Endometriosis is defined as the presence of endometrial tissue (mucosa of the uterine cavity), in places and organs outside the uterus, such as the pelvic peritoneum, the ovaries, the tubes and rarely the small and large intestine.
It is a clinical entity, recognised and studied for the last 100 years. Nevertheless, the exact etiology and mechanism of the disease contributing to infertiliy is still unknown.
How frequent and in which age endometriosis appears
Endometriosis is a very common disease and usually appears during the reproductive years, with a peak incidence between 30 and 40 years of age.
In women reporting infertility, the incidence of endometriosis rises to 21-48%. In women treated with laparoscopic sterilisation, endometriosis is found in 1.3-5% of them.
25% of gynecologic operations are currently performed for treatment of endometriosis, second only to fibroid resection operations.
What causes endometriosis
The cause of endometriosis is still unknown. Many theories have been proposed, but none explains all of its characteristics.
The most known is Sampson’s theory. Sampson conducted his research in 1920 and believed that endometrial cells during menstruation, are transferred through the fallopian tubes inside the pelvic cavity, and cause endometriosis.
According to a recent theory, the reduction of the immune system allows the implantation of endometrial cells and the progression of the disease.
Enviromental factors or inheritance might influence immune status. Immune changes may determine time of onset and stage of the disease.
How endometriosis is diagnosed
The most common symptoms leading to the diagnosis of endometriosis, is pelvic pain, mainly during period (dysmenorrhea), pain during intercourse (dyspareunia) and infertility.
Symptoms do not always correlate with the severity of the disease. Advanced endometriosis might be asymptomatic, whereas minimal endometriosis might cause severe symptoms.
History, pelvic examination and ultrasonography demonstrating endometriotic cysts, give initial information. Definite diagnosis can be made only by open surgery or laparoscopy and biopsy. Laparoscopy is considered the most accurate method for exact staging. Depending on size, adhesions, extent of the disease to the ovaries and adjacent organs and tubal obstruction, endometriosis is divided in four stages.(Stage I being the minimal and IV the most advanced).
What treatment options are available
Therapy can be medical (hormonal), surgical, or combination of both.
Hormonal treatment, aims at ovarian supression, reduction of estrogen levels and cease of the menstrual period. Estrogen reduction causes endometrial and endometriosis atrophy. Pregnancy also supresses the disease, but the duration of this effect after labor is debated.
Whether treatment reduces infertility in minimal stages is also a matter of debate. Our experience shows, that in those cases, early and accurate treatment can give 50-75% pregnancy rates.
In advanced stages, where endometriotic cysts, adhesions or blocked tubes are present, medical therapy is combined with surgical treatment. Results differ according to disease stage and the surgeon’s skills. Surgery aims at restoration of normal anatomy, removal of cysts, adhesiolysis and even salpingostomy. The classic open method tends to give place to operative laparoscopy. The latter was performed for the first time in Greece by our team in 1990. All operations for the treatment of endometriosis, and even tubal microsurgery, are performed in our center. One day surgery is offered, recovery is short and complications are minimal in the hands of a skilled surgeon.
Cummulative pregnancy rates within 2 years of surgical treatment, are 30-57%.