Endometriosis affects 20-40% of women with infertility against a background risk of 5-10% of women in the general population. Thus endometriosis can be responsible in some cases for failure to conceive.

It is thought that endometriosis can cause infertility by

·      Making sexual intercourse painful thus women avoid having intercourse (dyspareunia)

·      Altering the pelvic anatomy making it difficult for the sperm and the egg to meet (interfering with fertilization)

·      Interfere with the development of the embryo (after the sperm and egg have met)

·      Interfering with implantation. Interfering with the process by which the embryo embeds itself in the womb

Endometriosis is staged from stage I- 4, and though the actual stage does not determine the ability to get pregnant or symptoms that women have, it is used by doctors and carers to give a possible prognosis and outcome of treatment.

Stage I is minimal disease whilst stage 4 is severe disease

For women who want to get pregnant with endometriosis

It is first important that the male partner have a sperm test to ensure that the semen is of acceptable standard to achieve pregnancy.

 A pelvic ultrasound scan is usually performed as this will help find out whether there are any cysts associated with endometriosis and on occasion can determine the severity of the disease.

If doctors feel that the disease is severe they will ask for other tests.

For women with mild pain symptoms treatment with painkillers may be all that is required and doctors will advise them to try and get pregnant naturally.

Other forms of medical management with hormones are not compatible with fertility.

For women who have more pain a laparoscopy is usually required.

The aim of the laparoscopy would be

1.     To diagnose the disease

2.     To stage the disease

3.     To debulk the disease

a.     To remove all visible disease

4.     Restore anatomy

5.     Test tubal patency

With superficial/minimal endometriosis medical studies have shown that removing the disease improves pregnancy rates in women with endometriosis. One particular study showed a 2 fold increase in fertility rates, however when the study was pooled with other existing data the effect was not that great, the number needed to treat to improve fertility for one person was about 8.

The treatment effect on women with more severe endometriosis is not that clear, however treatment has been shown to improve pain symptoms and thus increase the frequency of intercourse in women who suffered from difficulty with intercourse, thus potentially improving fertility.

In women with ovarian endometriosis (endometriomas) the general advice is to get them treated. This is usually done by laparoscopy. Some medical studies show that removing these cysts can improve pregnancy rates by up to 50%. It also improve painful sex in women who suffer from dyspareunia and painful periods

Removal of the cyst is usually advised as opposed to just drainage of the cyst as this reduces the risk of recurrence.

The recurrence risk is nearly 100% if the cysts are only drained as opposed to removed where the recurrence risk is less than 10%

A more complete assessment is required for women in whom the cysts recur as repeated operations for endometriomas may reduce ovarian reserve and adversely affect pregnancy rates

In relation to IVF there is still great medical debate, but most would suggest that endometriomas larger than 4cm should be treated prior to IVF.

For most women it is best that they be seen to endometriosis experts in endometriosis centers as this optimizes treatment and reduces the risk of recurrence. 

Endometriosis is a condition where tissue similar to the cells that line in inside of the womb are found outside the womb, most commonly in the pelvis.



It is responsible for:

Painful periods

Painful intercourse

Pelvic pain

Infertility.

The diagnosis of endometriosis. Why does it take so long?

Endometriosis should be diagnosed based on symptoms, however it is not uncommon for women to go for many years with the symptoms mentioned above without a definitive diagnosis.

In some countries it takes up to 7 years before definitive diagnosis is made in some women.

Reasons for delay in diagnosis include

Knowledge of healthcare professional looking after the woman 

The type of symptoms women present with

Influence of pressure groups


Consequences of Delay in diagnosis

Delay in diagnosis leads to physical, emotional, financial and social consequences.

Because pain can be unrelenting, women may withdraw from social contact as a result of their symptoms and have to take a lot of time off work

Making a diagnosis is important as it provides women with

• An explanation for their symptoms hopefully in a language they can understand
  

• Allows them to become aware of strategies to control their symptoms
  

• Allows them to plan their lives around a potentially debilitating disorder.
  

• Endometriosis is progressive in up to a third of women which is another reason for early diagnosis.
  

If women have these symptoms they need to speak to their doctor. If they do not get a response or are unsatisfied they should always seek a second opinion

What is endometriosis?

Endometriosis is a condition where cells that normally line the inside of the womb find themselves outside the womb.  These cells can find themselves anywhere in the pelvis: on the bladder, on bowel, on the ovaries or on the ligaments that support the womb.

They can be found on the appendix and on occasion in any organ of the body.



How common is endometriosis?

Endometriosis affects between 5-10% of the general female population

In the United Kingdom about 2 million women of reproductive age suffer with endometriosis.

It is commoner in women who find it difficult to get pregnant and have children; it is also commoner in women who have painful periods.

It tends to run in families; about 10% of women who have endometriosis will have a family history of this condition.

What causes endometriosis?

No one knows exactly why some women have endometriosis and others do not.

A number of theories have been put forward to the possible causes. No single theory can explain the reason for endometriosis in all women who are diagnosed with it.

1.     Spillage of cells through the fallopian tubes during periods.

During menstruation about 90% of women will have some spillage of menstrual cells through the fallopian tubes into the abdominal cavity (into the tummy). For most women the body absorbs these cells. In women who develop endometriosis it is thought that these cells are not entirely absorbed. The body then tries another way of protecting itself from these cells. In some women it forms adhesions to block these cells off from the rest of the body. This process may be due to altered immunity in some women.

2.     Transport of menstrual cells through the blood stream

Some scientists believe that the cells travel through the blood to reach other organs of the body. They believe that this is why endometriosis can be found in organs far away from the pelvis

3.     Normal cells can change into endometriosis cells

Other scientist thinks that we are born with cells that have the potential to transform themselves into other cells under certain conditions. And in certain women these cells are triggered by unknown mechanisms to become endometriosis cells

Symptoms of endometriosis:

Endometriosis is not cancer but can be responsible for a variety of symptoms, which include:

1.     Pelvic pain

a.     Pain during periods (cyclical pain)

b.     Pain when not having a period (non cyclical pain)

c.      Pain when opening bowels

This pain may be due to endometriosis on the bowel or endometriosis on the ligaments that support the womb.

 Some women describe this type of pain as worse when they are having periods

d.     Pain during sexual intercourse

e.     Pain on emptying the bladder. This may be due to endometriosis on the bladder

The pain of endometriosis is often described as central lower abdominal pain that can radiate round to the lower back and down the legs

other symptoms include bladder symptoms like going to empty the bladder very often (frequency), or blood in faecal motions (in stool)

2.     Infertility

There is a well-documented link between endometriosis and infertility.

Endometriosis can be responsible for fertility problems in up to 50% of women who have it. However things to note are:

1.     The majority of women who have endometriosis will get pregnant with not problem and the pregnancy will be without problems.

2.     Problems related to endometriosis depend sometimes on the stage of endometriosis

3.     The more advanced the endometriosis the more fertility becomes and issue.