By Dr. Marc Laufer
Recently, I saw 37-year-old woman who was concerned about her difficulty becoming pregnant after she and her husband had been trying for four months. Though her pelvic ultrasound was normal, she mentioned she had significant pain during her periods and some pain with sex. She had experienced this pain for many years. Given her history, I suspected she might be suffering from endometriosis.
Endometriosis occurs when the cells that normally line the inside of the uterus (endometrial cells) are found in other parts of the body, usually in the abdomen or pelvic cavity. Endometriosis can cause severe pain and, if undiagnosed or untreated, can result in fertility problems. There is no correlation between the amount of disease and the amount of pain experienced. Some women have a small amount of disease but experience significant pain, while others have no pain but still experience fertility problems. The more advanced your endometriosis, the more difficult it may be to become pregnant.
There are four levels or stages of endometriosis:
- Stage I (minimal disease): there are few small implants of endometrial cells in the pelvic cavity but there is no scar tissue.
- Stage II (mild): there are more implants of endometriosis cells than in Stage I, and there may also be scar tissue formation.
- Stage III (moderate): there is more extensive endometriosis tissue found throughout the pelvis. These cells may be deeply implanted and may create pockets of endometriotic fluid (chocolate cysts or endometriomas) in the ovaries. There also may be scar tissue around the fallopian tubes or ovaries.
- Stage IV (severe): there are many endometriosis cells implanted in the abdomen or other areas farther from the pelvic region. Additionally, there may be some large endometriotic cysts in the ovaries, and/or scar tissue between the uterus and the rectum (lower part of the intestines), and around the ovaries or fallopian tubes.
There is no blood, urine or imaging test to diagnose endometriosis. It is diagnosed by laparoscopy – minimally invasive surgery done through small incisions and utilizing fiber optic cameras. (We are currently working to develop a non-surgical means to diagnose endometriosis based on testing of saliva, urine or blood as well as new treatments.)
Women with endometriosis may become pregnant on their own, although there is some evidence that pregnancy rates may improve if endometriosis is removed surgically. Generally, when women are younger than 35 years old, with low stage disease, it is reasonable to surgically remove any visible endometriosis to see if pregnancy can occur without fertility interventions or with simple fertility treatments.
If women are 35 or older, fertility treatments are usually recommended instead of surgery. If Stage III or IV endometriosis is present, patients usually proceed directly to in vitro fertilization.
In patients with Stage I and II endometriosis, clomiphene citrate, a fertility medication may be prescribed along with intrauterine insemination (IUI). If this treatment is not successful after three or so months, the next step is the use of injected infertility medications or in vitro fertilization (IVF). The likelihood of a pregnancy from one try of in vitro fertilization is about 40% for women younger than 35, but less than 15% for women aged 41-42.
As for my patient, she had a laparoscopy and was back to work in a few days. Her laparoscopy confirmed that she had endometriosis resulting in adhesions or scar tissue around her fallopian tubes and ovaries. I was able to remove the endometriosis and break down the adhesions and scar tissue that caused her pain and fertility problems. After she recovered, she was able to conceive naturally and is now the proud mother of a beautiful baby daughter.
If you are have endometriosis it’s important to have a complete fertility evaluation before starting treatment. This can include hormone and other blood testing and checking your partner’s sperm count. Medical treatments will also depend on the stage of your endometriosis and your symptoms.
March is Endometriosis Awareness Month. Learn more about endometriosis here at our blog.