INTRODUCTION to moderate endometriosis impairs fertility without pelvic




Endometriosis is in itself a perplexing and
bewildering pathology, a puzzle whose pieces remain largely disconnected
despite some decades of investigation and is defined as the presence of
endometrial tissue (glands and stroma) outside the uterine cavity.
Infertility is a frustrating and distressing symptom associated with endometriosis
and the optimal choice of management in this context remains obscure. Though,
23-25% patients are not symptomatic, endometriosis commonly presents with pain.
The principal aim of the therapy includes providing primary relief to the
presenting symptoms, resolution of the present pathology, preventing the occurrence
of the new foci of ectopic endometrial tissue. The existing modalities of
treatment focus more on managing the clinical symptoms of the disease rather
than fighting it. Uncertainty persists about the casual relation between the
two, although infertility and endometriosis are clearly connected.

Endometriosis is a
destructive disorder that causes distortion of the normal pelvic anatomy which
easily explains the association of moderate to severe endometriosis with infertility.1,2
However, it’s unclear and difficult to understand how mild to moderate
endometriosis impairs fertility without pelvic distortion,3-5 though
a number of theories exist.6-8 To what extent can the
treatment of the clinical manifestations of endometriosis improve fertility? Randomized
controlled trials are required to demonstrate the efficacy of different


The true prevalence of
endometriosis remains unclear. It is a relatively common debilitating disease
that occurs in 6 to 10% of the general female population; in women with pain,
infertility, or both, the frequency is 35– 50%.9 About 25 to 50% of infertile
women have endometriosis, and 30 to 50% of women with endometriosis are
infertile.10  More recent data indicate
that the incidence of endometriosis has not increased in the last 30 years and
remains at 2.37–2.49/1000/y, which equates to an approximate prevalence of
6–8%.11 It has been reported that infertile women are 6–8 times more likely
than fertile women to have the disease.12 A review by D’Hooghe et al. concluded
that the prevalence of endometriosis is higher in infertile women as compared
to fertile women. Also, the infertile women are more likely to have advanced
stages of the disease.13

Endometriosis in adolescents and reproductive
age group

Endometriosis is common presentation in the reproductive age group,
comprising about 10-15%. Endometriosis is also commonly seen in the adolescent age
group and almost 70% of the adolescents who present with chronic pelvic pain
have underlying endometriosis.14 besides bearing the excruciating
pain which is often misdiagnosed and many times goes undiagnosed, the girls may
have to miss the academic and other extracurricular activities. It is most
commonly diagnosed later in the reproductive life and mistreated usually as a
gastrointestinal symptom. Treating clinicians often face challenge in diagnosis
because of presentation of atypical symptoms. 20 Endometriosis is
often diagnosed in adolescent girls not responding to conventional medical treatment
with non-steroidal anti-inflammatory drugs. Almost two thirds of the women present
later in reproductive life are diagnosed with endometriosis; give a history of presenting
similar symptomatology earlier in life. In women who underwent laparoscopy, the
prevalence in the adolescents was found to be 47%15. In adolescents
with chronic pelvic pain unresponsive to medical therapy, endometriosis was
diagnosed in 70 to 73%.16, 17 the diagnosis of the presenting
symptoms is often delayed. The most common presenting symptom is dysmenorrhoea (64%),
other symptoms include menorrhagia, pain, abnormal uterine bleeding, gastrointestinal
symptoms and genitourinary symptoms. Consequently if delay occurs in the
diagnosis of the pathology then it may lead to disease progression, further
distortion of the pelvic anatomy and reduce the future reproductive potential
and functional outcomes. Early diagnosis may prevent the further progression
and preserve fertility.19 Laparoscopy is the gold standard for the
diagnosis of endometriosis. The intra operative lesions may also be differ from
the typical presentation of the “powder burn” lesions seen in the adult group.20

Endometriosis may be often misdiagnosed as pelvic inflammatory disease
and inflammatory bowel syndrome, especially when the patients presents with
atypical abdominal symptoms, gastrointestinal distress, and genitourinary

First line of treatment for endometriosis in the adolescent age
group includes medical line of management. Goals of surgical intervention are simultaneous
diagnosis and conservative treatment. The aim is to reduce the bulk of disease
while decreasing pain and maintaining reproductive capacity.