Learn what endometriosis is and how it can affect your fertility. Every month when a woman has a period, the cells that line the uterus, known as the endometrium, are shed in the menstrual flow. Some small portion of this combination of blood and endometrial cells may also pass out through the fallopian tubes into the abdominal cavity. Most of the time, the body’s natural defense systems attack and destroy these cells before they can begin to grow. However, for reasons that are not clear, this is not always the case.
How Endometriosis Works
In certain individuals, these endometrial cells actually implant on structures in the abdominal cavity and begin to grow. This is endometriosis: the presence of viable endometrial cells in places other than the uterine cavity. Then, each month when the normal hormonal changes result in a menstrual period, much the same change occurs in the endometriosis. A small amount of bleeding occurs from the endometriosis cells. This is very irritating to the body, and as a result of this, scarring occurs around the endometriosis. Most often this is a progressive process, with a small additional amount of bleeding and scarring occurring every month.
Once the endometrial cells begin to grow in the abdominal cavity, they are known as implants. Implants can occur on any structure, including the ovaries, fallopian tubes, bladder, bowel, and on the lining of the abdominal cavity (known as the peritoneum). The area behind the uterus, between it and the rectum, is known as the cul-de-sac, and this is the most common site for endometriosis. Implants may appear as small, clear or red, fluid-filled sacs, or most commonly, as dark brown or black areas. The collection of old blood in the implants gives them this appearance. Some scarring is typical around the implants, and can be very localized or, at times, quite severe. When endometriosis develops in the ovaries, large cysts full of old blood, known as chocolate cysts or endometriomas, may result.
There are other theories as to how endometriosis develops, and this scenario (known as retrograde menstruation) certainly cannot explain all cases of endometriosis. It is, however, the most widely held theory and does explain all but the most unusual cases of endometriosis.
Symptoms
Although in some individuals endometriosis may cause no symptoms, it is typically associated with two problems: difficulty conceiving and pain.
The pain may be present as extremely painful menstrual periods. This pain with periods, known as dysmenorrhea, often becomes worse as a woman gets older. Pain with intercourse is not uncommon in women with endometriosis, and there may even be pain that persists throughout the month but is worse during periods.
Not everyone with endometriosis has pain; in fact, there is little correlation between the amount of endometriosis an individual has and the amount of pain she experiences. Sometimes a single, small implant may cause excruciating pain, while someone with severe disease may be pain free.
The association of endometriosis with difficulty conceiving has long been known, and research shows many different ways in which endometriosis interferes with normal conception. Endometrial implants are irritating to the body, and as a result, the body produces a group of substances known as prostaglandins. Prostaglandins can alter not only the maturation and development of the egg within the ovary, but also the release of the egg from the ovary.
The ability of the fallopian tube to function normally may also be impaired. Whereas in “nature’s way” the tube is poised and ready to pick up an egg if one appears on the surface of the ovary, in the presence of endometriosis the tube may be “lazy” or “floppy.” Not only is the overall tone of the tube decreased, but the fimbria, which are responsible for egg pickup, may end up being very far from the ovary itself. The combination of these factors may make it very difficult for the tube to pick the egg up off the surface of the ovary. Thus, even if ovulation does occur, the egg may not get into the fallopian tube.
Endometrial implants also result in the increased production and activation of a group of cells known as macrophages. Macrophages are part of the body’s natural defense system and can be visualized as little “Pac-men,” actively attacking and destroying any cells that they encounter. In women with endometriosis, macrophages attack and destroy sperm cells more than normal, thus making it more difficult for the sperm to reach and fertilize the egg. The macrophages may also interfere with tubal function, ovarian function, and perhaps even early embryo development.
It is important to keep in mind the number and variety of ways endometriosis affects fertility, particularly when discussing the ways of treating endometriosis.
