Endometriosis and Infertility:
Endometriosis is a benign disorder where the tissue which constitutes the uterus lining grows outside the uterus and affects other organs. Usually these organs are the ovaries, fallopian tubes and tissues which surround the area outside the uterus. Other sites for growth can include the vagina, cervix, vulva, bowel, bladder or rectum.
It affects 10–15% of all women in their reproductive age. Among those affected, 40-60% suffer from dysmenorrhoea (normal menstruation that happens to be painful) and 20–30% suffer from sub fertility (any form of reduced fertility with prolonged time of unwanted non-conception). According to published data endometriosis represents ~176 million affected women worldwide. Focus on the prevalence of endometriosis in the Indian population at present is quite high due to multiple cases of infertility reported involving endometriosis. The age group affected in the Indian cohort was 23-40 years.
Types of endometriosis:
Peritoneal endometriosis: Peritoneal endometriosis is a particular form of the disease that is strongly associated with pain and pelvic symptoms such as dysmenorrhea, deep dyspareunia, chronic pelvic pain and painful defecation.
Recto-vaginal endometriosis: Recto-vaginal endometriosis (RVE) is one of the most severe forms of endometriosis. Although medicinal treatments for RVE are available, they are often ineffective or only temporarily effective in controlling the associated symptoms.
Ovarian endometriosis: Ovarian endometriosis is an indicator of the presence of more severe pelvic and intestinal disease.
Stages in Endometriosis:
These stages are classified according to the revised American Fertility Society (AFS) endometriosis classification system:
Stage 1: Minimal
Minimal endometriosis comprises small lesions or wounds and shallow endometrial implants on the ovary. There may also be inflammation in or around the pelvic cavity.
Stage 2: Mild
Mild endometriosis involves light lesions and shallow implants on the ovary and the pelvic lining.
Stage 3: Moderate
Moderate endometriosis involves deep implants on the ovary and pelvic lining. There can also be additional lesions.
Stage 4: Severe
The most severe stage of endometriosis comprises deep implants on the pelvic lining and ovaries. There may also be lesions on your Fallopian tubes and bowels.
Causes of endometriosis:
The exact causes of endometriosis are unknown. One theory suggests that the endometrial tissue is deposited in unusual locations by the retrograde flow of menstrual debris through the fallopian tubes into the pelvic and abdominal cavities. The cause of this retrograde menstruation is not clearly understood, apart from these, hereditary factors and metaplasia could also be responsible.
Complications of endometriosis include the following:
- – Bleeding can form bands of scar tissue (adhesions) that can attach to organs in the pelvis and abdomen.
- – Reduced fertility may result from the adhesions forming on or near the ovaries or fallopian tubes.
- – There is an increased risk of miscarriage or premature child birth.
- – Cysts can bleed or rupture, causing severe pain.
- – Endometriosis of the intestine can cause the bowel to become blocked or twisted.
- – An increased risk of certain types of cancer, particularly ovarian.
- – Pain in lower abdomen and pelvic area, usually worse on the days just before and during a period.
- – Painful periods, it is different from the normal pain of a period, which is usually not severe, and does not last as long.
- – Difficulty in getting pregnant (reduced fertility).
- – Pain in bowel movement and painful defecation during periods.
- – Visual recognition through laparoscopy: The laparoscope is a thin viewing tube similar to a telescope which is passed through a small incision (cut) in the abdomen.
- – Confirmatory diagnosis through histopathology.
- – Trans-vaginal sonography: It is useful for identifying rectal endometriosis.
- – Magnetic resonance imaging (MRI): This is another common imaging test that can capture an image inside the body at a desired site.
- – Ultrasound: Ultrasound is useful in viewing blood filled cysts in the ovaries.
Treatment for endometriosis is typically with medications or surgery. The choice of treatment depends on the severity of pain and/or associated symptoms and whether or not the patient wants to conceive a baby.
Medicines: The doctor prescribes over-the-counter pain relievers to ease menstrual pain.
Hormone Therapy: Supplemental hormones are occasionally helpful in reducing or eliminating the pain associated with endometriosis. This is because the increase and decrease of hormones during the menstrual cycle leads to thickening of the endometrial implants followed by their rupture and eventually bleeding. Hormone therapy may impede the growth and avert new implants of endometrial tissue.
Conservative Surgery: In cases where the patient is trying to conceive, surgery to remove as much endometriosis as possible while preserving the uterus and ovaries (conservative surgery) may increase the chances of pregnancy.
Assisted Reproductive Technologies: Assisted reproductive expertise such as IVF help conceiving and doctors often suggest one of these approaches when conventional surgery is not an option.
Hysterectomy: In extreme cases, surgery to remove the uterus and cervix (total hysterectomy) as well as both the ovaries may be the best treatment. Hysterectomy is normally considered as a last resort, especially for women in their reproductive age.
- The chances of developing endometriosis can be reduced by lowering the levels of estrogen in the body.
- Regular exercise (more than 4 hours a week) can be immensely useful. This lowers the percentage of body fat which, in turn, decreases the amount of estrogen circulating throughout the body.
- Alcohol raises estrogen levels. Not more than one drink per day is recommended for women who choose to drink alcohol.
- Reducing the consumption of caffeinated drinks. Studies show that drinking more than one caffeinated drink a day can raise estrogen levels.
Kritika Mishra, M.Sc (Bioinformatics), Mumbai University, India.
March 11, 2018
1) Rajeswari, Mohan, Thirunavukarasu Ramanidevi, and Balamuthu Kadalmani. “Cohort study of endometriosis in south Indian district.” International Journal of Reproduction, Contraception, Obstetrics and Gynecology 5.11 (2016): 3883-3888.
2) Mishra, Vineet V., et al. “Prevalence; characteristics and management of endometriosis amongst infertile women: a one year retrospective study.” Journal of clinical and diagnostic research: JCDR 9.6 (2015): QC01.