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Endometriosis is the name given to the condition in which tissue similar to the endometrium is found outside the uterine cavity. This is a common condition in certain parts of the world, especially in infertile women.

The tissue may be found on the ovaries and tubes another result of endometriosis is the formation of ovarian cysts called endometrioma that may also interfere with ovulation. It can also be found on the lining of the pelvic wall (called the peritoneum) The reason why endometrium-like tissue exists outside the uterine cavity is not clear. Some theories have tried but do not provide a complete explanation for the appearance of this tissue in all reported sites. All that is known is that endometriosis is related in some way to menstruation. It is less common in females who start having children early or have many children. It is possible that the absence of menstrual periods during pregnancy and lactation allows the body enough time to tackle and eliminate any small area of developing endometriosis

While the menstrual loss from the endometrium that lines the uterine cavity normally leaves the body through the cervical canal and vagina, the broken down tissue and blood from the endometriotic tissue in the pelvis and on the pelvic organs have nowhere to go.

These irritate the peritoneum causing pain. The pain corresponds to the time of menstruation but is distinct from the 'period type pain' many women normally have. It tens to be more severe and lasts longer.

The body responds to the presence of irritants in the pelvis by forming adhesions in an attempt to wall them off and prevent further irritation of the peritoneum. With each menstrual cycle more endometriotic tissue is formed, more irritant material accumulates in the pelvis and more adhesions result. These come a time when the adhesions begin to involve part or all of the fallopian tubes and ovaries. In fact these adhesions begin to involve part or all of the fallopian tubes and ovaries. In fact these adhesions can bury the tubes and ovaries such that ovulated oocytes cannot pass into the tube. Even in milder cases it is believed that the endometriosis tissue produces toxic compounds that can interfere with the interaction between the spermatozoa and oocytes in the fallopian tube thereby causing infertility. Endometriosis also interferes with ovulation in about 10% of patients.

A laparoscopy, an outpatient surgical procedure, is necessary to confirm a diagnosis of endometriosis after a medical history review and pelvic exam. After the initial diagnosis, your physician will classify your condition as stage 1 (minimal), stage 2 (mild), stage 3 (moderate) or stage 4 (extensive) based on the amount of scarring and diseased tissue found. Based on the stage of endometriosis, your physician will determine the best treatment plan for you which may include medication or surgery, or a combination of both.

Management of Endometriosis :

The aim of treatment of endometriosis in an infertile patient is aimed at neither neither worsening the infertile state nor prolonging the period of infertility.

Medical treatment of endometriosis has been a traditional modality and various agents like combined oral contraceptive pills, Progestogens, Danazol, Gonadotrophin releasing hormone agonists such as Luprolide, Decapeptyl, Zoladex.

The use of these regimens evolve from the fact that endometriotic tissue is hormone dependent. Endometriotic tissue has been shown to contain receptors for oestrogen, progesterone and androgens. Stimulation by oestrogen encourages growth of the endometriotic tissue while androgens have an opposite effect, inducing atrophy of the tissue. Progesterone preparations that are used in treating endometriosis usually have androgenic properties and this eventually leads to atrophy of the tissue. In addition to these direct effects on endometriotic tissue most medical treatment aims to suppress ovulation when administered long enough and at a high enough dosage thereby inducing an oestrogen deficiency state akin that of menopause. This leads to the atrophy of endometroitic tissue due to a lack of significant oestrogenic stimulation.

Surgical treatment aims at excision of endometriotic tissue, including endometrioma, release of adhesions and repair of associated damage to pelvic organs.

The type of management adopted towards infertility in a couple in which the woman is shown to have endometriosis will depend on

  1. How long have the couple been trying for a pregnancy
  2. How much longer do the couple with to continue trying
  3. How old is the woman and
  4. Can the couple afford assisted conception treatment.
A couple who have been trying to achieve pregnancy for eight years and the woman is shown to have mild to minimal endometriosis, will not be helped in any way at all by the current debate regarding the uncertain relationship of this degree of endometriosis and the presence of infertility. In the same vein medical or surgical treatment of the endometriosis is not a reasonable option. Such a couple should ideally have assisted conception treatment with IUI or preferably IVF. The presence of moderate to severe endometriosis in another patient who is aged 39 years should also be disregarded and IVF treatment offered. However, pre-treatment with GnRH agonists for two to three months may be suggested as this seems to have a beneficial effect on the outcome of IVF treatment in patients with such a degree of endometriosis. Laparoscopic resection may be the best option for a couple who have been trying for one year to achieve a pregnancy and the woman is aged 25 years with moderately severe endometriosis; they usually do not wish to have assisted conception treatment until they have tried more traditional treatment.


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