Endometriosis
is defined as the presence of endometrium
(the tissue that normally lines the uterine cavity) in parts
of the body outside of the uterus. The most common sites
of endometriosis include the surface of the ovaries, bladder,
rectum, pelvic sidewalls, and uterosacral ligaments. Endometriosis
is found in 5% of normal fertile women, compared to 20 to
30% of infertile women. While many women with endometriosis
complain of painful periods (dysmenorrhea),
pain with intercourse (dyspareunia),
and premenstrual spotting, many have no symptoms. Rarely,
when endometriosis has grown into the rectum or bladder,
bloody bowel movements or urine can be noted.
In our experience, endometriosis is best treated by laparoscopic
surgery. The goals of laparoscopic therapy are straightforward:
to safely remove all endometriotic implants from the patient's
pelvis. While this surgery can take many hours, gratifying
fertility rates afterwards make it more than worthwhile.
We use the standardized American Fertility Society scoring
system to categorize endometriosis as minimal, mild, moderate,
or severe. Approximately 15% of women have moderate or severe
endometriosis. The presence of chocolate cysts in the ovary
(endometriomas) are common among women with advanced disease.
Moderate and severe endometriosis can be suspected preoperatively
by pelvic examination and/or transvaginal ultrasonography.
It is critically important in caring for women with endometriomas
that the entire endometriosis cyst wall is removed at the
time of surgery. Failure to remove the entire cyst wall
leads to a higher endometrioma recurrence risk in the future.
Women with minimal and mild endometriosis frequently have
implants that coat the surfaces of the pelvis. These implants
can vary in vary in appearance from black (classical)
to a more white, raspberry colored, or gelatinous look
(atypical implants).
The mechanism by which endometriosis causes infertility
is controversial. In women with moderate and severe endometriosis,
pelvic adhesions are frequently found and make it difficult
for normal ovulation
or egg pickup by the fallopian
tube. Several different theories have been proposed
to explain why women with minimal and mild endometriosis
suffer from an increased rate of infertility. A landmark
article published by Dr. Castelbaum and colleagues (REFERENCE)
showed that women with minimal and mild and endometriosis
have diminished uterine
receptivity, making it more difficult for an embryo
to attach to the uterine lining.
It has long been our clinical impression that women with
endometriosis benefit from complete removal of all implants
at the time of laparoscopy,
with subsequently higher pregnancy rates. However, it was
not until 1997 that an important study published in the
New England Journal of Medicine (Marcoux, New England Journal
of Medicine, 337: 217, 1997) demonstated a doubling of pregnancy
rates following destruction of minimal and mild endometriosis.
Post-operatively infertile couples benefit from aggressive
ovulation
induction often coupled with intrauterine
inseminations. Because we are compulsive about removing
all visable endometriosis at surgery, very few of our patients
are treated with Depot-Lupron
afterwards.
Many women who are afflicted with severe pain with menses,
or with coital activity, do not desire pregnancy. Aggressive
laparoscopic surgery, often with resection of endometriosis
often improves symptoms. Many women with disabling mid-line
pain and dysmenorrhea have significant relief after laparoscopic
presacral
neurectomy.
