38'},{id:"B29",body:'Wang, C., et al., Investigation of (1 − x)LiMnPO4·xLi3V2(PO4)3/C: Phase composition and electrochemical performance. Journal of Power Sources, 2014. 263: p. 332-337'},{id:"B30",body:'Bi, Y., et al., Influence of Li3V2(PO4)3 complexing on the performance of LiMnPO4 based materials utilized in lithium ion battery. Ceramics International, 2014. 40(5): p. 7637-7641'},{id:"B31",body:'Bi, Y.J., et al., Reversible planar gliding and microcracking in a single-crystalline Ni-rich cathode. Science, 2020. 370(6522): p. 1313-+'},{id:"B32",body:'Xu, C., et al., Phase Behavior during Electrochemical Cycling of Ni-Rich Cathode Materials for Li-Ion Batteries. Advanced Energy Materials, 2021. 11(7)'},{id:"B33",body:'Bi, Y., et al., Highly stable Ni-rich layered oxide cathode enabled by a thick protective layer with bio-tissue structure. Energy Storage Materials, 2020. 24: p. 291-296'},{id:"B34",body:'Noh, H.-J., et al., Comparison of the structural and electrochemical properties of layered Li[NixCoyMnz]O2 (x = 1/3, 0.5, 0.6, 0.7, 0.8 and 0.85) cathode material for lithium-ion batteries. Journal of Power Sources, 2013. 233: p. 121-130'},{id:"B35",body:'Liu, J., et al., Re-considering the LiMn1-xFexPO4/C cathodes utilized in electric vehicles. Ionics, 2020. 26(7): p. 3215-3221'},{id:"B36",body:'Sun, G., et al., Synergistic Effect between LiNi0.5Co0.2Mn0.3O2 and LiFe0.15Mn0.85PO4/C on Rate and Thermal Performance for Lithium Ion Batteries. ACS Appl Mater Interfaces, 2018. 10(19): p. 16458-16466'},{id:"B37",body:'Zhang, H.S., et al., Olivine LiFePO4 as an additive into LiCoO2 electrodes for LIBs to improve high-voltage performances. Journal of Alloys and Compounds, 2021. 869'},{id:"B38",body:'Heubner, C., et al., Internal dynamics of blended Li-insertion electrodes. Journal of Energy Storage, 2018. 20: p. 101-108'},{id:"B39",body:'Etiemble, A., et al., Multiscale morphological characterization of process induced heterogeneities in blended positive electrodes for lithium-ion batteries. Journal of Materials Science, 2017. 52(7): p. 3576-3596'},{id:"B40",body:'Besnard, N., et al., MultiscaleMorphologicaland Electrical Characterization of Charge Transport Limitations to the Power Performance of Positive Electrode Blends for Lithium-Ion Batteries. Advanced Energy Materials, 2017. 7(8)'},{id:"B41",body:'Klein, A., P. Axmann, and M. Wohlfahrt-Mehrens, Origin of the Synergetic Effects of LiFe0.3Mn0.7PO4 - Spinel Blends via Dynamic In Situ X-ray Diffraction Measurements. Journal of the Electrochemical Society, 2016. 163(9): p. A1936-A1940'},{id:"B42",body:'Klein, A., P. Axmann, and M. Wohlfahrt-Mehrens, Synergetic effects of LiFe0.3Mn0.7PO4-LiMn1.9Al0.1O4 blend electrodes. Journal of Power Sources, 2016. 309: p. 169-177'},{id:"B43",body:'Zhan, C., et al., Mn(II) deposition on anodes and its effects on capacity fade in spinel lithium manganate-carbon systems. Nat Commun, 2013. 4: p. 2437'},{id:"B44",body:'Tran, H.Y., et al., LiMn2O4 Spinel/LiNi0.8Co0.15Al0.05O2 Blends as Cathode Materials for Lithium-Ion Batteries. Journal of The Electrochemical Society, 2011. 158(5)'},{id:"B45",body:'Jobst, N.M., et al., Ternary Cathode Blend Electrodes for Environmentally Friendly Lithium-Ion Batteries. Chemsuschem, 2020. 13(15): p. 3928-3936'},{id:"B46",body:'Liebmann, T., et al., Investigations on the Effective Electric Loads in Blended Insertion Electrodes for Lithium-Ion Batteries. ChemElectroChem, 2019. 6(22): p. 5728-5734'},{id:"B47",body:'Feng, X.N., et al., Thermal runaway mechanism of lithium ion battery for electric vehicles: A review. Energy Storage Materials, 2018. 