Endometriosis

Endometriosis is a medical condition where the tissue that lines the inside of your uterus (also called the endometrium) spreads to other areas of your body, usually to your pelvic organs. Endometrial tissue found on your fallopian tubes or ovaries can lead to scarring, adhesions, and blockages within your pelvis. (See Figure 1.2.)

Figure 1.2. Endometrial Lesions

Figure 1.2. Endometrial Lesions

Illustration copyright © Nucleus Medical Art, all rights reserved, nucleusinc.com.

Endometriosis is estimated to affect about 7 percent of women of childbearing age. However, endometriosis is found in approximately one-third of infertile women. Therefore, endometriosis is a major factor when considering the causes of female fertility problems.

The main symptom of endometriosis is pelvic pain. The pain and cramping occurs most often just before and during your menstrual cycle. The pain sometimes occurs during sexual intercourse, urination, or bowel movements. The amount of pain does not always tell you the severity of your condition. For example, some women with slight pain may have a severe case of endometriosis. However, those with significant pain may actually have mild endometriosis. And some women with endometriosis have absolutely no symptoms. In many situations, endometriosis is only diagnosed as part of an infertility evaluation, after a woman has been unable to conceive on her own.

What Does Endometriosis Do? How Does It Affect My Fertility?

It's important to understand exactly what endometriosis does and how it affects your fertility. Under normal circumstances, the only place that endometrial tissue can be found is the inside of your uterus. However, if you have endometriosis, that means endometrial tissue is also growing somewhere else within your body. It most often appears in various places within your pelvis, such as the ovaries, fallopian tubes, outside surface of the uterus, space behind the uterus, bowel and rectum, and bladder. It may occasionally be found in more distant parts of the body, though this is rare.

Wherever endometrial tissue is found within your body, it basically still acts the same as that found within your uterus. Endometrial tissue is very responsive to changes in your hormones. So during your menstrual period, the tissue breaks down and bleeds, just the same way that the lining of your uterus does. This bleeding can cause pain, especially just before and during your period. The breakdown and bleeding of the endometrial tissue located throughout your pelvic organs can cause scar tissue and adhesions.

Oftentimes the scarring and adhesions cause various pelvic organs to bind together and distort the normal pelvic anatomy. This could cause the ovaries to become anchored in an awkward position so that the egg cannot properly reach the opening of the fallopian tube. In another case, the scarring and adhesions may block the fallopian tubes so that an egg cannot pass from the ovary into the uterus. Endo-metrial tissue may grow within an ovary and cause a cyst, usually called a chocolate cyst or endometrioma. The affected ovary and cyst may not be able to ovulate and function normally. Sometimes an ovary cannot properly release an egg because the egg is trapped within the follicle by scarring on the ovary's surface.

Endometriosis may also reduce fertility in other ways besides the scarring and adhesions already discussed. For example, toxic substances may be released by the endometrial tissue scattered about your pelvis. In this case, even if the egg is successfully released from the ovary and passes to the fallopian tube, the toxins might diminish the egg's ability to become fertilized. In addition, endometriosis can lessen fertility by giving off an immune response. That means that the endometrial tissue outside the uterus sends a signal to release destructive cells within the pelvis that can destroy eggs, sperm, and even an embryo.

Who Is at Risk? What Causes Endometriosis?

No one is certain of the cause of endometriosis, but several good theories exist. Some believe that menstrual cycle flow can go backward from the uterus, move up through the fallopian tubes, and spill into the pelvis. Others suggest that endometrial cells can be carried through the blood and lymph vessels to various parts of the body. Still others suggest a more complex method involving antibodies and changes at the cellular and hormonal level.

Endometriosis seems to occur most commonly in women who are in their 30s and 40s. It also occurs more frequently in women who have never had children. Endometriosis appears to have a genetic component. In fact, women with a mother, sister, or daughter who have endometriosis are more likely to have it themselves.

How Is Endometriosis Diagnosed?

First, your doctor will take a detailed medical history and perform a physical exam, including a pelvic exam. If you and your doctor are suspicious that you may have endometriosis, your doctor may perform a laparoscopy to view the inside of your pelvic cavity. If endometriosis is found, your doctor will determine the extent of the disease and in some cases also destroy or remove the tissue at the same time.

How Is Endometriosis Treated?

