Endometriosis and Infertility. Endometriosis symptoms and treatment.

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Endometriosis is estimated to affect 5.5 million women and girls in North America alone. Still, as with many gynecologic disorders, many cases remain undiagnosed, causing silent suffering until the repercussions are serious.

Dr. Eric Surrey of the Colorado Center for Reproductive Medicine describes endometriosis as a disorder in which the tissue (endometrium) lining a woman's uterus appears "to flow in a backwards or retrograde fashion through the fallopian tubes and typically implants itself and proliferates inside the abdominal cavity."

This backwards flow of tissue is also referred to as "reflux menstruation" and, according to Dr. Steven Ory of IVF Florida, it actually occurs in about 90 percent of all women. However, Ory says, about five percent of those women go on to develop endometriosis.

Simply put by the Endometriosis Association, a support and education non-profit founded in 1980 by Mary Lou Ballweg and Carolyn Keith, endometriosis occurs when endometrium tissue is found outside the uterus. The tissue continues to respond to the woman's menstrual cycle, building up, breaking down, and shedding, regardless of its location in the body. The result is internal bleeding and inflammation which causes pain which can be very severe, scar tissue formation, bowel problems, and sometimes, infertility.

Ballweg, who recently authored her third book on the subject (Endometriosis: The Complete Reference for Taking Charge of Your Health, Mcgraw-Hill, 2003), remarks that because girls are taught by most cultures that pain is to be expected with menstrual periods, many go for years and into adulthood without learning more about the disease. The result is that early diagnosis and treatment does not occur and endometriosis progresses unchecked.

"We're working hard to bring awareness to teen girls through our publications, video, and affiliations with school districts," says Ballweg, who emphasizes that endometriosis can be so severe in nature that she knows of teens who are homeschooled and women who've had careers curtailed because of its disabling effects.

Surrey cautions that not all women with endometriosis-related infertility experience pain.

"Once laparoscopy is performed in women with otherwise unexplained infertility," Surrey reports, "endometriosis is diagnosed in 30 percent." While patient history, pelvic and ultrasound examinations are a start in the diagnostic process, the only definitive diagnosis of endometriosis is through laparoscopy.

Not every case of endometriosis results in fertility problems, but in general, women with the disease are more likely to have trouble conceiving. The connection between endometriosis and infertility is related primarily to structural issues, that is, resulting distortions such as tubal blockage and adhesions. Endometriosis may also play a role in fertility problems by creating an environment in the local abdominal cavity that is hostile to egg fertilization and embryo development.

"Several investigators have also suggested that patients with endometriosis may be missing key proteins within the uterine wall that may impair embryo implantation," says Surrey who recently conducted a one-day course for reproductive experts attending the annual meeting of the American Society for Reproductive Medicine.

Ory elaborates on the different mechanisms involved in endometriosis-related infertility. "We know that endometriosis attracts special scavenger cells called macrophages into the pelvis and these can be directed against either the egg, the sperm, or the fertilized embryo so that they are ingested or lethally damaged prior to successful conception. There are other peptides which appear to interfere with fertilization, embryo migration, and the process of implantation of the embryo in the uterine cavity."

The cause of endometriosis is still unclear, although much of the current research points to alterations in a woman's immune system. While it's been determined that endometriosis tends to run in families, research has not yet concluded whether its cause is specifically genetic or environmental.

Investigators are working to better understand the etiology of endometriosis, and why those five percent of women who experience reflux menstruation go on to develop the disease. Dr. Ory presented at this year's ASRM on the advances and controversies surrounding endometriosis, its diagnosis and treatment. He says that women who develop endometriosis appear to have abnormalities in their ability to clear out the inflammatory tissue.

"Also, we have recently learned," Ory continues, "that the normal endometrial tissue (in the uterine cavity) is different in women destined to develop endometriosis. This process is quite complex and involves genetic factors and over a score of proteins and cytokines which have been implicated in the propagation and subsequent infertility associated with endometriosis."

Fortunately, the treatment of endometriosis related infertility is less of a mystery. A combination of minimally invasive surgery and controlled ovarian hyperstimulation, along with intrauterine insemination, have been shown to be beneficial in many cases. According to Surrey, assisted reproductive technologies, especially in vitro fertilization (IVF), "represent the single most efficient means of treating this problem."

"Traditional medical therapies, for example Lupron or Danazol, do not enhance pregnancy rates when given alone," says Surrey. "However, we have recently shown that pre-treatment of endometriosis patients with Lupron prior to an IVF cycle significantly improved IVF pregnancy rates."

Because of the progressive nature of endometriosis and its apparent connection to the immune system, Ballweg echoes others in saying that "living a healthy lifestyle helps a lot" toward lessening the symptoms of discomfort and perhaps slowing the disease's spread. In addition to the use of ART for fertility issues, many women have found relief through complementary and nutritional approaches.

"Sometimes, I think women are so busy," says Ballweg, whose association sponsors support networks in 66 countries, "trying to meet others' expectations and taking care of others, that they forget their own needs." Those who work with endometriosis patients are spreading the word that pain is a woman's body signalling distress, and that hope for both comfort and fertility is available.

Links:

Dr. Steven Ory

Dr. Eric Surrey

Endometriosis Association

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