Reproductive Endocrinology and Infertility
Infertility - Endometriosis

What is it?

Endometriosis is a disease of unknown cause that primarily affects women of reproductive age. The lining of the uterus, called the endometrium, is found outside the uterus. Common places for endometriosis to be found are on the ovaries, behind the uterus, intestines, fallopian tubes and the tissue (peritoneum) that lines the pelvis and abdomen.

What are the symptoms?

Endometriosis usually causes pelvic pain. This may include pain with menstrual periods, pain with intercourse, pain with urination or bowel movements, and generalized pelvic pain at other times in the cycle. Women with endometriosis have a higher risk of fertility problems and infertility may be the only symptom of this disease. Some women with endometriosis have normal fertility and no pelvic pain.

How Common is Endometriosis?

Approximately one-third of infertility patients will have endometriosis. It is not known with certainty how common this disease is in the general population, but some studies have estimated that 4-5% of reproductive aged women may have endometriosis. Women undergoing laparoscopy for chronic pelvic pain have a high chance of having endometriosis. Therefore, infertility and/or pelvic pain are potential symptoms of endometriosis and may warrant further investigation.

How is Endometriosis Diagnosed?

Endometriosis can be suspected based on the patient’s history, physical exam and ultrasound findings. The only way to make a definitive diagnosis, however, is to perform a laparoscopy. There is no reliable blood test for endometriosis. A pap smear will not detect endometriosis.

How is Endometriosis Treated?

The primary treatment of endometriosis is surgical at the time of a diagnostic laparoscopy. A variety of surgical instruments and techniques have been used to treat endometriosis including laser, electrical coagulation, thermal ablation and excision. All appear to be equally efficacious in treating the disease. Women with pelvic pain and endometriosis usually have improvement of their pain after surgery, but the duration of this improvement is variable and recurrence of the pain is common. There is not always a good correlation between the degree of pain and the extent of disease found at laparoscopy. Patients with minimal disease may have severe pain, whereas patients with advanced disease may have few symptoms. Various forms of medical treatment of endometriosis associated pain are used. Birth control pills, medroxyprogesterone (Provera), danazol(Danocrine), and gonadotropin releasing hormone agonists (Lupron, Synarel, Zoladex) are used to hormonally suppress the endometriosis and improve the pain. These drugs work equally well, but differ mainly in their expense and side effects.

The issue of endometriosis and infertility is controversial. Although there is a strong association between endometriosis and infertility, it has not been conclusively demonstrated that endometriosis actually causes infertility. Consequently the treatment of endometriosis and the subsequent effect on fertility is a subject of considerable debate. Recent studies do suggest some improvement in fertility in women with early stage disease treated surgically compared to those that are not treated. No form of medical treatment of endometriosis has ever been demonstrated to improve fertility. Specifically, hormonal treatment of endometriosis before or after surgical treatment does not improve fertility. To the contrary, fertility is inhibited during medical treatment as all forms of medical therapy involve hormonal suppression of ovulation. Therefore, hormonal suppression of endometriosis to improve fertility is not indicated.

Women with endometriosis should be thought of as being "sub-fertile" and not "infertile". The monthly probability of conceiving in a natural cycle in women with endometriosis is about 3-4% as compared to 25% in a normal woman. With appropriate treatment, most women with endometriosis will be able to have a baby. Treatment of endometriosis-associated infertility depends on the extent of disease, age of the female and duration of her infertility. If surgical treatment fails to result in a pregnancy, empiric therapy with clomiphene and intrauterine inseminations (IUI) is started. If this is not successful, then gonadotropin/IUI’s are performed, followed by in vitro fertilization (IVF). Some women with advanced endometriosis may be advised to proceed directly to IVF.