Diagnosing Endometriosis
It is not clear why endometriosis occurs in some individuals and not in others, but about 10 to 20 percent of all reproductive-age females have been found to have endometriosis. In women with infertility, this number may be as high as 30 to 50 percent. Factors associated with the development of endometriosis include delayed childbearing, long periods of uninterrupted menstrual cycles, abnormal pelvic anatomy, and stress. Many other factors have been associated with the development of endometriosis and there is even a genetic factor, meaning that you may inherit an increased likelihood of developing this process if a close relative has it.
A physician can often suspect endometriosis on the basis of a history and physical exam. A history of progressively worsening pain with menstrual periods is suggestive. A history of cramping that begins two to three days before the onset of menstrual bleeding is also common with endometriosis, as is deep dyspareunia (pain with deep penetration during intercourse). During the physical exam, the physician may be able to feel endometriosis, particularly if it is in the cul-de-sac. Endometriosis is not visible by ultrasound unless there is ovarian involvement; endometriomas are visible by ultrasound. If significant endometriosis is present, the combination of a history, pelvic exam, and ultrasound will reveal it.
There are tremendous variations in the amount of endometriosis an individual may have. The American Society for Reproductive Medicine has developed a grading system for quantifying the amount of endometriosis present, recording the size, number, location, and character (filmy versus dense, deep versus superficial) of implants.
The only way to definitively diagnose endometriosis is by visualizing it. With a laparoscopy, the surgeon notes the endometriosis present and any adhesions or scarring that may have formed. These findings are recorded on the classification sheet and a score assigned. That score is then used to determine the grade of disease, on the scale of: I = minimal, II = mild, III = moderate, and IV = severe. While there are many limitations to this system of classification, it does provide a way to compare the extent of endometriosis from patient to patient and may be useful in prognosticating about the chances of conceiving.
Medical Therapies
Before discussing any form of medical therapy, it is important to stress that there is no medical therapy that cures endometriosis. Medical therapy offers ways of temporarily suppressing the process only, not of curing it.
Endometrial implants depend on cyclic hormonal function. All medical therapies are aimed at disrupting cyclic hormone production and creating a state in which the hormones are constant from day to day. When estrogen and progesterone remain steady over a prolonged period of time, endometriosis typically does not progress, and may even regress. There are two normal physiological states in a woman’s life during which her hormones are essentially constant from day to day—pregnancy and menopause. Medical therapies aim to simulate one of these states.
Pseudo-Pregnancy
In the majority of women, endometriosis improves during pregnancy. During pregnancy, ovulation stops and relatively constant, high levels of estrogen and progesterone are present. Using birth control pills can simulate these high constant levels of hormones, or create a state of “pseudo-pregnancy.”
To bring on this pseudo-pregnancy, the pill must be taken continuously. In other words, a pill is taken every day without ever stopping for a week or without taking the “sugar pills” at the end of the pack, as you would do for contraception. Thus, no periods will occur because a hormonally active pill is being taken every day, and a steady hormone state is achieved. For women who can take the pill, this is a perfectly safe way to do so. Because of the balance of the hormones in the pill, the lining of the uterus does not build up while on continuous therapy, and if anything, it actually thins out. There is no need to have a period each month while on the pill, and having one will probably render the pill far less effective against endometriosis because of the bleeding and resulting changes in the endometrial implants.
Pseudo-Menopause
There are basically two types of medications available for creating a state of pseudo-menopause. The first of these is danocrine (Danazol). This is an altered male hormone. When taken in adequate doses, it suppresses the ovaries so that they temporarily stop functioning. This combination of decreased female hormone levels and increased male hormone levels is what makes danocrine effective in suppressing endometriosis.
Danocrine has been around for years and for a long time was the most commonly used form of medical suppression of endometriosis. It does, however, have many unpleasant side effects, including menopausal symptoms such as hot flashes and vaginal dryness. In addition, side effects from its being a derivative of a male hormone, such as weight gain, increased muscle mass, increased hair growth, and muscle cramps, limit the acceptability of danocrine. With the availability of the GnRH agonists (see below), danocrine is not widely used to treat endometriosis at this time.
