Defined as the presence of the endometrium outside the uterus.

Prevalence 3-10 % of reproductive age group and 25 – 35 % of infertile women.

Various theories have been proposed including the outward flow of menstrual fluid via the fallopian tubes. But not all women with menstrual reflux develop endometriosis,there maybe genetic or immunologic factors involved.


  • Smptoms
    • Asymptomatic
    • Infertility
    • Secondary dysmennorrhoea,
    • Deep dyspareunia,
    • Chronic pelvic pain
    • Rectal/urinary symptoms.

Examination: Uterus may e tender, fixed, retroverted and the ovaries may be enlarged.

Ultrasound and MRI: Can diagnose endometriomas i.e. the classic chocolate cyst of the ovary, which are blood filled cavities.

Laparoscopy is diagnostic for all lesions of endometriosis, be it ovarian or extraovarian.
The lesions can range from the classic blue or black powder burn appearance to pink or white and non-pigmented. Adhesions also can be observed. Although the ovary is the commonest site it can occur in almost every organ of the body.

How does endometriosis cause infertility?

Severe endometriosis can cause anatomical distortions resulting in tubal blocks or interfere with ovum pickup.

Minimal endometriosis may interfere with infertility either by producing prostaglandins or via peritoneal macrophages.
Leutinised unruptured follicle syndrome has also been implicated.


The cumulative pregnancy rate after 5 years is around 90% in women not treated for minimal endometriosis.

From a fertility standpoint, surgical Rx is superior to medical management

  • Lysis of adhesions
  • GnRH-a - not a cure and has side effects, and is expensive
  • Danazol - side effects, cost – no longer recommended
  • Continuous OCP’s/Progesterone - Poor fertility rates

Surgical ablation of minimal and mild endometriosis improves fertility in subfertile women. In moderate to severe disease, surgical treatment may improve fertility but controlled studies and comparisons with assisted reproduction techniques are required.

The object of conservative surgery should be to restore anatomy and to excise or fulgurate as much of the endometriosis as possible.

Severe disease require treatment to correct tuboovarian relationship with minimal tissue injury Adequate visualization, knowledge of anatomy and protection of bowel and deep tissue from injury is essential Endometriomas more than 2 cm should be excised with an effort to leave behind any normal ovarian tissue. Even one tenth of an ovary can be enough to preserve function and fertility.

The highest pregnancy rates occur in the first year after surgery.

Ovarian stimulation with IUI more effective than either no treatment or IUI alone.
Ovulation induction with intrauterine insemination if not successful should be followed with IVF.

The recurrence rate reported after surgery is 20% within 5 years.

Radical surgery involving total hysterectomy and bilateral salpingo oopherectomy is performed for symptom relief if infertility is not an issue.HRT with a progestational agent can be used.

Hormonal therapy for ovulation suppression cannot be recommended as a standard therapy for endometriosis-associated infertility, surgery is the preferred therapy Drug treatments don’t improve conception rate.

Thus medical treatment has no role in the management of endometriosis associated with infertility. However, it has a role in the relief of symptoms like dysmennorrhoea, and pelvic pain.
Combined oral contraceptives ,progesterones(Medroxy progesterone acetate) both oral and depot injections, Danazol, GnRh agonists are all equally effective.

Reproductive Endocrinology
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Dr. Patil’s Fertility and Endoscopy Clinic

Center for Assisted Reproductive Technology, Endoscopic Surgery and Andrology

No 1, Uma Admirality, First Floor, Bannerghatta Road, Bangalore - 560029
Ph: 080 - 41201357, 41462419 Mobile: 9945221622

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