Endometriosis

Endometriosis is a common cause of infertility in women

Endometriosis is the presence and growth of endometrial cells, which are usually found in the lining of the uterus, in other locations throughout the body. Endometrial implants have been found in areas as distant as the lung and brain.

The symptoms of endometriosis include pelvic pain, painful menstruation, pain when urinating or having bowel movements, pain during intercourse, and infertility.

Endometriosis – Causes

The exact cause of endometriosis remains unknown. Although there are several theories to explain its presence, no single theory adequately explains the broad-ranged manifestations of this disease.

Retrograde (Back-flow) Menstruation

The most popular theory is that endometriosis results from the implantation of endometrial tissue fragments, which are secondary to the back flow of blood, into the pelvic cavity during menstruation. It is more common in women with cycle intervals of less than 27 days in length, women whose menses last longer than seven days, and women with partial outflow blockages of the genital tract. These findings have been documented by numerous clinical studies.

Lymphatic and Vascular Spread of Endometriosis

Endometriosis has been found in the pelvic lymph nodes of women with this disease. Pulmonary endometrial implants and the presence of disease at other distant sites are best explained by lymphatic or vascular transmission of the disease.

Immune Defects

Virtually all women experience retrograde menstruation, yet only some develop endometriosis. These findings lend credence to the theory that some women have an immune defect that allows endometrial cells to implant and thrive.

Endometriosis – Genetic Links

Women with a family history of endometriosis are seven times more likely to develop this disease than women without one. Women with a family history of endometriosis in first-degree relatives have a tendency to develop the disease earlier in life, and have more advanced versions of the disease. The inheritance is likely transmitted by multiple factors, perhaps involving the immune system.

The Incidence of Endometriosis

The true incidence of the disease is unknown because formal diagnosis requires a surgical evaluation. About 30 percent of asymptomatic patients undergoing a laparoscopy for infertility are found to have the disease, as well as approximately 40 percent of patients undergoing surgical evaluation for pelvic pain. Endometriosis was also found in 2 percent of fertile, asymptomatic patients undergoing a laparoscopy for elective tubal ligation.

Endometriosis and Infertility

Advanced endometriosis causes infertility with adhesions and the distortion of pelvic anatomy, leading to mechanical interference (tubal obstruction). This is a known cause of infertility; however, the role of minimal or mild endometriosis in infertility is less certain.
Medical treatments such as birth control pills, progestins, or Lupron, are sometimes recommended for pain, but are not prescribed solely for infertility. For many patients with infertility associated with mild disease, a laparoscopy with ablation of endometrial implants may improve long-term pregnancy rates if IVF is not a viable option.

Signs

Infertility specialists can sometimes feel endometrial implants during pelvic examinations, which are best performed on the first day of menses. A Mulberry spot is a blueish vaginal or cervical discoloration secondary to endometriosis.

Management 

Endometriosis management may be performed in the following ways: expectant management, medical treatment with fertility drugs, surgical treatment, or any combination thereof. The type of treatment selected is dependent upon many factors, including the severity of the symptoms, the type of symptoms experienced, the location of the disease, and the stage of the disease at the time of diagnosis.

Examples of medical management include the use of birth control pills, progestins, Lupron and aromatase inhibitors. Surgical therapy is generally employed for treatment of pelvic pain or infertility. This surgery should be performed by a fertility specialist in many cases, especially if the laparoscopy is being done for infertility. Since the diagnosis must be made laparoscopically, it can often be treated by an infertility specialist during the diagnostic procedure. In these cases, a second laparoscopy for treatment is not required.

Summary

The variety of medical and surgical options available for women with endometriosis allows treatments to be tailored individually to the patient, her desires for fertility, and the physician’s experience. There is no one therapy or combination of therapies that is right for every woman. The infertility specialist should have a thorough knowledge of the benefits and limitations for each therapeutic modality.

Dr. Gada Discusses Endometriosis