OBSERVATIONS REGARDING THE TREATMENT OF ENDOMETRIOSIS IN INFERTILITY
Received for publication: 5th of June, 2007
Revised: 19th of August, 2007
SUMMARY: (Hide the summary)
Endometriosis is a common medical condition in ginecology that affectis frequently women of reproductive age. In endometriosis, tissue that looks and acts like the endometrium starts growing out side the uterus. Endometriosis represents one of the three most important causes of infertility. Almost 30-40% from women with endometriosis have infertility and 30-50% from women with infertility have endometriosis. The incidence of endometriosis in women with infertility is 10 times higher than in general population rate. We selected three cases of women with infertility caused by endometriosis, that we monitored until labour in the University Clinic of Obstetrics and Gynecology "Bega" from Timisoara . There are considerations of the modern treatment of endometriosis (medical, surgical or combined) that can be a cure for the female infertility. The laparoscopical and classical conservative surgery can be performed in minimal, mild or moderate forms of endometriosis for women that want children, while the radical surgery is for those women between 35-40 years old that have already children. The best treatment in advanced stages of endometriosis and infertility is medical treatment with Difereline, followed by laparoscopy.
Endometriosis is a common medical condition in ginecology, affecting frequently women of reproductive age. In endometriosis, tissue that looks and acts like the endometrium starts growing out side the uterus.(4) Endometriosis has several clinical signs, but two of them are important - pain and infertility, because they determine the women go to the doctor.
The infertility in endometriosis is one of the three most important causes of infertility(18). Almost 30-40% of the women with endometriosis have infertility and 30- 50% of the women with infertility have endometriosis.(12) The incidence of endometriosis in women with infertility is 10 times higher than in general population rate.(11)
Endometriosis is three times frequent in women with primary infertility than in women secondary infertility. In 70% of cases there are minimal, mild or moderate forms. (11)
The incidence of endometriosis in female population, according to medical literature is (1):
- real to female – unknown
- estimated to female – 2-3%
- to the laparotomy in ginecology – 1-50%
- to the laparoscopy in ginecology – 5-53%
- to the sterile women – 15-24%
- to the unknown infertility – 70-85%
- to the sterilizations by laparoscopy – 2-40%
- to the histopatological exam – 5-10%
In severe forms of endometriosis, infertility is explainable by the presence of pelvic or tubar adherences and ovarian cysts. In minimal, mild or moderate forms, the causes of infertility is not entirely known.
Endometriosis stages are based on the revised staging criteria, defined by the American Society for Reproductive Medicine – ASRM (1997). This classification is based on the location, depth and dimensions of the injuries. The endometriosis classification system contains four stages (Stage I - minimal, Stage II - mild, Stage III - moderate, Stage IV - severe) of disease severity. According to this, there is an agreement to deciding in favour of medical or surgical treatment for severe forms of endometriosis, but for the minimal, mild and moderate forms there are many points of view in connection with the treatment. (10)
In stage I, the treatment can be laparoscopy (pregnancy rate in 15 months for stage I is 70-80% and for stage II is 55-60%) or in vitro fertilization. In stage III the treatment can be laparoscopy (pregnancy rate in 15 months for stage I is 40-45%), medical treatment (GnRH agonists) or in vitro fertilization. In stage IV, the optimal treatment is in vitro fertilization. (23, 25)
Material and methods
We selected from medical records of the patients treated in the University Clinic of Obstetrics and Gynecology “Bega” from Timiºoara three cases of women with infertility caused by endometriosis, that we followed-up from arrival until labour.
In all three cases we performed diagnostical laparoscopy.
We found stage II endometriosis, with multiple focuses of endometriosis on the utero-sacral ligaments, vesical peritoneum, ovaries and superficial focuses of endometriosis with narrow adherences in one patient. The other two cases presented stage III/IV endometriosis, with dense adherences beetween ovaries, tubes and peritoneum, with a cysts of 3/3 cm on the left ovary, with multiple, extensive and generalized focuses of endometriosis on the peritoneum and with narrow adherences and focuses of endometriosis on the right ovary.
To the woman with stage II of endometriosis we practiced diatermocoagulation of utero-sacral ligaments, peritoneum and bilateral resection of ovary’s focuses of endometriosis. To the other two cases we difficultly cut the adherences, we practiced as much as we could the diatermocoagulation of the focuses of peritoneum and of the utero-sacral ligaments and also the puncture and evacuation of the endometriomas and cystectomy. After laparoscopy, we prescribed Dipherelineâ 3,75 mg (Triptorelinum ) by intramuscular injection for three months in the first case and for six months in the other two cases. The first injection of Diphereline was administered on the 2-5 days of the first menstrual cycle after laparoscopy, and after that we administered 1 i.m. injection/28 days. After the second injection, all the women had drug amenorrhea. The menorrhea came in 90 days after the third injection and the couples were guided to monitorized sexual contact and ovulation. Then, the three women had a positive pregnancy test.
All the three pregnancies developed normally, the birth was by cesarian section, at 38-40 weeks and all children were eutrophical.
Endometriosis is an important cause of female infertility and we have to be careful in this way to any unknown infertility. Endometriosis is one of the most investigated medical condition in ginecology and it must be investigated more.
The modern treatment of endometriosis (medical, surgical or combined) can be a cure for the female infertility.
The analogue GnRh therapy is the most eficient one. This treatment is recommended in all severe forms of endometriosis (stage III and IV). The medical treatment can be associated before the surgery for reducing the inflamation, dimensions and activity of endometriosis focuses. (19)
The medical treatment is indicated after surgery too, when the diagnosis is a surgery surprise or a histopatological one. It is indicated for the prevention of recurrences. (32)
The studies show an efficient castration, an improvement of the simptomatology in 80% of the cases and the appearance of the amenorrhea in 90% of the cases. The large majority of the authors obtained pregnancies in 20% cases after the treatment.
The administration of medical treatment is various: intramuscular retard, subcutaneus and nasal spray. (30) The medical treatment has not only salutary effects, but bad effects too: casual amenorrhea, menopause induced facts, vaginal atrophy and osteoporosis (osseous loss 1% per month). (31)
Nowadays, the treatment with Diphereline 3,75 mg is the most acceptable therapy because of its reduced secondary effects.
The stage of endometriosis may be a cause of failure in infertility treatment.
Laparoscopical and classical conservative surgery can be performed in minimal, mild or moderate forms of endometriosis to women that want children, while the radicale surgery is for those women between 35-40 years old that have already children. (14, 20, 26) The best treatment in advanced stages of endometriosis and infertility is medical treatment with Difereline, followed by laparoscopy. (28, 32, 36) Prevention, precocious diagnosis and combined treatment, although expensive, is the solution for a better obstetrical prognosis for these women.(2,31)
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