The GnRH agonists are a class of medication that can temporarily suppress the pituitary gland’s production of luteinizing hormone (LH) and follicle stimulating hormone (FSH). If the pituitary does not produce LH and FSH, the ovaries receive no stimulation and therefore stop producing hormones. Thus, once again, a temporary state of menopause is achieved.
The most commonly used form of this therapy is the depo, or long-acting, form of leuprolide acetate, known as Depo-Lupron. An injection of this medication given once a month results in very effective suppression of the ovaries. The major side effects associated with this medication are menopause-related ones, specifically hot flashes and vaginal dryness. In some women, these side effects may be severe. Although it may slightly limit the overall effectiveness of the therapy, small doses of estrogen may be given along with the Depo-Lupron. That way the side effects may be eliminated without significantly compromising the effectiveness of the treatment, making this therapy very tolerable for most individuals.
Precautions in Using Suppressive Therapies
While on suppressive therapies, particularly those that induce pseudo-menopause, it is important to take a good multivitamin and calcium supplement. The lack of estrogen in these therapies can lead to development of at least a small amount of osteoporosis, or thinning of the bones. Calcium and vitamins help minimize bone loss; however, because of the risk of osteoporosis and other menopause-related side effects, the length of time that these therapies may be used is limited. Circumstances may dictate special considerations for some individuals, but six months of therapy is usually considered maximal.
All forms of suppressive therapy must be viewed as exactly that—a means of suppressing the endometriosis. In the vast majority of cases, endometriosis will not progress while on this therapy. In most cases it actually improves. Upon stopping the therapy, normal menstrual function resumes and the endometrial implants, which had been suppressed, also begin to function and respond to the cyclic hormone changes. Sometimes within a relatively brief time, the endometriosis is right back where it was before the treatment was begun. Suppressive therapies should be viewed only as ways of buying time.
For example, if you know you have endometriosis and want to get pregnant, but for one reason or another must postpone your attempts to do so for another six months, then suppressive therapy may be a great idea. There is no data to suggest, however, that medical therapy results in improved chances of conceiving. To repeat: Medical suppressive therapy is a good way to buy some time during which the endometriosis will not get worse; it is not a good way to improve your chances of getting pregnant.
Surgical Treatments
The obvious goal of surgical therapy is the elimination of all the endometrial implants. There are many different techniques for surgically treating endometriosis, but there are two important principles that need to be stressed:
- a major surgical procedure is rarely indicated to treat endometriosis for purposes of increasing your chances of getting pregnant, and
- if there is no alteration of normal anatomy as a result of scarring from endometriosis, surgery to eliminate the endometriosis does not improve one’s chances of getting pregnant.
Surgical therapy for endometriosis must be considered from the standpoint of the two major symptoms of endometriosis; that is, pain and infertility.
Pain
As noted above, endometrial implants are small collections of blood surrounded by scarring. The progressive nature of these implants causes more blood to accumulate while the scarring around it increases, often causing severe pain. The surgical removal of these implants is an excellent means of reducing if not eliminating endometriosis-associated pain. Again, even a small single implant can cause severe pain and there is little correlation between the amount of endometriosis present and the amount of pain. Therefore, if the history and physical exam are suggestive enough, laparoscopy and destruction of any endometriosis encountered should be considered for the potential relief of pain.
Laparoscopy is a minor surgical procedure done under general anesthesia and usually performed on an outpatient basis. A small incision less than an inch long is made under the belly button and a telescope-like instrument is inserted. A small amount of carbon dioxide is placed in the abdominal cavity to allow the surgeon to see the abdominal and pelvic organs. One to three additional incisions less than a quarter inch may also be used to introduce additional instruments. Through the laparoscope, the surgeon should be able to treat all but the most severe cases of endometriosis. Full recovery usually takes only a few days. Major surgery is typically required only if there is significant involvement of the bowel with endometriosis.
It does not seem to matter how the endometrial implants are destroyed. There are several different types of lasers available to do the job, including carbon dioxide, argon, KTP, and YAG. The physician can also use electro-cautery. All that is important is that the cells of the implant are destroyed without causing significant damage to the surrounding tissue. Surgical therapy can bring tremendous relief for pain associated with endometriosis .
