ENDOMETRIOSIS

No subject in fertility or gynecology is as controversial as endometriosis.  This is my overview of endometriosis and infertility.  It is not meant as an overview of endometriosis and pelvic pain.

Stage I, or minimal endometriosis, involves small spots of endometriosis in the pelvis or the ovaries without scarring.  There is little evidence that it causes infertility and there is no evidence that surgery is a cost effective treatment.  The value of a laparoscopy to diagnose stage I endometriosis is debatable.  Many patients conceive without treatment.

Stage II, or mild endometriosis, involves more extensive areas of endometriosis, often with "nodules" in the cul-de-sac on exam.  The ovaries can be scarred to the sides of the pelvis making the ovaries immobile.  A careful exam and vaginal ultrasound will usually make the diagnosis without surgery.  Again, many patients conceive without surgical treatment but surgery can be helpful when the ovaries are immobile.

Stage III, or moderate endometriosis, has more scarring and/or endometriomas (collections of endometriosis in the ovaries).  Vaginal ultrasound done in the first half of the cycle will detect endometriomas.  The presence of an endometrioma is diagnostic for stage III or IV endometriosis.  Surgical treatment is indicated.

Stage IV, or severe endometriosis, is like stage III but with either endometriomas in both ovaries,  involvement of bowel and/or bladder or very extensive scarring.  Surgery is needed for general health reasons.  Often IVF will eventually be needed to achieve fertility to bypass the scarring.

Endometriosis and Tubal Disease

Endometriosis nearly always spares the fallopian tube.  This allows the patient and physician to consider GIFT as a treatment option,except for Stage IV endometriosis.  The presence of tubal damage, particularly hydrosalpinx indicates another problem--usually previous tubal infection.  The best treatment for damaged tubes is IVF.