The Relation of Endometriosis and Infertility

Melvin R. Cohen, M.D.
Director, Fertility Institute, Ltd., Chicago

Endometriosis, Aspects and Proceedings of a Symposium
Saint John's Hospital and Health Center, Santa Monica, California
Editor: J.J. Marik

Prior to August, 1966, culdoscopy was the only endoscopic procedure performed. With culdoscopy, patients who might have far-advanced endometriosis were deleted because of technical problems, viz, fixed retroversion or cul-de-sac masses. Since August, 1966, laparoscopy has been the endoscopic procedure of choice.

During this time, 1,380 patients from The Fertility Institute were laparoscoped. Three hundred and twenty of these or 23% had mild, moderate or severe endometriosis. Of this group, there were 240 who had mild, asymptomatic endometriosis. Therefore, if one would rely upon the diagnosis of endometriosis as suggested by a history of dysmenorrhea, dyspareunia, menometrorrhagia plus pelvic findings of adnexal mass or cul-de-sac nodularity, one would miss an enormous number of patients with early or mild endometriosis.

At laparoscopy the gross appearance of the pelvic organs is usually sufficient for the diagnosis of endometriosis. Brownish hemorrhagic or purplishto-black areas are typically found (1) at the vesicle uterine fold; (2) in the cul-de-sac or uterosacral ligaments; (3) involving the ovaries. Implants may be found on the surface of the ovary, but endometriosis should be suspected when an ovary is found adherent to the cul-de-sac or posterior leaf of the broad ligament. One should always suspect endometriosis when pelvic adhesions involve the ovaries, but do not involve the tubes. When indigo carmine is instilled through the intrauterine cannula, there would be evidence of tubal patency and normal fimbria.

The classic pelvic finding of a retroverted uterus with irregular nodules in the cul-de-sac is frequently visualized at laparoscopy as an erect uterus with both ovaries glued to the cul-de-sac by endometrial implants and adhesions.

We recently reported a series of 1,093 laparoscopies in infertile patients from The Fertility Institute. From this group, 163 had surgical procedures which included lysis of adhesions, liberation of adherent ovaries, biopsy of ovaries for the diagnosis of amenorrhea and endometriosis, biopsies of other areas of suspected endometriosis, cautery of endometrial implants, retrieval of tubal splints, and dilatation of fimbria. The anesthesia of choice is general with intubation.

Patients usually ran a very benign postoperative course, and were ambulant almost immediately. Among the 163 patients in whom surgical laparoscopy was performed, only one complication occurred. In this patient lysis of extensive adhesions was followed by bleeding severe enough to require laparotomy. Emergency laparotomy was performed with control of bleeding from a tiny area of small bowel.

Forty-seven of the 163 patients conceived. Forty-six of these were intrauterine pregnancies and in one case a tubal pregnancy ensued.

Following surgical laparoscopy, additional modalities of therapy were utilized, such as suppressive therapy for endometriosis, the use of ovulatory stimulating drugs, ovulation timing and, when indicated, homologous or heterologous insemination.

Diagnostic laparoscopy is usually scheduled immediately following the mucorrhea phase of the cycle to document the occurrence of ovulation as well as the presence of obscure pelvic disease. Surgical laparoscopy for infertility is best performed postmenstrually to minimize possible bleeding from lysis of adhesions.

Endometriosis was our most frequent finding in this group of patients. At laparoscopy the gross appearance of the pelvic organs is usually sufficient for diagnosis. Implants may be found on the surface of the ovary, but endometriosis should be suspected when an ovary is found adherent to the cul-de-sac or posterior leaf of the broad ligament.

For a definitive diagnosis it is necessary to release the ovary by means of a blunt probe. Unless two portals of entry are utilized, one for a holding instrument and the other for a dissection instrument, it is necessary to rely upon a blunt instrument to release an adherent ovary. When this can be done easily and safely, it is recommended. Otherwise, it would be more prudent to employ laparotomy.

Adhesions involving the surface of the ovaries or tubes are more easily accessible to the use of a scissors activated with electrocautery or a simple hook. The surgeon must be very cautious in employing these techniques to avoid injury to adjacent organs or bowel. When bowel is intimately adherent to the ovary, it is better to leave this bowel undisturbed or perform a laparotomy. With experience one begins to learn what adhesions and implants can be safely treated via laparoscopy and what pathology is better treated by laparotomy.

My most gratifying results have been in patients with moderate endometriosis involving one or both ovaries wherein it is possible to liberate these ovaries from their attachments to the posterior leaf of the broad ligament or cul-de-sac. Uusally during this procedure there is minimal bleeding and it can be controlled by simple cautery. Further, it is possible to inject saline through a cannula through a second puncture and wash out the peritoneal cavity, as one does at the time of laparotomy.

The use of pituitary-inhibiting drugs for the treatment of endometriosis, given continuously to create a pseudopregnancy, has been well documented in the literature. Recently we have been testing a new drug, Danazol (Danocrine®, Winthrop Laboratories) which is neither estrogenic nor progestational, though it is mildly androgenic and, of course, anabolic. Side effects to this drug have included mild acne, weight gain, and mild vaginitis due to the induced hypoestrogenic state. Medical treatment is indicated following surgical laparoscopy for endometriosis. Many patients have had diagnostic laparoscopy followed by suppressive therapy for endometriosis and a repeat laparoscopy with laparoscopic surgery of residual implants and adhesions. Several of our patients had as many as three laparoscopies for the diagnosis and management of this frustrating illness.

During a seven year period, from 1/1/67 through 12/31/73, a total of 1,093 infertile patients were laparoscoped. One hundred sixty-three required surgical procedures including lysis of pelvic adhesions, liberation of adherent ovaries, biopsies, and retrieval of tuboplastic splints. Postoperatively, the patients ran a very benign course. One patient had intra-abdominal hemorrhage requiring immediate laparotomy. In this group of 163 patients, there were 46 intrauterine pregnancies and one extrauterine pregnancy.

Back to Table of Contents