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Endometriosis

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endometriosisThe uterus is lined with a layer of tissue called the endometrium. Endometrial tissue normally grows only inside the uterus (womb), but sometimes it grows outside the uterus - commonly in the reproductive organs (ovaries, fallopian tubes) or on the intestines, rectum or bladder. This condition is called endometriosis.

During menstruation the uterine lining is expelled through the vagina, but blood from endometrial tissue growing outside the uterus has no place to go. As a result, monthly bleeding in this tissue leads to the growth of cysts, lesions and scar tissue and causes the surrounding area to thicken. Some women have little or no discomfort from endometriosis but others experience great pain before and/or during their menstrual cycle. The symptoms of endometriosis usually subside after the menopause.

How does it occur?
The causes of endometriosis are still not known and there is no simple cure. Estimates of how common it is range from 1 to 15 per cent of women of reproductive age. No single theory explains why some women develop the condition. Some experts suggest that during menstruation, endometrial tissue "backs up" through the fallopian tubes and then settles, and grows, in the abdomen.

However, others believe that all women experience menstrual tissue back-up. In most cases, the immune system automatically destroys abnormal tissue before it attaches in the abdomen. But if the immune system is unable to get rid of the misplaced tissue, endometriosis develops. Another theory is that remnants of a woman's own embryonic tissue, which formed while she was in her mother's womb, may develop into endometriosis during adulthood or may transform into reproductive tissue under certain circumstances.

What are the symptoms?
Some women have no symptoms. Others may experience one or more warning signs that can range from mild to severe. The type and severity of the symptoms can depend on where the endometriosis has implanted, how deeply, and how long a woman has had it; over time the extent of the adhesions build up and can cause more problems.

Common symptoms include:

• chronic pelvic pain

• very painful periods

• deep pain during sexual intercourse

• difficulty becoming pregnant

• pain during ovulation

• heavy or abnormal menstrual flow, such as premenstrual spotting/staining

• painful bowel movements, diarrhoea, constipation or other intestinal upsets during menstruation

• painful or frequent urination during menstruation

• exhaustion.

How is it diagnosed?
A doctor can evaluate your symptoms by discussing your medical history and performing a pelvic examination to check for cysts, unusual tenderness or a thickening of the pelvic area. This is best done when you are menstruating. An ultrasound scan may also be used to evaluate the pelvis. However, you'll need a minor, day-care key-hole surgical procedure called a laparoscopy to get a firm diagnosis of endometriosis. Laparoscopy can be carried out at any time during your menstrual cycle.

Under a general anaesthetic, a surgeon will insert a small tube with a light in it (a laparoscope) into a small cut near your navel. The surgeon fills your abdomen with carbon dioxide gas to make the organs easier to see and then checks the size, location and number of endometrial growths. Sometimes it's necessary to remove a piece of tissue (a biopsy) to reach a diagnosis. Often it is possible for the surgeon to carry out treatment at the same time as diagnosis, unless moderate or severe disease is found. Because treatment for endometriosis-associated infertility cannot begin without a definite diagnosis, you must have a laparoscopy to confirm the condition.

Can endometriosis cause a fertility problem?
Endometriosis can cause the fallopian tubes to become blocked and can damage the ovaries. It is estimated to be the cause of infertility in 3 per cent of couples, and is one of the factors behind tubal problems which cause infertility for about 17 per cent of couples. However, evidence suggests even if your endometriosis is severe, you may still have a chance of getting pregnant naturally - it depends on how the disease has affected your reproductive organs. If you know you have endometriosis and you are having problems conceiving then you should seek help sooner rather than later. Don't wait longer than six months of trying before making an appointment with your doctor.

How is it treated?
Although no certain cure exists, the two main forms of treatment for endometriosis are drug therapy and surgery. The treatment depends on:

• the severity of your symptoms

• the location and size of endometrial growths

• your plans for having children

• your age, as symptoms intensify as you grow older.

Treatment options if you're trying to get pregnant
Your doctor should refer you on to a fertility specialist who will offer to carry out a laparoscopy and dye ("lap and dye"), so that an assessment can be made of any damage to your fallopian tubes and ovaries.

You may also be offered an ultrasound scan of your pelvic organs, which can be carried out using an ultrasound probe inserted into your vagina. If your endometriosis is comparatively mild, doctors may suggest no treatment for six to 12 months to see if you become pregnant without any intervention. Your doctor will want to discuss possible treatment before the investigatory laparoscopy, as one option is for the surgeon to remove abnormal growths and tissue during this initial laparoscopy. This is a relatively simple procedure using a laser and/or surgical tool to cut away the endometrial tissue. It makes some sense to carry out the surgery during the investigatory laparoscopy, as it avoids having to go through the procedure again at a later date. Tubal flushing is an alternative to surgery for blocked fallopian tubes and also has a high success rate.

