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Endometriosis

Endometriosis is a chronic inflammatory disease in women of reproductive age and can cause both pain and infertility. The gold standard for diagnosing endometriosis is laparoscopy. In subfertile women the prevalence seems to be ranging from 20% to 50%, but with significant variation over time periods and the age of patients In a large cohort study on women of reproductive age, the risk of infertility was increased two-fold in women <35 years with endometriosis compared with women without endometriosis Endometriosis is therefore a frequent cause of infertility, either by itself or in conjunction with other fertility-reducing factors.

Classifications

In fertility studies, The American Society for Reproductive Medicine, ( revised ASRM) classification is a scoring system based on localization and size of implants, and extent of adhesions. Unfortunately, it has for many years remained unclear whether the ASRM classification has any prognostic significance regarding prediction of a woman’s fertility potential.

Very recently AAGL ( American Association of Gynaecology laparoscopists) proposed a surgical classification of Endometriosis which is similar to ASRM classification.

A more recent classification system is the Endometriosis Fertility Index (EFI). This classification system is based on the point scores from the ASRM system combined with additional anamnestic, and post-surgical information. The EFI gives a score from zero to 10 points, and the score predicts results well from subsequent non-IVF treatments. After 3 years, those with a point score of 0–3 had only 10% probability of becoming pregnant, whereas those with the highest score of 9–10 points had an approximately 75% success rate. Similar results were found in external validations of the EFI the latter study including results from both non-IVF and IVF treatments.

Etiology/Pathogenesis

There are many theories exist as to the development of endometriosis, the most generally accepted one is that it may be initiated by retrograde menstrual flux through the Fallopian tubes. Epithelial progenitor cells derived from the shedding of endometrial tissue can implant on the peritoneum, ovaries, or in the rectovaginal pouch. Once established, these hormone-responsive and cyclically active endometriotic lesions drive acute then chronic inflammatory reactions, and lead to pelvic adhesions, pain, and infertility. Individual susceptibility to endometriosis, however, is influenced by genetic, anatomical, endocrine, and environmental factors.

Among women with minimal/mild endometriosis, approximately 50% will be able to conceive without treatment, whereas in women with moderate disease, only 25% will conceive spontaneously, and few spontaneous conceptions occur in the case of severe disease.

Possible causes for reduced fertility in women with endometriosis

  • Adhesions
  • Chronic intraperitoneal inflammation
  • Disturbed folliculogenesis
  • Luteinized unruptured follicle
  • Luteal phase defects
  • Progesterone resistance
  • Detrimental effects on spermatozoa
  • Anti-endometrial antibodies
  • Reduced endometrial receptivity
  • Dysfunctional uterotubal motility
  • Reduced ovarian response secondary to chronic inflammation
  • Disturbed hypothalamic -pituitary ovarian axis

Treatment

Endometriosis may impair fertility through multiple pathways, including peritoneal inflammation and endocrine derangements, which interfere with ovarian function and ultimately reduce oocyte competence. Removal of superficial peritoneal foci in minimal/mild endometriosis has been shown to improve fertility modestly, whereas resection of endometriomas and deep infiltrating lesions has an undocumented effect on fertility. Intrauterine insemination is a simple treatment procedure, but with modest effect. IVF is a successful treatment option with results comparable to other causes of infertility.

Surgery for endometriosis:

Surgery has previously played an important role in the treatment of endometriosis-associated infertility. When considering the efficacy of surgical treatment, the disease stage (minimal/mild, moderate/severe, and endometriomas) and outcomes compared with alternative treatment modalities must be taken into account.

  1. In minimal/mild endometriosis without disruptive anatomy, the objective of surgery is to destroy or remove all or most of the endometriotic implants. In such women, two meta-analyses published in 2014 concluded that removal or destruction of endometriosis improves fertility.
  2. In moderate/severe endometriosis, the goal of surgery is to restore normal anatomy of the pelvis and remove large endometriomas. Unfortunately, there are no randomized controlled trials on the effect of surgery in women with moderate/severe endometriosis-associated infertility vs. medical or no treatment.

Excision of endometriomas in infertile women has been controversial, given the risk of damage to the ovarian reserve.

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