Awadia Gareeballah ¹ Moawia Gameraddin ¹ Sultan Abdulwadoud Alshoabi ¹ Amirah Alsaedi ¹ Maisa Elzaki ¹ Walaa Alsharif ¹ Ibrahim Mohamed Daoud ² Shoroog T. Aldahery ³ Magbool Alelyani ⁴ E Abdelrahim ⁵ Fahad Elhazmi ¹ Raga Ahmed Abouraida ⁴ Mayeen Khandaker ⁶ Zuhal Y Hamd ^7*

• ¹ Taibah University, Medina, Al Madinah, Saudi Arabia
• ² Al Zaiem Al Azhari University, Khartoum, Khartoum, Sudan
• ³ Jeddah University, Jeddah, Makkah, Saudi Arabia
• ⁴ King Khalid University, Abha, Saudi Arabia
• ⁵ Taif University, Ta'if, Saudi Arabia
• ⁶ Sunway University, Bandar Sunway, Selangor Darul Ehsan, Malaysia
• ⁷ Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia

Introduction Adnexal masses are a common health issue in gynecology; the challenge lies in the differential diagnosis of these masses. The International Ovarian Tumor Analysis Simple Rules (IOTA-SR) offer the first scoring system to aid in diagnosis. They are based on a set of five ultrasound imaging features indicative of a malignant ovarian tumor and five features indicative of a benign tumor. This review aims to assess the diagnostic performance of IOTA-SR for classifying ovarian tumors as benign or malignant.Methods A systematic review was conducted on MEDLINE, EMBASE, Google Scholar, Scopus, and Web of Science. The "IOTA -SR," "Adnexal, mass," and "ovarian tumors scoring" were terminology employed. Twenty-seven research articles conducted from 2008 -2022 were included in the metanalysis; the publication outcome indicates performance quality tests were extracted directly or indirectly, including true positive (TP), false positive (FP), true negative (TN), and false negative (TN). The Quality Assessment of the Diagnostic Accuracy of Studies (QUADAS-2) was used to evaluate the study quality and estimate the risk of bias. After estimating the pooled effect of the sensitivity, specificity, and diagnostic odds ratio (DOR), the summary receiver operating characteristic (SROC) curve was estimated using the bivariate random effects model. Utilizing the Cochrane Q statistics and Higgins inconsistency test through the I 2 index for pooled analysis, the heterogeneity of studies was quantitatively evaluated. The funnel plot and Egger test were utilized to visually and quantitatively evaluate potential publication bias. Results: Among 27 studies, including 7841 adnexal masses, the results of this meta-analysis showed excellent diagnostic performance with a pooled sensitivity of 92% (95% confidence interval (CI) 0.89-0.94) and a pooled specificity of 92% (95% CI 0.89-0.94). The IOTA-SR is applicable in 85.7% of adnexal masses. Conclusion The IOTA-SR is highly effective in the presurgical differentiation of malignant versus benign adnexal masses when applied by an expert ultrasonography operator.