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Can Endometriosis Cause Infertility?
Endometriosis is generally linked to fertility problems as it is often detected during an infertility check-up, but it does not typically lead to infertility. The symptoms of endometriosis include pain in the lower abdomen and pain during sexual intercourse or menstruation. Endometriosis is a pathology that has a prevalence of approximately 0.5 to 5% in fertile women and 25 to 40% in women suffering from infertility
Endometriosis: what is it?
Endometriosis is a complex, polymorphic, and often frequent condition diagnosed by histology: uni- or multifocal heterotopic elements comprise the uterine lining. Elements of the uterine mucosa outside the endometrium undergo normal variations during the menstrual cycle that can simultaneously cause disorders. These disorders usually involve pain, such as dyspareunia and dysmenorrhoea, and infertility.
Anatomopathology of endometriosis
There are two endometriotic locations: internally (also called adenomyosis) and externally. These endometriotic locations induce three types of endometriosis: superficial peritoneal endometriosis, endometrioma or ovarian endometriosis, and deep subperitoneal endometriosis.
The management of this pathology will depend on its location and whether the patient wishes to have children.
The causes of endometriosis
Currently, no scientific study has clearly established the causes of endometriosis. However, there are many speculations on the aetiology of this pathology, many of which are linked to infertility. One common speculation is that during the menstrual cycle, the blood flowing out of the endometrium leaves residues that, over time, develop into extensions that become endometriosis. Another speculation is that the genesis of endometriosis is hormonal and could develop in any area of the body. The lack of an explicit cause of endometriosis and the chronicity of this disease makes it difficult to diagnose and treat.
Clinical forms of endometriosis
The clinical forms of endometriosis vary, but some symptoms are more common and require investigation.
Dysmenorrhoea, or painful menstruation, is a common functional symptom and is found in approximately 60% of cases. It often appears after menstruation and does not respond to usual treatments. Moreover, its intensity increases over time and differs from one cycle to another. However, the diagnosis of endometriosis should not be ruled out when dysmenorrhoea is absent, primary, not intense, or resistant to usual treatments. Yet, cyclic worsening is a reliable sign.
Present in approximately 30% of cases, dyspareunia is variably intense pain felt deep in the vagina and during sexual intercourse. In contrast to the pain felt in dysmenorrhoea, dyspareunia is proportional to the extent of lesions. This is a reliable clinical sign for establishing a diagnosis.
Other clinical signs
Other clinical signs help establish a reliable diagnosis, including
- Pelvic pain not accompanied by menstruation, especially in women with fertility problems.
- Cystalgia (or bladder pain) or rectal pain, which can occur if endometriosis invades the bladder or rectal peritoneum.
- Disorders of the menstrual cycle, such as metrorrhagia or menometrorrhagia.
- Extra-genital signs. Although rare, these signs include haemoptysis, digestive disorders, and respiratory disorders and often vary during the menstrual cycle.
Infertility or difficulties in becoming pregnancy
Problems with conceiving are a common sign of endometriosis. It is also the symptom that commonly leads to a consultation. In fact, endometriosis is often diagnosed during an infertility examination. Infertility that exists in women with endometriosis often has a clear mechanism, such as blocked fallopian tubes. However, sometimes endometriotic foci are located outside the genital tract, and the mechanism of infertility is not well understood.
Laparoscopies performed during an infertility assessment reveal endometriosis in more than 20% of cases. Thus, it is now standard to assess for endometriosis during an infertility assessment. It is also essential to assess for endometriotic foci during laparoscopy, regardless of the reason for the examination.
Diagnosis of endometriosis
Endometriosis is diagnosed during a consultation with various examinations. First, the doctor interviews the patient to uncover the reason for the consultation. Second, a clinical examination is performed, followed by hysterosalpingography to assess for infertility: when the hysterosalpingography rate is normal, endometriosis is ruled out. Pelvic magnetic resonance imaging will highlight the foci of peritoneal endometriosis, while an endovaginal ultrasound will highlight lesions of adenomyosis (internal endometriosis) or the presence of cysts suggestive of external endometriosis. Laparoscopy will detect external endometriosis, and a hysteroscopy will confirm the diagnosis when adenomyosis is suspected.
Treatment of endometriosis
The choice of therapy depends on whether the woman wishes to have children. The treatment is first medicinal and then, in some cases, surgical.
Medicinal treatment involves administering synthetic progestins to treat an ovulation blockage and cause endometrial atrophy in the normal or ectopic position. Similarly, luteinizing hormone-releasing hormone agonists are used to block pituitary gonadotropin secretions that cause reversible menopause.
Surgical methods consist of hysterectomy or oophorectomy, which involve removing endometrial foci when they are small or removing a portion of the uterus if conception is not envisaged.
The treatment will depend largely on the desire to have a child. When the aetiology is related to infertility, treatment can be long, and artificial insemination may be required for procreation.
The consultation and diagnosis are therefore necessary to determine the appropriate choice of treatment.