Infertility
Surgical therapy for endometriosis-associated infertility is an entirely different matter. If there is no significant alteration of normal pelvic anatomy associated with endometriosis, there is little if any improvement of conception rates as a result of surgical treatment of the endometriosis. If you have less than moderate endometriosis, according the classification mentioned above, there is no benefit to doing a laparoscopy and destroying the lesions.
How do you know how much endometriosis there is without doing a laparoscopy? First of all, the physician has done a pelvic exam, which will provide reliable information about pelvic anatomy. Second, an initial pelvic ultrasound has revealed whether or not there is an endometrioma present in the ovaries. It is very uncommon to have moderate endometriosis without some ovarian involvement that will be visible on ultrasound, or significant findings on the pelvic exam. Therefore, a good initial evaluation will allow a reliable determination of the potential extent of disease.
If there is ovarian involvement or significant scarring (adhesions) present, laparoscopic surgical intervention is warranted. Any endo-metrioma(s) can be removed from the ovaries, any adhesions cut and removed, and all visible lesions destroyed. This can and should all be done through the laparoscope rather than with major surgery. Aside from the fact that recovery is much easier and quicker for a laparoscopy than for major surgery, studies have shown that the results achieved from laparoscopic treatment are every bit as good if not better than those achieved with major surgery. We now have the technology and instrumentation necessary to perform thorough treatment for all but the most severe cases of endometriosis through the laparoscope. If you are going to have an evaluation for the presence of endometriosis, ask your surgeon how she or he intends to treat it. Do not have major surgery to treat endometriosis unless it is determined to be very severe.
There is no rationale for doing a laparoscopy to treat minimal or mild disease when dealing with endometriosis-associated infertility. Many studies have been done, and all but one demonstrate that surgical treatment of mild endometriosis is not associated with any improvement in the chances of getting pregnant.
Remember that there are many mechanisms by which endometriosis impairs fertility. None are really altered by eliminating the endometrial implants. For example, if the endometriosis has altered the ability of the fallopian tube to pick up an egg from the ovary, it is difficult to imagine that treating the implants will restore this function. The same is true for most of the other proposed mechanisms of endometriosis-associated infertility.
There is ample evidence showing that the chances of getting pregnant with mild endometriosis are the same whether you pursue “expectant management” (simple continued attempts at conceiving without any intervention) or have a laparoscopy to destroy the endometriosis. Couples with infertility associated with endometriosis without anatomic alteration should be treated and approached like couples with unexplained infertility, and this does not include doing a laparoscopy.
Endometriosis and Conception
Overall, the chances of successfully conceiving with endometriosis are inversely proportional to the extent of the disease: The worse the endometriosis is, the harder it becomes to get pregnant. Fortunately, truly severe endometriosis is uncommon. Results obviously are very individual, but with proper management and treatment, the vast majority of women with endometriosis will successfully conceive.
If you have mild endometriosis and are going to have a laparoscopy in hopes of helping you conceive, use that laparoscopy to do gamete intrafallopian transfer (GIFT). Pregnancy rates as high as 40 to 50 percent can be achieved after a single laparoscopy and a GIFT procedure. This percentage is far better than that which can be achieved following a laparoscopy and laser or cautery of endometriosis. And GIFT works just as well when endometriosis is present as it does when the endometriosis has previously been treated.
Of course there will be cases and circumstances where surgical intervention for endometriosis is clearly indicated. But the point is this: In the past, the possibility of finding a small amount of endometriosis and treating it has been the justification for many, many surgical procedures. Some women have actually had several laparoscopies, or even major surgeries, for this reason. Not only is this invasive, in that an individual must endure one or more surgical procedures, it is also expensive.
There are now far more effective ways of achieving pregnancy—ones that are more cost-effective and far less invasive. Some of these approaches will include ovulation induction and other assisted reproductive technology, or ART procedures.
