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Thursday, 13 February 2014

Endometriosis and Infertility

The cells that line the inside of the uterus (endometrium) are special in that there is a cycle of growth and shedding with bleeding in response to the hormones that are released from the ovaries (oestrogen and progesterone). When an abnormal growth of cells that resemble the endometrial cells occurs outside uterus, this condition is called endometriosis. The sites where the cells may grow vary, commonest being the ovaries, the Fallopian tubes, the outer surface of uterus, and the surface lining of the pelvic cavity. Rare sites of endometriosis that have been reported are plenty including vagina, cervix (the neck of the uterus), old surgery scars, nose, bladder, bowels and even brain!

What causes endometriosis is not known. The most popular theory is that the retrograde flow of menstrual blood causes some of the cells to get implanted in the pelvis. The inflammation that is caused at the time of menstruation causes pain, scarring and also makes organs stick to each other. In ovaries, the periodic bleeding causes accumulation of this blood that over time becomes thick and degeneration leads to a colour change to brown. The contents resemble liquid chocolate, these cysts that form in the ovaries are therefore also called chocolate cysts.

The symptoms of endometriosis are variable. The commonest symptom is cyclical pain that builds up premenstrually and is at its peak during periods. What is baffling is that the symptoms may not mirror the extent of the disease. While some women with a few spots of endometriosis may have severe pelvic pain, some others with severe endometriosis may have little or no pain. Other symptoms are painful intercourse, heavy periods, infertility, pain while passing urine or opening bowels, etc. 

The only way to diagnose endometriosis is through laparoscopy or keyhole surgery. The prevalence is difficult to quote as not all women who may be suffering undergo laparoscopy but has been reported to be higher in infertile women than in women undergoing laparoscopy for sterilisation (33 vs 4)!

As many as 30 to 50% of women with endometriosis may have difficulty in conceiving. The most plausible explanation of endometriosis causing infertility is the distortion that occurs with organs sticking together and scarring. As a result there be an impaired egg release, or pick up and transport by the fallopian tubes. This does not however explain infertility in all affected women as many have a normal ovulation, patent tubes with no distortion of anatomy. The other explanations are an altered immune system, changes in the hormonal environment of eggs and decrease in the number and quality of eggs in the ovaries.

The treatment of endometriosis has to be individualised by the treating doctor. Medical management is of little or no use in women trying to conceive. It may be prudent not to delay conception in women who have endometriosis. Please consult an infertility specialist for guidance regarding further surgery (especially if you have already undergone operations such as cystectomies) and plan fertility treatment for best results.


  1. Effectively simplification of a very complex condition. I am sure many who read this will be benefited by this information. Good work.