10: p. 246-267'},{id:"B48",body:'Chen, Y.Q., et al., A review of lithium-ion battery safety concerns: The issues, strategies, and testing standards. Journal of Energy Chemistry, 2021. 59: p. 83-99'},{id:"B49",body:'Zaghib, K., et al., Enhanced thermal safety and high power performance of carbon-coated LiFePO4 olivine cathode for Li-ion batteries. Journal of Power Sources, 2012. 219: p. 36-44'},{id:"B50",body:'Bak, S.M., et al., Structural Changes and Thermal Stability of Charged LiNixMnyCozO2 Cathode Materials Studied by Combined In Situ Time-Resolved XRD and Mass Spectroscopy. Acs Applied Materials & Interfaces, 2014. 6(24): p. 22594-22601'},{id:"B51",body:'Du, R., et al., Improved cyclic stability of LiNi0.8Co0.1Mn0.1O2 via Ti substitution with a cut-off potential of 4.5 V. Ceramics International, 2015. 41(5): p. 7133-7139'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Yujing Bi",address:"biyujing15@hotmail.com",affiliation:'
Ningbo Institute of Materials Technology and Engineering, CAS, China
Ningbo Institute of Materials Technology and Engineering, CAS, China
Jianghan University, China
'}],corrections:null},book:{id:"10969",type:"book",title:"New Perspectives on Electric Vehicles",subtitle:null,fullTitle:"New Perspectives on Electric Vehicles",slug:"new-perspectives-on-electric-vehicles",publishedDate:"March 30th 2022",bookSignature:"Marian Găiceanu",coverURL:"https://cdn.intechopen.com/books/images_new/10969.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-83969-615-2",printIsbn:"978-1-83969-614-5",pdfIsbn:"978-1-83969-616-9",isAvailableForWebshopOrdering:!0,editors:[{id:"169608",title:"Prof.",name:"Marian",middleName:null,surname:"Găiceanu",slug:"marian-gaiceanu",fullName:"Marian Găiceanu"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}}},profile:{item:{id:"440667",title:"Mr.",name:"Ajithkumar",middleName:null,surname:"Balakrishnan",email:"ajibioinfo7597@gmail.com",fullName:"Ajithkumar Balakrishnan",slug:"ajithkumar-balakrishnan",position:null,biography:null,institutionString:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",totalCites:0,totalChapterViews:"0",outsideEditionCount:0,totalAuthoredChapters:"1",totalEditedBooks:"0",personalWebsiteURL:null,twitterURL:null,linkedinURL:null,institution:{name:"Bharathiar University",institutionURL:null,country:{name:"India"}}},booksEdited:[],chaptersAuthored:[{id:"79814",title:"Cellular Functions of ER Chaperones in Regulating Protein Misfolding and Aggregation: An Emerging Therapeutic Approach for Preeclampsia",slug:"cellular-functions-of-er-chaperones-in-regulating-protein-misfolding-and-aggregation-an-emerging-the",abstract:"Proteinuria is one of the hallmarks of preeclampsia (PE) that differentiates other hypertensive disorders of pregnancy. 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IntechOpen is the first native scientific publisher of Open Access books, with more than 116,000 authors worldwide, ranging from globally-renowned Nobel Prize winners to up-and-coming researchers at the cutting edge of scientific discovery. Established in Europe with the new headquarters based in London, and with plans for international growth, IntechOpen is the leading publisher of Open Access scientific books. The values of our business are based on the same ones that any scientist applies to their research -- we have created a culture of respect, collegiality and collaboration within an atmosphere that’s relaxed, friendly and progressive.
