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Endometriosis

Endometriosis is a common cause of infertility that may be present in about 20 % of patients that seek care. Endometriosis is the presence of uterine lining glandular and stromal tissue outside the uterus. It is often found on the ovaries, behind the uterus, or in other parts of the pelvis. It can appear as vesicles in the peritoneum or as brown, white or powder-burn lesions. It is generally diagnosed with laparoscopy. Note the powder-burn lesion below on the left pelvic sidewall compared to the normal right side.

Many patients, though not all, report painful menses as a teen. The may have been placed on birth control pills for resolution of the pain. Once off the birth control pills, the patient may have difficulty conceiving and may have increased pelvic pain. Painful intercourse, bladder and bowel movements may be noted. It is not easy to diagnose endometriosis by physical exam (nodularity of the uterosacral ligaments, tipped uterus) or by ultrasound exam. Most patients with endometriosis do not have ovarian endometriomas (cysts) that are easily seen with trans-vaginal ultrasonography. Endometriosis is staged from I-IV. Stages III and IV often involve significant scar tissue affecting the tubes and ovaries.

Many potential mechanisms exist for endometriosis to affect fertility. Tubal function may be compromised with decreased peristalsis or egg pick up. The fluid that bathes the pelvis contains factors that appear to inhibit fertilization. The environment is inflammatory with increased reactive oxygen species of molecules. Patients that undergo IVF have the same pregnancy rate regardless of clinical stage. This suggests that factors other than staging parameters (scar tissue, lesion location and extent) are important. Possibly the factors that affect fertilization are more important.

Treatment is generally surgical as a first line therapy. A large prospective study in Canada showed improved pregnancy rates with stage I and II disease. Many patients will attempt ovulation induction with Clomid or Gonadotropins combined with intra-uterine insemination. Of course, IVF is a good therapy as well. IVF removes the eggs from the environment where the endometriosis exerts its negative effects as described above. When endometriosis affects the tubes and ovaries with scar tissue (Stage III and IV) IVF may be a good first line of treatment.
 

 

 

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