 |
 |
 |
|
 |
|||
 |
 |
||
| |
|
|
|
| |
|
|
|
| |
|||
| |
|
||
| |
|
|
|
 |
|
||||||||
|
Endometriosis And Infertility November 2000 Welcome This is the third in our series of cases designed to address common issues in infertility. This case demonstrates the importance of endometriosis as a contributing factor to infertility, even when there is no actual tubal obstruction. When fertility is the main issue, then randomised controlled trials indicate that surgery is the preferred option at the time of diagnostic laparoscopy. With more advanced endo-metriosis, IVF is optimal treatment for fertility. Initial Presentation Susan is 25 years of age and presents for management of primary infertility of eighteen months duration. Six years ago she commenced a combined oral contraceptive pill because of dysmenorrhoea and since she stopped the pill she has resumed a regular monthly cycle which is associated with dysmenorrhoea, but without dyspareunia. On examination there was no abnormality and in particular, no evidence of abdominal or pelvic tenderness. A cervical smear was normal and a transvaginal ultrasound showed a normal uterus with an endometrial thickness of 6 mm and an 11 mm follicle on her right ovary. Subsequently, serum progesterone confirmed that she had ovulated. Her husband John, aged 28 is also fit and well. He has a normal semen analysis with negative anti-sperm antibodies. Following discussion with Susan and John it was decided to proceed with hysteroscopy and laparoscopy with dye studies. At laparoscopy Susan was found to have several superficial deposits of endometriosis in the right ovarian fossa and on the right uterosacral ligament. These were treated with laser vaporisation. Both tubes were patent and pelvic findings were otherwise normal. Consultant Comment Susan's endometriosis is essentially asymptomatic. Laparoscopy remains the most sensitive diagnostic test for detecting endometriosis. Susan's endometriosis is graded as mild. In the absence of tubal occlusion, her endometriosis does not exclude spontaneous pregnancy. In assessing the efficacy of any treatment, it is important to know the background rate of fertility over time in untreated women with endometriosis. The best evidence suggests that the monthly fecundity is reduced to around 3% compared to 15% in "normal" couples. The therapeutic value of laparoscopic surgery for patients like Susan is still debated but the biggest prospective study showed that the monthly fecundity was increased from 2.4 to 4.7% when laser treatment was used at the time of laparoscopy to treat endometriotic deposits. (Marcoux et al 1997). Conversely, controlled trials of medical treatment have failed to demonstrate improvement in the background rate of fecundity with GnRH analogues (Goserelin) or Danazol. A meta-analysis confirms that surgical treatment is more effective than medical (Adamson & Pasta 1994).
Marcoux et al (1997) New Eng. J. Med. 337.217 Subsequent Progress Six months after laparoscopy, Susan conceived and in the course of time safely delivered their son, Paul. She remained on a combined oral contraceptive for a year after his birth. Having stopped the pill, her periods remained regular but she developed increasing dysmenorrhoea and dyspareunia. This necessitated a further visit 15 months later. At this time she had lower abdominal tenderness worse on movement of the cervix. A transvaginal ultrasound shows a 4cm echogenic cyst on the right ovary, suggestive of an endometrioma. A repeat laparoscopy confirms this and shows moderate to severe endometriosis throughout the pelvis but with patency of the fallopian tubes Consultant's Comment Clearly Susan's endometriosis is symptomatically and laparoscopically more severe than it was previously. It is likely that fecundity has been reduced further. Laparoscopic surgery could be expected to improve some aspects of Susan's pelvic pain and to improve ongoing fecundity. Cumulative rates of pregnancy over 3 years are approximately 50% following surgery for moderate grade endometriosis. (Adamson and Pasta 1994). Although the cause of infertility is not known in moderate-severe endometriosis, in the absence of tubal occlusion fecundity can be improved by gonadotropin treatment or assisted reproduction with IVF (Fig 2). In the presence of tubal occlusion, assisted reproduction with IVF or ICSI, offers the best hope of a successful pregnancy.
Conclusion Susan and John are keen to optimise their chance of a second pregnancy before Paul gets too much older. They elect for IVF which results in a successful pregnancy in their second cycle of treatment. Susan's symptoms improve during her pregnancy but she will be followed carefully and will discuss the medical options if her symptoms recur again. References Marcoux S, Maheux R, Berube S, Canadian collaborative Group in Endometriosis (1997). Laparoscopic surgery in infertile women with minimal or mild endometriosis. N. Eng.J. Med. 337;217-22. Adamson GD, Pasta DJ (1994). Surgical treatment of endometriosis-associated infertility: meta-analysis compared with survival analysis. Am. J. Obstet Gynaecol 171(6): 1488-505; Hughes E, Fedorkow D, Collins J, Vandekerckhove P. (2000). Ovulation suppression for endometriosis. The Cochrane Database of Systematic Reviews; Vol 2. Selak V, Farquhar C, Prentice A, Singla A. (1999). Danazol vs Placebo for treatment of endometriosis (Cochrane review). The Cochrane Library. Issue 1 Oxford: update software More Information SA Endometriosis Support Group  PRINT THIS PAGE
|