",metaTitle:"Social Media Community Manager and Marketing Assistant",metaDescription:"We are looking to add further talent to our team in The Shard office in London with a full-time Marketing and Communications Specialist position. The candidate will bring with them a creative and enthusiastic mindset, high level problem-solving skills, the latest marketing and social media platforms skills and strong involvement in community-best practices to engage with researchers and scholars online. The ideal candidate will be a dynamic, forward thinking, approachable team player, able to communicate with all in the global, growing company, with an ability to understand and build a rapport within the research community.",metaKeywords:null,canonicalURL:null,contentRaw:'[{"type":"htmlEditorComponent","content":"
We are looking to add further talent to our team in The Shard office in London with a full-time Social Media Community Manager and Marketing Assistant position. The candidate will bring with them a creative and enthusiastic mindset, high level problem-solving skills, the latest marketing and social media platforms skills and strong involvement in community-best practices to engage with researchers and scholars online. The ideal candidate wll be a dynamic, forward thinking, approachable team player, able to communicate with all in the global, growing company, with an ability to understand and build a rapport within the research community.
\\n\\n
The Social Media Community Manager and Marketing Assistant will report to the Senior Marketing Manager. They will work alongside the Marketing and Corporate Communications team, supporting the preparation of all marketing programs, assisting in the development of scientific marketing and communication deliverables, and creating content for social media outlets, as well as managing international social communities.
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Responsibilities:
\\n\\n
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Assist in developing creative ideas and implementing materials to support marketing campaigns and events. Deliver projects as part of overall company marketing programme
\\n\\t
Play a key part in workshops for current and new programme ideas, collate ideas and recommendations for tactical programme elements
\\n\\t
Support marketing program preparation and wrap up (e.g., agendas, meeting notes, topics for discussion, background research, setting up campaigns, preparing lists)
\\n\\t
Preparation and content building for online and print material.
\\n\\t
Support relationships with external partners from across the scholarly communications and research, including overall research and support of the academic and institutional liaison program
\\n\\t
Social and Community moderation and monitoring to ensure high quality of answers provided via digital communities (e.g. research communities, LinkedIn, forums)
\\n\\t
Identify and implement effective social media coverage and monitoring tools. ie. Social listening
\\n\\t
Create content for different social media platforms (e.g. LinkedIn, Twitter, Facebook, blogs)
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Influencer and community outreach content
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Contribute creative ideas for using social media in existing programmes
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\\n\\n
Essential Skills:
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2-3 years of experience supporting marketing programme, including social and community experience with an understanding of how digital communication fits into the overall communications and marketing programmes
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Excellent communications skills -- able to write in a clear, explanatory and customer-focused manner, with a demonstrated strong command over the English language.
\\n\\t
Strong copywriting skills -- will be called upon to write online including hard copy content.
\\n\\t
Experience of engaging customers using social media technologies, platforms, listening programs and tracking/analytics. Evidence will be required.
\\n\\t
Experience of leveraging influencer communities and managing content strategies to maximise customer engagement. Examples will be required.
\\n\\t
Superb organisational skills - ability to take ownership and manage time effectively, as well as manage multiple priorities while maintaining a high level of accuracy within an environment of continuous change
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Self-starter able to work to deadlines with minimal supervision
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Team player with a learning and forward-thinking mindset who fosters a strong working environment with flexibility and willingness to work on a variety of different programs
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Desired Skills:
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Experience in supporting programs with external partners, including global companies
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Previous experience of working with research, academia or scholarly communications
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Knowledge of open science, open research or open access
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What makes IntechOpen a great place to work?
