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Endometriosis
Endometriosis is a common condition in which the
endometrium proliferates and spreads outside the uterus. It may
then implant on the ovaries and other pelvic organs and cause
infertility. However, the condition is often relatively benign and
many women conceive normally without the condition ever being
diagnosed. The cause of endometriosis is unknown, but it has been
suggested that it is a disease of angiogenesis (the formation of
new blood vessels). This is because, in this disorder, the
endometrium, as well as endometriotic plaques, seems to have
greater angiogenic activity than the endometrium of normal
women.
Endometriosis is thought to compromise fertility
by causing mechanical obstruction through pelvic adhesions,
distorted anatomy and ovarian or tubal damage. In addition, the
ovulatory process and ovum capture may be disturbed. The following
figure depicts common sites of endometriosis.
Common sites of endometriosis
Types of Endometriosis
There are a number of different classification
systems for endometriosis. The most widely used is that of the
American Fertility Society in which endometriosis is classified
into four stages: minimal, mild, moderate and severe, depending
upon the extent of proliferation and the degree of associated
scarring and adhesions.
The symptoms of endometriosis may include heavy, painful and
prolonged menstrual periods. However, there is little correlation
between the severity of symptoms and the extent of the disease.
Some patients with extensive endometriosis may not experience any
symptoms. The treatment of endometriosis depends upon its severity,
whether it is causing infertility and whether it is causing
symptoms. Several treatments are available, including both surgery
and drug treatment.
Treatment of Endometriosis
- If the patient is infertile as
a result of severe endometriosis, surgery to remove
the endometrial growths and free adhesions may be necessary. Laser
surgery to burn away endometrial implants and divide adhesions is
becoming increasingly popular but requires specialised and
expensive equipment. Its advantages are that it is very precise and
that the risk of adhesions forming after surgery is reduced. The
main advantage of surgery of any type is that if it is successful,
conception is possible within a few weeks of the operation.
- If the patient is infertile but
the endometriosis is mild or moderate, the specialist
may recommend a trial of medical treatment before major surgery is
undertaken. Since it is derived from the normal endometrium,
endometriosis is the hormone dependent. Medical treatment therefore
depends upon suppressing female hormone secretion for a period of
up to 6 months with drugs such as gonadotropin-releasing hormone
analogues. During the period of suppression, endometriosis
regresses, but unfortunately all current treatments prevent
conception. The main problems with suppressive drug therapy are the
length of time that it takes (a major problem for older infertile
women) and the fact that distressing 'menopausal' side effects may
occur during treatment.
- In infertile women
with severe endometriosis, which does not respond to
a trial of drug therapy and in whom surgery is contraindicated, the
best option may be to use an assisted reproductive technique such
as superovulation and intrauterine insemination (IUI), moving on to
in vitro fertilisation (IVF).
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