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. The presence of tubal damage,
particularly hydrosalpinx indicates another problem--usually
previous tubal infection. The best treatment for damaged
tubes is IVF.
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