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IntechOpen is a global, dynamic and fast-growing company offering excellent opportunities to develop. We are a young and vibrant company where great people do great work. We offer a creative, dedicated, committed, passionate, and above all, fun environment where you can work, travel, meet world-renowned researchers and grow your career and experience.
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Competitive salary
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Interactions with all areas of our business in all offices, which can lead to opportunities for career advancement
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Collaboration with scientists and publishing experts worldwide
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Insight into book editorial and production processes
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To apply, please email a copy of your CV and covering letter to hogan@intechopen.com stating your salary expectations.
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Note: This full-time position will have an immediate start. In your cover letter, please indicate when you might be available for a block of two hours. As part of the interview process, all candidates that make it to the second phase will participate in a writing exercise.
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*IntechOpen is an Equal Opportunities Employer consistent with its obligations under the law and does not discriminate against any employee or applicant on the basis of disability, gender, age, colour, national origin, race, religion, sexual orientation, war veteran status, or any classification protected by state, or local law.
We are looking to add further talent to our team in The Shard office in London with a full-time Social Media Community Manager and Marketing Assistant position. The candidate will bring with them a creative and enthusiastic mindset, high level problem-solving skills, the latest marketing and social media platforms skills and strong involvement in community-best practices to engage with researchers and scholars online. The ideal candidate wll be a dynamic, forward thinking, approachable team player, able to communicate with all in the global, growing company, with an ability to understand and build a rapport within the research community.
\n\n
The Social Media Community Manager and Marketing Assistant will report to the Senior Marketing Manager. They will work alongside the Marketing and Corporate Communications team, supporting the preparation of all marketing programs, assisting in the development of scientific marketing and communication deliverables, and creating content for social media outlets, as well as managing international social communities.
\n\n
Responsibilities:
\n\n
\n\t
Assist in developing creative ideas and implementing materials to support marketing campaigns and events. Deliver projects as part of overall company marketing programme
\n\t
Play a key part in workshops for current and new programme ideas, collate ideas and recommendations for tactical programme elements
\n\t
Support marketing program preparation and wrap up (e.g., agendas, meeting notes, topics for discussion, background research, setting up campaigns, preparing lists)
\n\t
Preparation and content building for online and print material.
\n\t
Support relationships with external partners from across the scholarly communications and research, including overall research and support of the academic and institutional liaison program
\n\t
Social and Community moderation and monitoring to ensure high quality of answers provided via digital communities (e.g. research communities, LinkedIn, forums)
\n\t
Identify and implement effective social media coverage and monitoring tools. ie. Social listening
\n\t
Create content for different social media platforms (e.g. LinkedIn, Twitter, Facebook, blogs)
\n\t
Influencer and community outreach content
\n\t
Contribute creative ideas for using social media in existing programmes
\n
\n\n
Essential Skills:
\n\n
\n\t
2-3 years of experience supporting marketing programme, including social and community experience with an understanding of how digital communication fits into the overall communications and marketing programmes
\n\t
Excellent communications skills -- able to write in a clear, explanatory and customer-focused manner, with a demonstrated strong command over the English language.
\n\t
Strong copywriting skills -- will be called upon to write online including hard copy content.
\n\t
Experience of engaging customers using social media technologies, platforms, listening programs and tracking/analytics. Evidence will be required.
\n\t
Experience of leveraging influencer communities and managing content strategies to maximise customer engagement. Examples will be required.
\n\t
Superb organisational skills - ability to take ownership and manage time effectively, as well as manage multiple priorities while maintaining a high level of accuracy within an environment of continuous change
\n\t
Self-starter able to work to deadlines with minimal supervision
\n\t
Team player with a learning and forward-thinking mindset who fosters a strong working environment with flexibility and willingness to work on a variety of different programs
\n
\n\n
Desired Skills:
\n\n
\n\t
Experience in supporting programs with external partners, including global companies
\n\t
Previous experience of working with research, academia or scholarly communications
\n\t
Knowledge of open science, open research or open access
\n
\n\n
What makes IntechOpen a great place to work?
