ARC® Fertility Articles

Endometriosis and Infertility

Eli Reshef. M.D.
http://www.integrisok.com/fertility
INTEGRIS Baptist Medical Center
3433 NW 56th, Building B
Oklahoma City, OK 73112
Ph: (405) 949-6060

Endometriosis

Definition:
 A condition in which tissue that resembles the lining of the uterus (endometrium) is found outside the uterus. While the most common locations for the lesions are behind the uterus (cul-de-sac), on the ovaries, or on the bladder surface, lesions have also been found in the bowel, appendix, c-section scars, lungs, and even the eye.

Incidence: In the general population, 7-10% of women have endometriosis. Among infertile women, 20-50% have this condition. The incidence of endometriosis has not been increasing. This condition can occur in any woman regardless of race. First-degree relatives of women with endometriosis have 10-fold increased chance of developing the condition.

Causes: Cells from the cavity of the uterus commonly are found in the abdominal cavity during menstruation (retrograde menstruation). In some women, perhaps because of inability of the immune system to reject such cells, they will implant and grow. Other theories of endometriosis include change of normal cells inside the abdomen to endometrial cells under unusual stimulation, and spread of cells from inside the uterus through blood vessels to distant areas.

Signs and Symptoms: Many patients with endometriosis have no symptoms. The severity of symptoms does not correlate with the severity of endometriosis. Painful periods (dysmenorrhea), painful intercourse (dyspareunia), infertility, and irregular periods are the most common symptoms. Tenderness during a pelvic examination and the presence of nodules or cysts are typical signs though not very common overall.

Diagnosis: Direct visualization of the condition confirmed by biopsy (if the surgeon is uncertain about the lesions) is the standard for diagnosis of endometriosis. This is usually done by laparoscopy as an outpatient. Physical examination and history are very unreliable and should not be used to establish the diagnosis. Imaging procedures such as ultrasound or MRI may be suggestive but not diagnostic. The severity of endometriosis is classified in 4 stages (minimal, mild, moderate, severe) based on visual criteria at surgery that take into account the size, depth and location of lesions, as well as accompanying scar tissue.

Treatment: Options include no treatment, medical treatment, or surgical treatment. No treatment is an appropriate option when endometriosis was diagnosed already and/or previously treated, and the patient is asymptomatic. Medical treatment includes birth control pills, progestin (e.g. norethindrone), danazol (rarely used due to side effects), or GnRH-agonists (e.g. Depo-Lupron). Surgical options include laparoscopic treatment (by laser or non-laser instruments) as an outpatient; by laparotomy (larger abdominal incision, usually requiring a short hospitalization- an uncommon practice nowadays); or a hysterectomy, with or without removal of ovaries. Treatment must take into account the patient’s wishes for future fertility; the severity of her symptoms and the resulting disability from symptoms; previous treatments and treatment failures; and side effects and tolerance of medications. FIRST DO NO HARM should be the motto for the doctor treating endometriosis and also what the patient should keep in mind when considering treatment options.

Endometriosis and Infertility:
Infertility patients have an increased prevalence of endometriosis. Patients with endometriosis are more likely to be infertile. The greater the extent of endometriosis, the lesser the likelihood of pregnancy. Medical or surgical treatment of endometriosis often improves fertility. How does endometriosis contribute to infertility? In cases of significant amount of endometriosis, scar tissue involving the tubes or ovaries may interfere with the normal mechanism of egg capture by the fallopian tubes following ovulation. Another possible mechanism contributing to infertility is the various inflammatory substances released in response to endometriosis lesions that may interfere with ovulation and sperm function.

Surgical treatment of endometriosis, now mostly accomplished by outpatient laparoscopy, may generally improve fertility by 25%. Treatment of low grades of endometriosis (minimal or mild) by surgery results in only modest amount of increase in fertility. Nevertheless, if laparoscopy is performed for diagnostic purposes, it is advisable to treat endometriosis even if it is limited. In vitro fertilization (IVF) should be considered for infertile patients with significant amounts of endometriosis (moderate or severe). While severe endometriosis may be associated with some reduction in egg quality, especially if present on the ovaries (endometriomas), IVF still offers greater chance of pregnancy to patients with severe disease compared with other infertility treatments. Care must be taken when surgically treating ovarian endometriosis (endometriomas), since overly aggressive treatment may result in reduction in blood supply to the ovary and reduction in ovarian response.

©Copyright Eli Reshef MD