Endometriosis

The National Institutes of Health define endometriosis as “…a female health disorder that occurs when cells from the lining of the womb (uterus) grow in other areas of the body. This can lead to pain, irregular bleeding, and problems getting pregnant (infertility).” An excerpt from their excellent fact sheet goes on to explain, “During a woman’s reproductive years, between the ages of about 13 and 50, the mucous membrane lining her womb (endometrium) thickens once a month. In women with endometriosis, this endometrial tissue also grows in other parts of the body. These growths are benign (non-cancerous) and doctors call them “endometriotic tissue” or “implants”.”  © IQWiG (Institute for Quality and Efficiency in Health Care)

Endometrial Cells

Endometriotic implants, regardless of where they are in the body, will bleed and slough off with each monthly cycle. This causes an adverse reaction by the body’s immune system whereas it senses that there is an “open wound” and will endeavour to heal that wound by forming scar tissue in those areas. This scar tissue can over time become the cause of pain and infertility. While scientists are not quite sure what causes endometriosis, some feel it could be a hereditary trait while others are looking into the role of the immune system in activating cells that may secrete factors which stimulate endometriosis.

Diagnosing Endometriosis

The physician will typically take a thorough history and do a pelvic exam. He will check for common symptoms which may include cramping during the woman’s menstrual cycle. Most women with endometriosis have pain that is severe and report that the pain increases over time. The following are the most common symptoms:

• Painful periods (dysmenorrhea). Pelvic pain and cramping beginning before and extend several days into the menstrual cycle, may include lower back and abdominal pain.
• Pain with intercourse. Pain during or after sex is common with endometriosis.
• Pain with bowel movements or urination. These symptoms occur during the menstrual cycle. Irritable bowel syndrome is often confused with endometriosis and can make diagnosis more difficult.
• Excessive bleeding. Occasional heavy periods (menorrhagia) or bleeding between periods (menometrorrhagia).
• Infertility. Endometriosis is first diagnosed in some women who have trouble conceiving.

Oddly enough, endometriosis is tricky in the sense that sometimes the severity of the pain isn’t necessarily a reliable indicator of the extent of the condition. A woman with mild endo may have a lot of pain whereas one with severe endo may be symptom-free. Laparoscopy (micro-surgery) is considered the gold standard when a definitive diagnosis is needed and it is sometimes indicated to not only to help diagnose severe cases but to also treat the disease by removing adhesions and endometrial implants.

Endometriosis and Infertility

So often, couples present with “unexplained infertility”, a diagnosis that Dr. Ramirez does not believe in. In most cases he can pinpoint a real cause for infertility due to endometriosis and recommend appropriate treatment depending on the severity of the disease. We know that for pregnancy to occur, an egg must be released from an ovary, travel through the neighboring fallopian tube, become fertilized by a sperm cell and attach itself to the uterine wall to begin development. Endometriosis may obstruct the tube and keep the egg and sperm from uniting. What we do suspect is:

• Most likely the woman’s tubes are functioning abnormally, due to adhesions and scarring
• Ovarian function may be negatively affected, possibly causing poor egg quality
• Endometriosis may release toxic substances that may harm embryos and reduce their ability to implant
• Patients with endometriosis may be at higher risk for miscarriages

Even so, many women with mild to moderate endometriosis are still able to conceive and carry a pregnancy to term. Women with endometriosis are advised not to delay having children because the condition may worsen with time. The longer you have endometriosis, the greater your chance of becoming infertile.

A staging system has been developed by the American Society of Reproductive Medicine. The stages are classified according to the following:

The stage of endometriosis is based on the location, amount, depth, and size of the endometrial implants. Specific criteria include: the extent of the spread of the endometriosis, the involvement of the pelvis in the disease, the severity and spread of the pelvic adhesions and whether or not the fallopian tubes are blocked.

Remember, it is possible for a woman in Stage I to be in tremendous pain, while a woman in Stage IV may be asymptomatic. What is most important is that women who receive treatment during the first two stages of the disorder have the greatest chance of regaining their ability to become pregnant following treatment.

Treatment Of Endometriosis

There is no permanent treatment for endometriosis. Medications to alleviate the pain exist but they are contraceptive in nature. It can often be treated surgically but requires special expertise. Dr. Ramirez is skilled in laparoscopic surgical excision of adhesions and will consider this as one possible avenue for pain management. On the other hand, if the patient desires to become pregnant, Dr. Ramirez may decide to treat it surgically followed by a three-month course of medication (Lupron) to eradicate any microscopic endometriosis. Afterwards, if the patient has mild endometriosis then she may proceed with trying to conceive naturally with timed intercourse, ovulation induction with Clomid or with IUI over the following six months. If, however, the patient has severe (stage 3 or 4) endo then IVF would be indicated. If the patient decides not to do the laparoscopy, then IVF would be the treatment of choice for conception, since it will bypass any endometriosis. When Dr. Ramirez and his wife were faced with infertility over a decade ago due to endometriosis, this was the decision they made. Happily they had success with their first IVF cycle…at a time when ART was not as advanced as it is today.

A recent analysis from Endometriosis.org explores the “potential benefits of an early diagnosis and consequent surgical treatment of this prevalent disease.” Dr. Ken Sinervo of the Center for Endometriosis Care states in conclusion:

“We do not claim that surgery is always a ‘cure’ for endometriosis, nor that the disease cannot recur or be overlooked. However, we do believe that who performs the surgery and how it is performed impacts both the long and the short term success of surgical treatment.

On the other hand, modern-day optics at laparoscopy and a well-trained eye have allowed the disease to be detected or seen in a way that has not been possible before [19]. Moreover, an expert surgeon can be expected to remove detectable disease in its entirety, even when found over vital organs.

Taken together, the data suggests that there is a potential to remove all relevant disease.”

Dr. Ramirez has found with many of his infertility patients that, strangely enough, pregnancy is considered to be the best treatment for endometriosis. Pregnancy stops all menstrual cycles and because of this, all endometriotic lesions stop bleeding. By interrupting the process of endometriosis, one pregnancy will often lead shortly thereafter to another, as has happened to some of our patients. By doing IVF for their first pregnancy, some of these patients go on to conceive one or more children naturally soon after.