\n\n
IntechOpen is a global, dynamic and fast-growing company offering excellent opportunities to develop. We are a young and vibrant company where great people do great work. We offer a creative, dedicated, committed, passionate, and above all, fun environment where you can work, travel, meet world-renowned researchers and grow your career and experience.
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\n\t
Competitive salary
\n\t
Interactions with all areas of our business in all offices, which can lead to opportunities for career advancement
\n\t
Collaboration with scientists and publishing experts worldwide
\n\t
Insight into book editorial and production processes
\n
\n\n
To apply, please email a copy of your CV and covering letter to hogan@intechopen.com stating your salary expectations.
\n\n
Note: This full-time position will have an immediate start. In your cover letter, please indicate when you might be available for a block of two hours. As part of the interview process, all candidates that make it to the second phase will participate in a writing exercise.
\n\n
*IntechOpen is an Equal Opportunities Employer consistent with its obligations under the law and does not discriminate against any employee or applicant on the basis of disability, gender, age, colour, national origin, race, religion, sexual orientation, war veteran status, or any classification protected by state, or local law.
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\r\n\tIn general, the harsher the environmental conditions in an ecosystem, the lower the biodiversity. Changes in the environment caused by human activity accelerate the impoverishment of biodiversity.
\r\n
\r\n\tBiodiversity refers to “the variability of living organisms from any source, including terrestrial, marine and other aquatic ecosystems and the ecological complexes of which they are part; it includes diversity within each species, between species, and that of ecosystems”.
\r\n
\r\n\tBiodiversity provides food security and constitutes a gene pool for biotechnology, especially in the field of agriculture and medicine, and promotes the development of ecotourism.
\r\n
\r\n\tCurrently, biologists admit that we are witnessing the first phases of the seventh mass extinction caused by human intervention. It is estimated that the current rate of extinction is between a hundred and a thousand times faster than it was when man first appeared. The disappearance of species is caused not only by an accelerated rate of extinction, but also by a decrease in the rate of emergence of new species as human activities degrade the natural environment. The conservation of biological diversity is "a common concern of humanity" and an integral part of the development process. Its objectives are “the conservation of biological diversity, the sustainable use of its components, and the fair and equitable sharing of the benefits resulting from the use of genetic resources”.
\r\n
\r\n\tThe following are the main causes of biodiversity loss:
\r\n
\r\n\t• The destruction of natural habitats to expand urban and agricultural areas and to obtain timber, minerals and other natural resources.
\r\n
\r\n\t• The introduction of alien species into a habitat, whether intentionally or unintentionally which has an impact on the fauna and flora of the area, and as a result, they are reduced or become extinct.
\r\n
\r\n\t• Pollution from industrial and agricultural products, which devastate the fauna and flora, especially those in fresh water.
\r\n
\r\n\t• Global warming, which is seen as a threat to biological diversity, and will become increasingly important in the future.
