E

ndometriosis is a chronic illness where cells similar to those that line the womb cavity are found in an unnatural site outside the womb in the pelvis and surrounding the reproductive organs.

Affecting 5 to 10 percent of women during their reproductive age, its symptoms include dysmenorrhea, dyspareunia, chronic pelvic pain and pain related to ovulation.

Management of endometriosis is multi-disciplinary, and depending on the priority, fertility or relief of pain, there are differing therapeutic options.

The cells that line the womb form a lining layer called the endometrium. The endometrium reacts to the hormones produced by the ovary every month when eggs are released from the ovary.

The endometrium builds up the cells to nourish a potential pregnancy and when this does not happen, it is shed as menstrual blood. Unfortunately, cells that have gone astray inside the pelvis and over the reproductive organs also build up under the influence of hormones but the blood and tissue shed from these implants have no way of leaving the body.

This results in '€œinternal bleeding'€ and breakdown of the blood and tissue from these sites leading to inflammation. This process can produce pain which is sometimes presents as debilitating menstrual pain (dysmenorrhoea) or painful intercourse (dyspareunia) due to the scarring cause by the disease (endometriosis).

It can also cause reduction in fertility potential by production of toxins, inflammation and scarring that blocks the fallopian tubes, affects the release of eggs or produce toxins that '€œpoison'€ the eggs and sperms and its transport within the fallopian tubes.

The true incidence of endometriosis is unknown. Many women with endometriosis can conceive, i.e., not all women with endometriosis are infertile. Endometriosis can be detected in about 30 to 40 percent of women undergoing laparoscopy as part of an infertility evaluation.

Infertility can affect around 40 percent of women with endometriosis. Although a direct relationship has not been established between endometriosis and infertility, it is accepted that, overall, certain women with endometriosis find it harder to become pregnant than women in general.

The only way to conclusively diagnose the existence and stage of endometriosis is to put in a '€œtelescope'€ through the umbilicus to look into the pelvis '€” a surgical procedure called '€œlaparoscopy'€.

Laparoscopy is not only diagnostic but therapeutic as it allows surgical procedures to remove endometriosis and to restore and repair any distortion of the fertility organs (e.g., the fallopian tubes and ovaries).

The major limitations of post-surgery medical treatment is that if we were to shut down the system, i.e., create a menopause-like state, this can only go on for a maximum of one year because it can cause loss of bone mass.

This can somewhat be mitigated by using a small amount of estrogen hormone called '€œadd-back'€ therapy to control the menopausal symptoms and minimize bone loss.

Other treatments include creating a false pregnancy state e.g. using progesterones like injections of Depo-
Provara; continuous contraceptive pills; Vissane and the Mirena intrauterine system.

However, in spite of all of these, recurrences still occur.

In spite of surgery to remove endometriosis, sometimes it is impossible to remove all the disease, and often it may involve vital organs such as intestines and ureters, such as the disease has to be left behind even if we do it through the laparoscopic, robotic or open approaches.

Thus, as detailed by K. Drews, M. Barlik and T. Łukaszewski in their recently published study, Conservative Treatment of Endometriosis, '€œmost of the time clinical treatment is not limited only to one possibility but usually joins a few therapeutic options. One of the possibilities is the surgical treatment, usually laparoscopic. Conservative treatment may be its completion.'€

While in many cases, surgery alone may be sufficient to enable the couple to conceive, in other instances, assistances through fertility treatments that can produce more eggs and concentrate sperms to enter the reproductive system at the right time which is called super-ovulation and intrauterine insemination may be necessary.

If the tubes are blocked or the disease is so extensive, and when time is running out in older women, doctors advise to promptly resolve to lVF.