Treatment for endometriosis depends on the extent of the disease, your symptoms, and whether you want to have children. Endometriosis can be treated with medication, surgery, or a combination of both. You should be aware that treatments may temporarily relieve pain and infertility, but the symptoms will most likely eventually return. That's because whatever process caused the endometriosis in the first place is probably still taking place within your body.

In some cases of endometriosis, medications are prescribed to relieve pain and cramping discomfort. Nonsteroidal anti-inflammatory (NSAID) medications such as Motrin, Advil, Aleve, or Anaprox may be recommended. Various hormones, such as birth control pills, gonadotropin-releasing hormone (GnRH), progestin, and danazol, are sometimes prescribed. Such hormones may relieve pain and also help to slow the growth of the endometrial tissue and new adhesions. These hormonal medications almost always prevent pregnancy and therefore are not used when a woman is trying to become pregnant.

In many cases of endometriosis, surgery is the best choice for treatment. Surgery is usually performed via laparoscopy. During the laparoscopy procedure, the endo-metrial tissue is either destroyed or removed. After surgery, you may have relief from pain and your doctor will be able to discuss your fertility chances. Some studies have shown that pregnancy rates after surgery for women with moderate endometriosis can be as high as 47 percent. Rates for those with severe endometriosis may be about 38 percent. These rates may not seem great, but they are much better than the chances of conceiving without treatment.

PELVIC INFLAMMATORY DISEASE (PID)

Pelvic inflammatory disease (PID) is a serious infection of your pelvic reproductive organs, such as fallopian tubes and ovaries. In most cases, the infection is caused by a sexually transmitted disease (STD) such as gonorrhea or chlamydia.

Unfortunately, PID is fairly common in the United States, being diagnosed in more than 1 million women each year. In fact, it is estimated that PID is the cause of about 20 percent of all infertility problems, and the incidence seems to be increasing.

Symptoms of PID can vary greatly from severe pain, fever, and discomfort to no symptoms at all. The more common symptoms of PID are as follows:

Abnormal vaginal discharge Pain in the pelvis or abdomen Abnormal menstrual bleeding Fever and chills Painful urination Nausea and vomiting Painful sexual intercourse

If you have one or more of these symptoms, that doesn't necessarily mean that you have PID. However, you should see your doctor for an evaluation. Even with no symptoms, PID is capable of causing severe damage to a woman's reproductive organs. Sadly, most cases of PID are undetected until a woman presents for an infertility evaluation.

What Does PID Do? How Does It Affect My Fertility?

PID can cause infertility by infecting, damaging, and scarring your pelvic reproductive organs. The fallopian tubes are especially vulnerable to PID and can become severely scarred and completely or partially blocked. If your fallopian tubes are completely blocked, the sperm and egg can never get together. If your tubes are partially blocked, the egg and the sperm may meet, but the fertilized egg may not be able to reach the uterus for implantation. In this situation, a tubal (ectopic) pregnancy will result. In a tubal pregnancy, the fertilized egg grows within the fallopian tube, instead of moving into the uterus as planned. This can lead to fallopian tube rupture, internal bleeding, and often emergency surgery. Unfortunately, tubal pregnancies are never viable, healthy pregnancies.

In some cases of blocked fallopian tubes, pus collects within the tube and causes the tube to expand. Over time, the pus is absorbed and replaced by a clear straw-colored fluid. The result is a fluid-filled, swollen, and often useless fallopian tube, called a hydrosalpinx (water in the tube). Medical research has shown that this fluid, which contains dead cells and other harmful products, may be toxic to egg and sperm.

PID can lead to serious long-term problems, such as infertility, ectopic pregnancy, and chronic pelvic pain. You have a greater risk of infertility if you experience multiple cases of PID or if the infections are especially severe.

Who Is at Risk? What Causes PID?

PID can occur in any sexually active women, but it's most common among young women. Here's a list that shows who is at an increased risk for developing PID:

• If you have STDs, especially gonorrhea or chlamydia infection

• If you have more than one sex partner

• If your sex partner has more than one sex partner

• If you are a sexually active woman who douches frequently

• If you have an intrauterine device (IUD), such as Paragard or Mirena

Since PID is an infection, it is caused by various types of germs and bacteria. Almost all cases stem from sexually transmitted diseases (STDs), such as gonorrhea or chlamydia. Without proper antibiotic treatment, the STD infection can move upward from the vagina and cervix, eventually finding its way into the uterus, fallopian tubes, and ovaries.