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Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. Since 2011, he has been a reviewer of grants and projects (including EU projects) in biomedical engineering.",institutionString:null,institution:{name:"University of Silesia",institutionURL:null,country:{name:"Poland"}}},subseries:[{id:"7",title:"Bioinformatics and Medical Informatics",keywords:"Biomedical Data, Drug Discovery, Clinical Diagnostics, Decoding Human Genome, AI in Personalized Medicine, Disease-prevention Strategies, Big Data Analysis in Medicine",scope:"Bioinformatics aims to help understand the functioning of the mechanisms of living organisms through the construction and use of quantitative tools. The applications of this research cover many related fields, such as biotechnology and medicine, where, for example, Bioinformatics contributes to faster drug design, DNA analysis in forensics, and DNA sequence analysis in the field of personalized medicine. Personalized medicine is a type of medical care in which treatment is customized individually for each patient. Personalized medicine enables more effective therapy, reduces the costs of therapy and clinical trials, and also minimizes the risk of side effects. Nevertheless, advances in personalized medicine would not have been possible without bioinformatics, which can analyze the human genome and other vast amounts of biomedical data, especially in genetics. The rapid growth of information technology enabled the development of new tools to decode human genomes, large-scale studies of genetic variations and medical informatics. The considerable development of technology, including the computing power of computers, is also conducive to the development of bioinformatics, including personalized medicine. In an era of rapidly growing data volumes and ever lower costs of generating, storing and computing data, personalized medicine holds great promises. Modern computational methods used as bioinformatics tools can integrate multi-scale, multi-modal and longitudinal patient data to create even more effective and safer therapy and disease prevention methods. Main aspects of the topic are: Applying bioinformatics in drug discovery and development; Bioinformatics in clinical diagnostics (genetic variants that act as markers for a condition or a disease); Blockchain and Artificial Intelligence/Machine Learning in personalized medicine; Customize disease-prevention strategies in personalized medicine; Big data analysis in personalized medicine; Translating stratification algorithms into clinical practice of personalized medicine.",annualVolume:11403,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/7.jpg",editor:{id:"351533",title:"Dr.",name:"Slawomir",middleName:null,surname:"Wilczynski",fullName:"Slawomir Wilczynski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035U1loQAC/Profile_Picture_1630074514792",institutionString:null,institution:{name:"Medical University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"5886",title:"Dr.",name:"Alexandros",middleName:"T.",surname:"Tzallas",fullName:"Alexandros Tzallas",profilePictureURL:"https://mts.intechopen.com/storage/users/5886/images/system/5886.png",institutionString:"University of Ioannina, Greece & Imperial College London",institution:{name:"University of Ioannina",institutionURL:null,country:{name:"Greece"}}},{id:"257388",title:"Distinguished Prof.",name:"Lulu",middleName:null,surname:"Wang",fullName:"Lulu Wang",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRX6kQAG/Profile_Picture_1630329584194",institutionString:null,institution:{name:"Shenzhen Technology University",institutionURL:null,country:{name:"China"}}},{id:"225387",title:"Prof.",name:"Reda",middleName:"R.",surname:"Gharieb",fullName:"Reda Gharieb",profilePictureURL:"https://mts.intechopen.com/storage/users/225387/images/system/225387.jpg",institutionString:"Assiut University",institution:{name:"Assiut University",institutionURL:null,country:{name:"Egypt"}}}]},{id:"8",title:"Bioinspired Technology and Biomechanics",keywords:"Bioinspired Systems, Biomechanics, Assistive Technology, Rehabilitation",scope:'Bioinspired technologies take advantage of understanding the actual biological system to provide solutions to problems in several areas. Recently, bioinspired systems have been successfully employing biomechanics to develop and improve assistive technology and rehabilitation devices. The research topic "Bioinspired Technology and Biomechanics" welcomes studies reporting recent advances in bioinspired technologies that contribute to individuals\' health, inclusion, and rehabilitation. Possible contributions can address (but are not limited to) the following research topics: Bioinspired design and control of exoskeletons, orthoses, and prostheses; Experimental evaluation of the effect of assistive devices (e.g., influence on gait, balance, and neuromuscular system); Bioinspired technologies for rehabilitation, including clinical studies reporting evaluations; Application of neuromuscular and biomechanical models to the development of bioinspired