Do I have endometriosis? How does endometriosis affect my health and fertility potential? Do I need to go for surgical intervention? These queries usually been asked.
In modern developed country, woman experiences early menarche, late childbirth, low birth rate, and short lactation period. This leads to increased menstrual cycles in her lifetime and that put woman at risk of endometriosis. Endometriosis is an enigmatic disease. It invades the surrounding tissue especially the ovarium and spread to other parts of the body by the hematogenous route. Endometriosis is a progressive disease and it can grow to a tremendous size with a high incidence of recurrence.
What is Endometriosis?
Endometriosis is defined as the presence of endometrial-like tissue outside the uterine cavity leading to a chronic inflammatory reaction, scar tissue, and adhesions. The actual cause of endometriosis is unknown. There are few theories been proposed. One theory suggests that ‘’reverse/ retrograde menstruation’’. During menstruation, some of the endometrial blood flows backward, out through the fallopian tubes and into the pelvic region. This tissue then implants over the ovaries and grows. Subsequently, it becomes endometrioma (chocolate cyst). Another theory suggests that endometrial tissue transverses and implants via blood or lymphatic channels. Genetic predisposition and immune dysfunction also contribute to endometriosis.
Symptoms:
- Pain during the menstrual cycle (dysmenorrhea)
- Pain during sexual intercourse (dyspareunia)
- Chronic pelvic pain
- Abnormal menstrual problems, and not uncommonly associated with fertility problems
Clinical presentation is not proportional to the severity of the disease. It is possible to have severe pain with minor endometriosis and minor pain with severe endometriosis.
The ‘gold-standard’ of diagnosing endometriosis is through laparoscopy ( keyholes abdominal surgery). Besides that, pelvic ultrasound is another useful modality to diagnose endometrioma. Endometriosis is classified into minimal, mild, moderate, and severe using the American Fertility Society Revised Classification of Endometriosis (AFS) score. *refer to chart*.
Endometriosis is common.
Approximately 10% of women in the reproductive age group have endometriosis. 30-50% of women with endometriosis are infertile. How does endometriosis cause infertility? Several mechanisms have been proposed to explain the association between endometriosis and infertility. These mechanisms include endometriotic tissues that consume the normal ovarian tissue, distorted pelvic anatomy, endocrine, and ovulatory abnormalities, altered peritoneal function, and altered hormonal and cell-mediated functions in the endometrium. The presence of endometrioma will result in diminished ovarian reserve by the destruction of normal histological structure in the ovarian cortex. Distorted pelvic anatomy caused by adhesion, scarring, and inflammatory agents that making difficulty in sperm-egg transportation, difficulty in oocyte pick-up by Fallopian tube, and difficulty or pain in sexual intercourse. Moreover, a complex alteration in mediators, immunity factors, and inflammatory factors may have adverse effects on the function of the oocyte, sperm, embryo, or fallopian tube. Thus, it will lead to difficulty in ovulation, fertilization, and implantation.
Treatment for every woman is individualized and specified.
Female age, duration of infertility, stage of the disease, pelvic pain should be considered while formulating a treatment plan. There is no “one-size-fits-all” approach to adopting and implementing a plan.
Generally, medical treatment for endometriosis does not improve fertility, either during or after treatment. It is only indicated for the treatment of pain associated with endometriosis or as a preparation for surgery. In moderate and severe endometriosis cases, clinicians should consider surgery (operative laparoscopy), instead of expectant management, to increase spontaneous pregnancy rate. Surgery will be offered to remove adhesions, endometriotic cysts, and scar tissue in order to restore fertility. Surgery must be complete and performed by a qualified gynecological surgeon with experience in dealing with endometriosis to ensure a lower risk of recurrence and avoidance of repeated surgery. Commonly, a high incidence of recurrence after surgery stated that 20% at 2 years, and 40-50% at 5 years.
Therefore, the decision for surgery should be considered very carefully, especially if the women have had previous ovarian surgery. It is because the removal of the endometrioma (cystectomy) will decrease the ovarian reserve. This process is irreversible and permanent. The diminished ovarian reserve will impair her fertility potential significantly. The discussion between clinician and patient is of paramount importance before proceeding with operation with fertility concerns.
The other scenario is a woman has decided for Assisted Reproductive Therapy (ART), should surgery performed prior ART to improve reproductive outcomes? Clinicians should only consider surgery (removal of chocolate cyst) prior to ART to improve endometriosis-associated pain or the accessibility of follicles during the egg retrieval procedure. Women with chocolate cyst larger than 3cm are no evidence that cystectomy prior to treatment with ART improves pregnancy rates. Thus, the answer is ‘ No-No ‘.
Conclusion
Endometriosis can be a very complex condition to treat and it imposes a huge impact on her quality of life and fertility property. It is important to tailor the treatment to the individual patient to account for symptom profiles, stage of the disease, and patient expectations.
Article by:
Dr. Lam Wei Kian
Consultant O&G and Fertility Specialist
Alpha IVF & Women’s Specialists
www.alphafertilitycentre.com
