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Abdominal environment

Implantation problems

Loss of eggs

Grading endometriosis


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Endometriosis and Infertility

Endometriosis is a chronic problem that manifests itself differently in different people. It occurs when tissue that normally grows inside the uterus is growing elsewhere.

Endometrial tissue is designed to support and nurture an early embryo. When it grows outside the uterus, it produces substances that don't belong there. Different people's bodies react to these substances in different ways. Endometriosis in the pelvic cavity has a range of appearances. Endometriosis that looks a particular way may cause very different symptoms in different people. Although there is a set of symptoms that increases the likelihood that a person has endometriosis (painful periods, painful intercourse, irregular uterine bleeding and infertility), endometriosis can only be diagnosed through surgery (visually or with tissue diagnosis). Endometriosis can be present without any physical symptoms. Generally, treatment for endometriosis is directed at improving or solving the problem associated with endometriosis that concerns the patient. This is because endometriosis is a chronic disease. Treating endometriosis does not make it go away forever. There are several theories about how endometriosis develops. Two theories explain most of the endometriosis we see in our patients. The first theory is that endometriosis grows from endometrial cells that are shed into the abdomen during menses. Such shedding occurs in all women, but only some women allow the cells to grow and develop in the abdomen. Some women also allow stem cells (which are present n many places) to transform into endometrial cells in certain locations.

Abdominal environment

In my practice, our focus is usually infertility. Endometriosis has been associated with infertility through many studies. The mechanism for causing infertility is likely multiple. The best-established cause is structural damage caused by adhesions (scar tissue) that the body forms in response to the foreign secretions produced by the endometrial tissue. The next best cause is related to the fact that endometriosis changes the environment in the abdomen. There is increased fluid (ascites) in the abdomen, which is filled with activated macrophages. These are scavenger cells, which in this context, destroy many sperm before they can get to the egg.

Implantation problems

Some very good recent studies connect endometriosis to difficulties in an embryo implanting into the uterus. Endometriosis has long been associated with spotting occurring at the start of a period and is associated with a high incidence of uterine polyps (40% in one study). It may also result in altered integrin expression which seems essential for implantation. This problem appears to be separate from endometriosis found (and treated) in the abdomen. It an only be treated medically. This implantation issue presents a difficult aspect to treating endometriosis since the "progesterone resistance" associated with endometriosis may be more than just altered integrin expression and it is hard to tell who is effected by it.  We treat a broad spectrum of patients for this as a possible contributing factor to their fertility.

There are many publications attempting to define other problems that occur with fertility due to endometriosis.

The problem with treating endometriosis to achieve pregnancy is that getting pregnant is a complex event in which there are frequently many contributing factors (commonly including increasing age). Most of the time established endometriosis is a contributing factor and not the only reason that pregnancy has not occurred. Getting pregnant is a probabilistic event and having endometriosis just decreases that probability. Helping someone get pregnant efficiently requires looking at the whole picture and developing a strategy directed at pregnancy.

Loss of eggs

Helping a patient achieve pregnancy does not always even require that the diagnosis of endometriosis be established with surgery (if that doesn't change the therapeutic approach). In fact, surgical therapy for endometriosis is worrisome when endometriosis occurs on or in the ovary. All of the eggs in the ovary occur on the ovarian surface and surgical treatment of the ovarian surface always destroys eggs. A younger patient may have enough eggs to spare, but a woman in her mid-thirties may shorten her reproductive life with such surgery. Our greatest concern is with endometriosis cysts or endometriomas in the ovary. The cyst lining of these cysts is the ovarian surface (folded inside out) and treating endometriomas requires vaporizing the interior to the cyst or excising the cyst lining. This will significantly decrease the number of eggs in the ovaries. In the earlier years of my practice, we always aggressively treated these cysts (that is still the standard practice today), but now we at most drain them and work around them with IVF. Our approach is based on some recent publications as well as our own experience with women who have become peri-menopausal after standard treatment.

Grading endometriosis

Although the American Society of Reproductive Medicine grades endometriosis as stage I through stage IV, for purposes of this discussion, it is simpler to think of endometriosis as mild, moderate or severe. A well-designed multi-center study showed that surgical treatment of mild endometriosis tripled the pregnancy rate after surgery compared to controls. This study justifies surgical evaluation in anyone without apparent other causes of subfertility who has not gotten pregnant in a normal time period. However, there are alternative approaches to surgery especially if an additional period of waiting for pregnancy to occur would potentially decrease a patient's chance of ever getting pregnant (the pressure of age).

Severe endometriosis involves extensive adhesions, which interfere with the ability of the fallopian tubes to pick up an egg, or large endometriomas (a quantity of endometriosis in ovarian cysts). Surgical therapy with the objective of getting pregnant is less valuable since there is a high probability of recurrent scar tissue forming within hours of the surgery since severe endometriosis often involves extensive inflammation or fused adhesions. In the process of healing, damaged or tissue that has been operated on, will attach to nearby or especially normal tissue and establish a new blood supply in order to facilitate transfer of healing substances. These connections often become permanent and prevent normal pickup of the egg by the tube.

Treatment of moderate endometriosis, which either involves extensive endometrial implants or limited adhesions, is the most useful. Surgery for moderate endometriosis is less likely to result in recurrent detrimental adhesions and the abdominal environment can be changed by surgery significantly for the better. Generally this surgery should be laparoscopic (minimally invasive) and use infertility techniques. Even after all visible endometriosis is removed and normal anatomy has been re-established, there is still subfertility associated with endometriosis compared to someone who has not had endometriosis. The reason for this is not well established and it may be that there are differing reasons for this subfertility. I believe it often is an immunological effect of the person's propensity to develop endometriosis. In my practice, we usually try to compensate for it by a fertility enhancing therapy.

With the gradually improving success rate with IVF, the best way to get pregnant with severe endometriosis is IVF. This is because the risk benefit ratio when the objective is pregnancy favors therapy over fixing the pathology caused by endometriosis, especially when the cost in terms of lost potential for pregnancy due to the aging process is factored in. Severe endometriosis usually involves severe adhesions or abnormal connections between pelvic structures or endometriomas, which are endometriotic cysts (which contain a thick irritating chocolate syrup-like material). Recurrent adhesions after such surgery are almost certain to occur. One can hope the location of those adhesions is not significant, but without a second-look laparoscopy one cannot know this. Such adhesions begin to form within hours of the initial surgery. The surgery to correct severe endometriosis also has potential to harm the blood supply to ovary as well as destroy eggs on the surface (cortex) of the ovary as one is destroying the endometriosis. The optimal management in this setting depends on a number of variables. Here again the solution is to individualize the approach to a person's situation and findings.

LINK TO GENERAL INFORMATION ABOUT ENDOMETRIOSIS