technology.',annualVolume:11404,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",institutionString:null,institution:{name:"Federal University of Uberlândia",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"49517",title:"Prof.",name:"Hitoshi",middleName:null,surname:"Tsunashima",fullName:"Hitoshi Tsunashima",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYTP4QAO/Profile_Picture_1625819726528",institutionString:null,institution:{name:"Nihon University",institutionURL:null,country:{name:"Japan"}}},{id:"425354",title:"Dr.",name:"Marcus",middleName:"Fraga",surname:"Vieira",fullName:"Marcus Vieira",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003BJSgIQAX/Profile_Picture_1627904687309",institutionString:null,institution:{name:"Universidade Federal de Goiás",institutionURL:null,country:{name:"Brazil"}}},{id:"196746",title:"Dr.",name:"Ramana",middleName:null,surname:"Vinjamuri",fullName:"Ramana Vinjamuri",profilePictureURL:"https://mts.intechopen.com/storage/users/196746/images/system/196746.jpeg",institutionString:"University of Maryland, Baltimore County",institution:{name:"University of Maryland, Baltimore County",institutionURL:null,country:{name:"United States of America"}}}]},{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering",keywords:"Biotechnology, Biosensors, Biomaterials, Tissue Engineering",scope:"The Biotechnology - Biosensors, Biomaterials and Tissue Engineering topic within the Biomedical Engineering Series aims to rapidly publish contributions on all aspects of biotechnology, biosensors, biomaterial and tissue engineering. We encourage the submission of manuscripts that provide novel and mechanistic insights that report significant advances in the fields. Topics can include but are not limited to: Biotechnology such as biotechnological products and process engineering; Biotechnologically relevant enzymes and proteins; Bioenergy and biofuels; Applied genetics and molecular biotechnology; Genomics, transcriptomics, proteomics; Applied microbial and cell physiology; Environmental biotechnology; Methods and protocols. Moreover, topics in biosensor technology, like sensors that incorporate enzymes, antibodies, nucleic acids, whole cells, tissues and organelles, and other biological or biologically inspired components will be considered, and topics exploring transducers, including those based on electrochemical and optical piezoelectric, thermal, magnetic, and micromechanical elements. Chapters exploring biomaterial approaches such as polymer synthesis and characterization, drug and gene vector design, biocompatibility, immunology and toxicology, and self-assembly at the nanoscale, are welcome. Finally, the tissue engineering subcategory will support topics such as the fundamentals of stem cells and progenitor cells and their proliferation, differentiation, bioreactors for three-dimensional culture and studies of phenotypic changes, stem and progenitor cells, both short and long term, ex vivo and in vivo implantation both in preclinical models and also in clinical trials.",annualVolume:11405,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",institutionString:null,institution:{name:"Autonomous University of Baja California",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"35539",title:"Dr.",name:"Cecilia",middleName:null,surname:"Cristea",fullName:"Cecilia Cristea",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYQ65QAG/Profile_Picture_1621007741527",institutionString:null,institution:{name:"Iuliu Hațieganu University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"40735",title:"Dr.",name:"Gil",middleName:"Alberto Batista",surname:"Gonçalves",fullName:"Gil Gonçalves",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYRLGQA4/Profile_Picture_1628492612759",institutionString:null,institution:{name:"University of Aveiro",institutionURL:null,country:{name:"Portugal"}}},{id:"211725",title:"Associate Prof.",name:"Johann F.",middleName:null,surname:"Osma",fullName:"Johann F. Osma",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSDv7QAG/Profile_Picture_1626602531691",institutionString:null,institution:{name:"Universidad de Los Andes",institutionURL:null,country:{name:"Colombia"}}},{id:"69697",title:"Dr.",name:"Mani T.",middleName:null,surname:"Valarmathi",fullName:"Mani T. Valarmathi",profilePictureURL:"https://mts.intechopen.com/storage/users/69697/images/system/69697.jpg",institutionString:"Religen Inc. | A Life Science Company, United States of America",institution:null},{id:"205081",title:"Dr.",name:"Marco",middleName:"Vinícius",surname:"Chaud",fullName:"Marco Chaud",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSDGeQAO/Profile_Picture_1622624307737",institutionString:null,institution:{name:"Universidade de Sorocaba",institutionURL:null,country:{name:"Brazil"}}}]}]}},libraryRecommendation:{success:null,errors:{},institutions:[]},route:{name:"profile.detail",path:"/profiles/440667",hash:"",query:{},params:{id:"440667"},fullPath:"/profiles/440667",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var t;(t=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(t)}()