See your doctor right away if you think you may have an STD or a PID. The earlier you receive proper antibiotic treatment, the better you will feel and your fertility will be better preserved.

How Is PID Diagnosed?

PID is sometimes difficult to diagnose. One reason is that the uterus, fallopian tubes, and ovaries are within your pelvic cavity and not as easy to examine as are your genitals on the outside of your body. Another reason is that the symptoms of PID can vary greatly. PID often mimics other serious medical conditions, such as appendicitis or ectopic pregnancy, so it may take a while for your doctor to properly diagnose your condition.

If you or your doctor suspects PID, your doctor will discuss your detailed medical history, sexual habits, birth control methods, and symptoms. Your temperature will be taken to see if you have a fever. The doctor will perform a pelvic exam to determine whether your pelvic organs are tender. Your vagina and cervix will be swabbed and cultured to check for STDs. Sometimes blood tests are also done.

If your diagnosis is still uncertain, the doctor may order further tests or procedures. Additional tests sometimes used to diagnose PID include ultrasound, endo-metrial biopsy, and laparoscopy.

How Is PID Treated?

PID is treated with antibiotic medications. Antibiotic pills are usually prescribed for two entire weeks. Even if you are feeling better after a few days, you must take all of the medication prescribed. That's the only way to make sure the infection is gone. Your doctor may schedule a visit several days after antibiotic treatment begins to see how you are doing. If your condition hasn't improved, you may need to be treated in a hospital with intravenous antibiotics. Early treatment is vital to prevent long-term problems, such as infertility.

Your sex partner needs to see his doctor because he will need to be treated for STD infection also. You can still pass STDs to your partner even while you are being treated. That's why it's best to avoid sexual intercourse until both you and your partner have completed your antibiotics treatment regimens and been cleared by your doctors.

DIETHYLSTILBESTROL (DES) ABNORMALITIES OF THE FEMALE REPRODUCTIVE ORGANS

Diethylstilbestrol (DES) was a widely prescribed medication during the late 1950s and early 1960s. Its purpose was to attempt to prevent miscarriages. Unfortunately, DES was later found to cause side effects in the mother's children, especially the female children. If your mother took DES during her pregnancy with you, you might have reproductive abnormalities that could decrease your fertility. DES has been associated with abnormal pelvic anatomy and also abnormal cervical mucus production. DES daughters are also at risk for a very rare type of vaginal and cervical cancer called clear cell adenocarcinoma, which occurs in about 1 in 1,000 DES daughters. This cancer is virtually nonexistent among premenopausal women not exposed to DES.

Only about 20 percent of these DES daughters experience problems with their reproductive tract and infertility.

Symptoms of DES exposure can vary. Some women with DES abnormalities experience irregular menstrual periods. However, most women have no symptoms and don't realize that they have a problem until they try to become pregnant.

What Do DES Abnormalities Do? How Do They Affect My Fertility?

Women whose mothers took DES during pregnancy are often referred to as DES daughters. DES daughters may have a variety of reproductive tract anatomical abnormalities. Table 1.1 highlights possible DES-associated abnormalities and how they might affect your fertility.

Table 1.1. Effects of DES

Pelvic How DES Can Change

Organ Your Body

Vagina The upper part of your vagina may have glandular tissue, usually absent in normal vaginas.

Cervix The outer part of your cervix may have increased glandular tissue. The cervical canal is usually long and somewhat distorted.

Uterus DES daughters classically possess an abnormally shaped uterus, called T-shaped. It has a very small and distorted inner uterine cavity. The muscle wall of the uterus tends to be more fibrous than usual. Fallopian The fallopian tubes are usually tubes shorter than regular tubes. The inner lining of the tubes are often irregular and distorted. Ovaries The ovaries are not affected by DES because they are formed from a different origin than the other organs already discussed.

How DES Might Affect Fertility

This particular abnormality should not affect your fertility.

These cervical malformations often lead to reduced cervical mucus. If you don't produce the proper amounts of cervical mucus, sperm may not be able to pass safely into your uterus. This small uterine cavity and fibrous muscle tissue cause lack of stretch and flexibility of the uterus. They may be responsible for higher incidence of premature births within DES daughters. These tubal abnormalities explain the increased tubal (ectopic) pregnancy rate associated with DES daughters. The ovaries almost always are not affected. They usually appear and function normally.

Who Is at Risk? What Causes DES Abnormalities?

