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Endometriosis

Endometriosis is a long-term, recurrent, benign, debilitating gynecological condition.

It is characterized by the growth of endometrial-like tissue outside the uterus mainly ovaries, fallopian tubes, peritoneum(lining of abdomen) but may also involve bladder and bowel.

It is a progressive disease and generally begins at young age.

Endometriosis affects 5-10% of women leading to pain and infertility.

About 25-50% of infertile women have endometriosis and about 30-50% of women with endometriosis are infertile.

Clinical presentation: Patients may have one or more of these symptoms:

Painful cramps during menstruation

Pain during intercourse

Lower back pain/ leg pain

Bladder symptoms- frequent urination

Bowel symptoms- constipation or diarrhoea

Infertility

20-25% patients are asymptomatic.

Endometriosis and infertility: 

Mild endometriosis is common in patients with infertility however the grade and severity is the reason of infertility.

It is suggested that endometriosis causes inflammation and release of cytokines which inhibits the sperm and oocyte in turn fertilization.

Adhesions and scarring in endometriosis blocks the Fallopian tubes.

Endometriosis in ovaries results in formation of endometrioma which is cyst in ovary with blood collected in it. It hampers ovulation.

Diagnosis: By Clinical presentation

Endometrioma is seen on transvaginal USG.

Confirmation is made only on laparoscopy with histology.

Endometriosis is staged from 1 to 4 i.e. minimal to severe depending on involvement and spread.

Management: Aims at treating 2 main problems

  1. Pain
  2. Infertility

Endometriosis associated pain treatment: 

Medical treatment-  Suppressive rather than curative. Recurrence is common after stopping medicines.

Aims at temporary relief of symptoms. Includes:

  • Hormonal treatment- oral contraceptives
  • GnRH agonists
  • Progestogens & antiprogestogens

Decision is taken based on patient preference, cost, efficacy and availability.

Surgical treatment: 

Advised in patients with severe symptoms and endometriomas >3 cm size.

Surgery is in form of laparoscopy with ablation and excision of peritoneal endometriosis.

In large endometriomas > 3cm cystectomy is advised depending on patient factors.

Treatment of endometriosis associated Infertility:

Infertility is a major problem in patients with endometriosis.

Decision of treatment for infertility depends on patient age, duration of infertility, ovarian reserve, male factor and stage of endometriosis.

Pretreatment with medical or surgical treatment or both depends on grade of endometriosis and patient factors.

In women < 35yrs of age with stage 1/ 2 of endometriosis with infertility- superovulation with IUI maybe considered.

In women > 35 yrs of age with endometriosis Grade 3/4- IVF ET is considered.

Mainstay of treatment for infertility due to endometriosis is IVF.

IVF indication in endometriosis:

  • Advanced age
  • Bilateral endometriomas
  • Tubal factor
  • Male factor
  • Other treatments have failed

Pretreatment with GnRH agonists for 3 – 6 months before IVF is said to improve the pregnancy rates.

Laparoscopic surgical ablation is beneficial in minimal to mild cases of endometriosis.

Combined medical, surgical or both treatment is advised to maximize the IVF outcome on patient basis.

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