Diagnosing Infertility
Endometriosis
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Endometriosis is a condition in which tissue similar to the lining of the uterus (the endometrial stroma and glands, which should only be located inside the uterus) is found elsewhere in the body. Endometriosis is one of the most common causes of pelvic pain and infertility in women.
Endometriosis lesions can be found anywhere in the body, but are most commonly found in the pelvic cavity: on the ovaries, the fallopian tubes, and on the pelvic sidewall. Other common sites include the uterosacral ligaments, the cul-de-sac, the Pouch of Douglas, and in the rectal-vaginal septum.
The endometrial tissue outside your uterus responds to your menstrual cycle hormones in the same way that your endometrial tissue inside your uterus responds. The tissue swells and thickens and then sheds to mark the beginning of your next cycle. However, blood from endometrial tissue in your pelvic cavity has no place to go. As the blood pools, inflammation occurs and scar tissue is formed. In addition, chemicals released from these tissue implants can be toxic to the eggs that are released from the ovaries prior to entering the fallopian tubes. Furthermore, scar tissue in your pelvic area can block the fallopian tubes from allowing eggs to enter and fertilization to occur.
Does Endometriosis Affect Fertility?
Endometriosis is a common finding in women struggling with infertility. In some cases, it is a known cause with scar tissue blocking the fallopian tubes, but researchers are investigating other links between endometriosis and infertility. Women with endometriosis have been shown to have eggs of poor quality, a lower fertilization rate and a lower implantation rate as compared to women who do not have endometriosis.
How is Endometriosis Diagnosed?
Symptoms of endometriosis can include painful menstrual cramps, abnormal menstrual bleeding, pain during intercourse and infertility. Some patients with endometriosis have no symptoms. Interestingly, the severity of symptoms a woman may exhibit has no relation to how extensive or severe the endometriosis is. In many cases moderate to very severe endometriosis (Stage III-IV) may be incidentally diagnosed at time of laparoscopic surgery on a woman who complains of no pain with periods or intercourse. Likewise, a woman who has excruciating pain and undergoes laparoscopic investigation may be found to have no endometriosis or only a mild case (Stage I-II).
To diagnose endometriosis, Dr. Zoneraich, or in most cases your Ob/Gyn, would perform a surgical procedure called a laparoscopy. During a laparoscopy, a thin lighted telescope, called a laparoscope, is inserted into the abdominal cavity through a small incision in or near the belly button. Through the laparoscope, Dr. Zoneraich or your Ob/Gyn can see the surface of the uterus, fallopian tubes, ovaries and other pelvic organs to visually confirm the presence and extent of endometriosis. During this same procedure, Dr. Zoneraich or your Ob/Gyn is frequently able to remove the scar tissue and endometrial tissue attached to other organs.
Treatment of Endometriosis & Fertility
How endometriosis is treated depends on the severity or stage that has been diagnosed. At one time, fertility experts believed that all endometriosis should be addressed surgically prior to undergoing any treatment. However, over the last several years, an overwhelming amount of research has shown that this is sometimes not the best approach. This section will deal only with those women desiring fertility since the treatment of endometriosis from a purely symptomatic perspective would be different.
For younger patients who have a family history of documented endometriosis, symptoms, and long standing infertility, and absence of any other female or male contributing factors to infertility, a diagnostic evaluation for endometriosis may be warranted. While a surgical laparoscopy to diagnose endometriosis is an outpatient procedure that can usually be performed in under two hours, it is not without its risks. Therefore, you should discuss this option in detail with either your Ob/Gyn or Dr. Zoneraich prior to proceeding. In general, for those women with diagnosed and treated mild endometriosis (stage I-II), initial treatment with superovulation (i.e. clomid) or ovulation induction (i.e. gonadotropins) is recommended.
However, for those patients with documented moderate to severe endometriosis (stage III-IV) with or without the presence of endometriomas (ovarian cysts filled with old blood or endometrial tissue), the most successful treatment has been shown to be in-vitro fertilization (IVF). The current thought is that any surgical intervention that involves the ovary may have a detrimental effect on the ovaries’ blood supply and future stimulation ability. Therefore, undergoing IVF would allow Dr. Zoneraich to stimulate the growth of the immature eggs in the ovary and surgically remove these eggs without exposing them to the potential toxic effects of the endometriosis in the pelvis, in the ovaries, or on the surface of the ovaries. Fortunately, this relatively newer approach to treating endometriosis has been shown to greatly improve the overall pregnancy success rates for patients with this diagnosis.
While endometriosis can be a daunting diagnosis, the good news is that advances in fertility treatment have made overcoming this obstacle a likely reality.