Daughters of women who took DES during pregnancy may have reproductive abnormalities that could reduce fertility.

The medication was a powerful hormone that had numerous side effects. Subsequently, DES is no longer prescribed in the United States today.

How Are DES Abnormalities Diagnosed?

If you are able, ask your mother if she took DES during her pregnancy with you. If you suspect that your mother might have taken DES during her pregnancy, be sure to talk with your physician.

Suspecting an exposure to DES will help your doctor diagnose this potential set of problems. Even without considering DES, your doctor might notice that your cervix appears abnormal during a routine Pap and pelvic examination. To diagnose uterine and fallopian tube abnormalities, you will have to undergo more tests. A hysterosalpingogram (HSG) is usually performed to evaluate the shape of the uterine cavity and also to determine if the fallopian tubes are blocked. In this test, a fluid with dye is injected through your cervix and into your uterus and the fluid's pathways are monitored with x-ray. DES daughters typically reveal a T-shape or butterfly-shape uterus on HSG rather than the normal rounded pear shape. The HSG will also test for fallopian tube length and openness but may not detect irregularities within the inner fallopian tube lining, as this is more difficult.

How Are DES Abnormalities Treated?

Depending on the nature and extent of the abnormalities, various treatments will be considered. For example, inadequate cervical mucus may be treated by the use of estrogens or perhaps intrauterine insemination. Surgical correction may be needed for a severely misshapen uterus. Various assisted reproductive technologies may be called upon if the fallopian tubes are a problem.

ASHERMAN'S SYNDROME

Asherman's syndrome is an acquired condition recognized by the formation of adhesions and scar tissue within the uterine cavity. In most cases, the adhesions are so severe that the front and back walls of the uterus stick to one another.

The primary symptom is lack of any menstrual periods. Sometimes patients with Asherman's syndrome do experience light vaginal spotting.

What Does Asherman's Syndrome Do? How Does It Affect My Fertility?

The severe adhesions and scarring of the inner uterine cavity usually causes collapse and also blocks the opening between the uterus and the fallopian tubes. In some cases, one or both tubes may remain open to the uterus. However, even if a fertilized egg is able to successfully travel from the tube and into the uterus, proper implantation within the scarred, collapsed uterine cavity is rarely possible.

Who Is at Risk? What Causes Asherman's Syndrome?

Only women who have had a prior uterine surgery are at risk for Asherman's syndrome. Asherman's syndrome occurs most often after a dilation and curettage (D&C) that may have been performed because of a miscarriage or retained placenta after delivery. However, Asherman's syndrome may also occur in other situations, such as after an abortion or Cesarean section.

How Is Asherman's Syndrome Diagnosed?

If you have had a D&C, an abortion, or any other type of surgery to your uterus, be sure to talk with your doctor. Being suspicious for the possibility of Asherman's syndrome will help with the diagnosis. The best way to diagnose these uterine adhesions and scarring is through a procedure called hysteroscopy. For this procedure, your doctor places a thin telescope-like device into your vagina and through your cervix. The doctor advances the device into your inner uterine cavity for optimal viewing. Scarring, adhesions, and blockages can then be seen.

How Is Asherman's Syndrome Treated?

Treatment involves the hysteroscopy procedure used for diagnosis just discussed. While the hysteroscope is still in place within the uterus, the doctor uses a special scissorlike instrument to remove the adhesions. The objective is to remove as much scar tissue as possible and free any adhesions along the walls of the uterine cavity. After the hysteroscopy, a small balloon is placed in the uterine cavity for a few days to prevent the recurrence of adhesions. Many doctors also prescribe estrogen after the surgery, because estrogen will stimulate the new growth of uterine tissue and promote healing.

According to a publication from the National Institutes of Health (NIH), Asher-man's syndrome can be cured in most women with surgery; however, more than one surgery is sometimes needed. The NIH estimates that approximately 70 to 80 percent of women who are infertile because of Asherman's syndrome will have a successful pregnancy after treatment.

Causes of Infertility: Health and Lifestyle Concerns for Men

Low sperm count, or oligospermia, is the main cause of male infertility. Under normal circumstances, between 60 to 100 million sperm are delivered with each ejaculation. Many of those sperm are killed by vaginal secretions or destroyed during their journey toward the fallopian tubes. Therefore, a man who begins with a lower than average sperm count may find he has fertility difficulties.

Sperm production may be influenced by a whole host of lifestyle choices, health issues, and environmental factors.

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