ENDOMETRIOSIS
Endometriosis affects about 10 -15% of the general population of reproductive age women. Endometriosis is found in 30-40% of all infertility patients.
What is Endometriosis?
Endometriosis is a medical condition where the endometrial tissue (the tissue that lines the inner cavity of the uterus) grows outside the uterus in other locations.
What are the symptoms of Endometriosis?
Common symptoms of endometriosis include:
1. Pelvic pain during menstruation
2. Discomfort with sexual intercourse
3. The inability to conceive
What I commonly encounter with endometriosis is that the pelvic pain becomes worse with time and is alleviated while taking the birth control pill. On an internal exam, one can sometimes feel tender nodules behind the uterus. On sonogram, there may be an ovarian cyst that appears to be solid in appearance rather than liquid.
How does one diagnose Endometriosis?
The only way to diagnose endometriosis is to do a laparoscopy.
The history, findings on exam, and sonogram appearance we discussed above can only suggest endometriosis is present – but do not in themselves allow for a diagnosis.
How does Endometriosis appear on laparoscopy?
Endometriosis may appear as dark implants (blood-filled nodules) or bands of scar tissue that bind the tubes and ovaries to the intestine or to other structures in the pelvis.
What is staging?
On laparoscopy, endometriosis can be “staged” by the appearance of the dark nodules as well as the amount of scar tissue or adhesions that are noted.
Stage 1 and 2 are minimal to mild.
Stage 3 and 4 are moderate to severe.
Not all surgeons stage endometriosis when they dictate their operative report and there’s also great variation in how different doctors assess what they see. Therefore, I caution patients to understand that mild, moderate or severe is very much dependent upon which doctor is assessing the situation.
Does Endometriosis always affect fertility?
Endometriosis can affect fertility if the scar tissue that forms distorts the normal relationship of the tubes next to the ovary. The tube must be free to move so that it can capture the egg after it is released with ovulation.
Why does endometriosis occur?
The most likely cause for endometriosis is that when the menstrual blood has a difficult time moving out of the uterus and through the cervix – it tends to “back up” into the fallopian tubes and enter the pelvis outside of the uterus. Once this blood gets there, there is an inflammatory response and this can lead to scarring.
Why is endometriosis painful?
When this menstrual blood remains in the pelvis and becomes permanently attached to pelvic organs, it can respond to the hormones of the menstrual cycle (Estrogen and Progesterone) and continue to grow just like the inner lining tissue that grows during the menstrual cycle. This menstrual blood and fragments of endometrial tissue will form implants. These implants will actually bleed during the period and this is most likely the cause of the pelvic pain one can experience.
Why does endometriosis cause scarring?
The more implants that are present, the more likely for scar tissue to begin to develop. As implants bleed, they cause an inflammatory response in the area around them, and this can cause tissues to bind together as part of the healing process.
Why does scar tissue cause infertility?
If scar tissue causes the end of the tube to be stuck to the ovary or the intestines, it will not be able to pick up the egg cell. If these implants grow on the surface of the ovary and form cysts, these cysts can grow in size and are often as big as an orange. Unfortunately when these blood-filled cysts rupture, they can release great amounts of blood in the immediate vicinity and cause even further scarring and pain. There are reports of endometriosis being found on the appendix as well as actually invading into the wall of the rectum causing rectal bleeding during the period.
What treatments are available for endometriosis?
The treatment options for any case of endometriosis are either surgical or hormonal.
Surgical treatments
The surgical treatment is to use either laser or electrocautery (burn) to vaporize the implants or larger lesions. If a surgeon has the skill required, these implants can also be removed by using tiny cutting instruments (small scissors) through the laparoscope. This requires far more surgical skill than just touching the implants with a laser or cautery (burning) probe.
What is the difference between diagnostic and operative laparoscopy?
A diagnostic laparoscopy is when the surgeon only looks and does not attempt to perform a surgical remedy. Operative laparoscopy is when, during surgery, there is a effort made to remove the scarring or the implants.
Hormonal treatments
Hormonal options that treat endometriosis have the sole purpose of reducing the implants. Remember that it is estrogen and progesterone that make these lesions grow. Therefore a hormone therapy is beneficial by reducing the amount of estrogen and progesterone. The birth control pill is able to accomplish this and can therefore can be used to treat this disorder. One can also Lupron because Lupron will suppress FSH and LH – and therefore there will be no stimulation of the follicle to produce estrogen and progesterone.
The advantage of adding hormonal therapy after surgery has been done is to hopefully reduce the likelihood of recurrence of the endometriosis.
Some studies have shown that these medications are not more useful than surgery alone.
When should one try to conceive after surgery for endometriosis?
The best time to try to conceive is immediately after surgery because the tubes have been flushed out and are open and hopefully the tubes and ovaries will remain in normal location.
A Personal Note
My approach to the treatment of endometriosis is a highly individual one where I consider the amount of discomfort the patient has, the length of time she has been trying, the age of the couple and whether there are other fertility factors such as a low sperm count or uterine fibroids.
Additionally, if a patient has had a failed insemination or failed in vitro procedures before the surgery, this must also be part of the equation.
If a patient tries to conceive on their own for several months after surgery for moderate or severe endometriosis – the options at that point are either to proceed with IVF or whether to repeat the laparoscopy and see whether the implants or scar tissue has returned.
In most cases, IVF will be the better choice