Some couples end up taking the assisted conception route. This is sometimes in preference to surgical techniques, when surgical and other interventions have not helped them to conceive, or when the disease is mild and conception hasn’t occurred naturally after about a year of trying. In the latter case, it is recommended that women with mild endometriosis are offered up to six cycles of IUI. If IUI is not successful or appropriate (such as where there is a male infertility problem as well), or when surgery has not made a difference, IVF is recommended. The overall success rate as a result of IVF is about 25 per cent, but it is lower for women with endometriosis - the reasons for this are unclear.

You won't be offered drug treatment because the drugs used usually suppress ovulation for a period of time or they may be harmful to a developing embryo. It has been shown that there is no improvement in pregnancy rates after finishing them. The exception to this is gonadotropin-releasing hormone (GnRH), which inhibits the production of hormones involved in ovulation. There is limited evidence that a 3-6 month course of GnRH prior to IVF can improve pregnancy rates for women with endometriosis.

Treatment success rates
Laparoscopic surgery can almost double the chance of pregnancy and a live birth for women with mild endometriosis compared with not having the surgery. Following surgery, rates of pregnancy for women with mild endometriosis as their only fertility problem range from 81 to 84 per cent, depending on the techniques used. Those with moderate or severe endometriosis, including damage to the ovaries, have a 36 to 66 per cent chance of conceiving after surgery. Pregnancy rates are highest within a year of surgery, since endometriosis commonly recurs in spite of the operation. Your own doctor will be able to give you more specific advice on your chances of pregnancy after the procedure. Tubal flushing is particularly successful for women with endometriosis, increasing their chances of pregnancy almost sevenfold and of a live birth fivefold.

Treatment options if you're not trying to get pregnant
If you aren't trying to have a baby and your symptoms are mild to moderate, you'll probably have regular check-ups to monitor the condition but no medical treatment. It's likely that the endometriosis will disappear when ovulation and menstruation stop after the menopause.

If you suffer only mild pain before or during your period and infertility is not a factor, over-the-counter pain relief may be enough to alleviate any discomfort.

A non-surgical option for managing the symptoms of endometriosis is to control hormone stimulation with contraceptive pills, progesterone pills or other drugs. These treatments block ovulation so that both the uterine lining and the endometrium stop bleeding each month. This in turn prevents the build-up of new cysts, scar tissue and swelling outside the uterus.

Drug therapies can also help your body heal the existing endometriosis. All the medical treatments available are equally successful at controlling symptoms, but they vary in their side effects. If you don't get on with one drug, ask if you can try another one that may suit you better.

The Mirena intrauterine system (IUS), which is a type of coil containing the hormone levonorgestrel (a synthetic progesterone), also shows promise. Several small research studies have found that using the Mirena IUS can reduce pain and control the symptoms of endometriosis for over three years. It can be used as an initial treatment or after surgery to stop the endometriosis recurring as quickly as it may do otherwise.

If your endometriosis is severe (deeply infiltrated into your organs and/or very painful), your doctor may suggest surgically removing it. This is usually carried out via key-hole, laparoscopic surgery using a laser or other instruments to cut out or destroy the endometriosis. In the worst cases, and when fertility is not an issue, it might involve removing affected organs such as fallopian tubes, ovaries or the uterus. If your uterus is removed, you can never become pregnant.

How long will the effects last?
All the current treatments offer a degree of relief from the symptoms of endometriosis but none provides a cure. Even after hormone therapy or surgery, endometriosis may recur.

How can I ease my symptoms?
It may help to record your symptoms on a calendar for three months. Make a note of the problems, as well as how they affect your work and leisure activities. Sharing this information with your doctor can help you get a speedy, accurate diagnosis.

Here are some suggestions for easing your pain:

• rest on a comfortable couch or in bed when pain strikes

• take warm baths

• put a hot-water bottle or heating pad on your abdomen

• avoid constipation by increasing the fibre in your diet

• practise relaxation exercises such as yoga, deep breathing and visualisation

• ask your doctor about prescription or over-the-counter pain relief.

What can be done to help prevent endometriosis?
A variety of treatments can help control the symptoms of endometriosis but nothing can completely prevent or cure it.
Read 592857 times Last modified on Thursday, 31 May 2012 18:11

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Team IVF Odisha

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