Endometriosis / Infertility
What is endometriosis?
Endometriosis is a condition whereby the normal endometrial tissue that lines the uterus is in an abnormal location, i.e., in the pelvis and/or abdomen. There are multiple theories as to the cause of endometriosis. The most widely held is the idea of retrograde menstruation, whereby menstrual efflux instead of draining through the cervix and vagina backs up, goes through the tube and implants on the surfaces (peritoneum) of the pelvis and abdomen. This tissue grows and bleeds just like the tissue in the uterus. Bleeding is looked at as an injury, i.e., an abnormal condition, whereby the body tries to heal itself, causing scarring. Scarring can distort or damage the tubes, ovaries and other pelvic/abdominal organs. Endometriosis if it is in areas where there are nerves can cause pain. The pain with endometriosis typically occurs just prior to and with menses and generally improves after bleeding.
How common is endometriosis?
Endometriosis is reported in 5-10% of menstruating women. Amongst infertility patients this number increases dramatically. If an individual has a first degree relative with endometriosis the incidence of endometriosis is approximately seven times greater.
How is endometriosis diagnosed?
Endometriosis is diagnosed primarily via laparoscopy. Laparoscopy involves introducing a small diameter scope through the umbilicus using CO2 to distend the pelvic/abdominal cavity. Using additional laparoscopic instruments endometriosis can be removed. There are various techniques to remove endometriosis depending on size, depth and location of the lesions. In general it is possible to remove lower degrees of endometriosis, i.e., stage 1, 2 and early stage 3 disease. Advanced stage 3 and stage 4 disease is often diffusely distributed throughout the pelvis and abdomen and may not be able to be fully removed. In cases of advanced endometriosis where fertility is desired, often IVF is the preferred option to “bypass” the disease. It is controversial whether endometriosis affects IVF success rates and to what extent. At the Florida Institute for Reproductive Medicine we have not seen any appreciable decrease in pregnancy rates. A particularly troubling form of endometriosis is when it organizes and grows in the ovary (an endometrioma) destroying the source of eggs. Sometimes it is appropriate to remove endometriomas, other times to leave them alone – whenever surgery is performed there is the potential to damage healthy egg producing tissue.
Treatment for endometriosis for non-fertility patients.
If an individual has endometriosis and infertility is not a concern often suppressive medication in the form of a birth control pill or shots of long acting progesterone or GnRH agonist can be used to “turn off” the menstrual cycle. In general anything that prevents the menstrual cycle will improve pain. Long acting progesterone and/or GnRH agonist can only be used for short periods of time as their suppressive effects can affect bone health. For long term suppressive care, a progestin dominant birth control pill, used in a continuous manner is the treatment of choice. Once childbearing has been resolved, if pain is still significant with suppressive therapy, hysterectomy with unilateral or bilateral removal of an ovary(s) with aggressive resection of disease offers the best chance for long-term pain relief.