Dr. Vineet Mishrais the Head of the Department of Obst. & Gynaec IKDRC, Ahmedabad. He has been a very activemember of FOGSI and has been elected as VP FOGSI West Zone in 2016. Over the years, Dr. Vineet Mishra’s contributionin academics has taken him all across the globe. He has been actively involved in fellowship programmes in Obst. & Gynaecsince 2005. He is a great teacher and mentor for the young aspiring gynaecologists throughout the country. He is a strongbeliever of revolution through innovation and is an eminent gynaecologist. He is specialized in urogynaecology, minimallyinvasive surgeries, assisted reproductive techniques, high-risk pregnancy care and runs a state-of-the-art genetic lab andfoetal medicine unit. Dr. Vineet Mishra has been the organizing chairperson of urogynaecology committee from 2011 to2013. He has a strong vision and has organized many prestigious CME programmes and has shared his knowledge as a guestlecturer across the country.
Objective: To study the prevalence, clinical and laparo-scopic characteristics of endometriosis in infertile women.Study DesignThis is a hospital-based prospective study.PatientsFive hundred and two (502) patients underwentdiagnostic laparoscopy for evaluation of cause for infer-tility. Staging of endometriosis was done according to therAFS scoring system.
Results: Out of 502 women, 276 (54.98 %) showed thepresence of endometriosis, while 226 (45.01 %) did nothave endometriosis. One hundred and eighty-three(66.3 %) women had stage I endometriosis, 49 (17.77 %)had stage II, 23 (8.33 %) had stage III and 21 (7.6 %) hadstage IV endometriosis.
Conclusion: More than 50 % of patients in our study wereasymptomatic; however, the presence of menorrhagia,dysmenorrhoea, dyspareunia and chronic pelvic pain arealso clinically statistically significant. So, we would like torecommend the evaluation and treatment of a patientreporting in gynaecological OPD with the above-men-tioned complaints with high suspicion of endometriosis.
Keywords : Laparoscopy, Infertile women, Endometriosis, Dysmenorrhoea, Chronic pelvic pain
Endometriosis is one of the most common diseases encountered in gynaecological outdoors, and increasing evidences suggest it to be a part of uterine reproductive dysfunction syndrome [1]. It is a chronic disease, which is characterized by the presence of functional endometrial glands and strom a outside the uterine cavity with locally invasive characteristics as first described by Thomas Cullen[2]. Carl Rokitansky was the discoverer of endometriosis, while the term was coined by John A Sampson who also gave the famous Sampsons theory of retrograde menstruation to describe the pathogenesis of it[3,4]. Its prevalence as reported in the literature is of very wide range [5]. 30–50 % women with endometriosis are infertile, while 25–50 % of infertile women have endometriosis [6]. 10–20 % of fertile women suffer from endometriosis [7]. It is, however, difficult to diagnose and treat it completely.
A prospective study was conducted in the Department of Obstetrics and Gynaecology, Institute of Kidney disease and Research Centre, Ahmedabad, Gujarat, for the period from January 2014 to August 2015. The study aimed to determine the prevalence, clinical and laparoscopic char-acteristics of endometriosis in infertile women.
Infertile females with either primary or secondary infertility whowere subjected to diagnostic hystero-laparoscopy and chro-mopertubation test and were diagnosed to have endometriosiswere included in the study; theircomplaints, physical exami-nation and sonographic findings were also noticed.
Women with normal fertility, pelvic inflammatory diseaseand adhesions due to infections or previous surgeries wereexcluded from the study.
All cases included in the study were analysed for thefollowing characteristics.
All collected data were entered into the SPSS version20. Categorical data are expressed in frequency or per-centage. Chi-square test and Fisher’s exact test have been performed to obtain Pvalue for categorical data.
Five hundred and two (502) patients with infertility were subjected to diagnostic hystero-laparoscopy and chromop- ertubation test during the period from January 2014 to August 2015. After all inclusion and exclusion criteria, only 276 (54.98 %) patients were included in the study as having laparoscopic evidence of endometriosis. The mean age of patients included was 28.55 ± 4.29 years (19–44 years). Of these, 235 (85.14 %) had primary infertility and 41 patients (14.85 %) had secondary infertility. Apart from infertility, the commonest complaints among the patients included in the study were dysmenorrhoea 176 (63.76 %) followed by dyspareunia 44 (15.94 %), menorrhagia 34 (12.31 %), menstrual irregularity 32 (11.59 %) and chronic pelvic pain 25 (9.05 %). However, more than 50 % of cases were asymptomatic. On examination, 37 (13.40 %) patients had tenderness, 90 (32.70 %) patients had adnexal mass and 67 (24.27 %) had restricted mobility. There was a statistically significant association between adnexal tenderness and restricted uterine mobility with staging of the disease (P \ 0.01). Abnormal USG findings as presence of endometrioma with ground-glass appearance were seen in 31 (11.23 %) cases. The presence of endometriomas on sonography is found to be statistically significant as con- firmed laparoscopically and also with the stage of the dis- ease. Based on revised AFS score (1985), stage I endometriosis was seen in 183 patients (66.3 %); stage II endometriosis in 49 patients (17.75 %); stage III endometriosis in 23 patients (8.33 %); and stage IV endometriosis in 21 patients (7.6 %). The association of clinical signs and symptoms with the stage of disease is shown in Fig. 1 and Table 1. The association of laparo- scopic and USG findings with the stage of disease is shown in Fig. 2 and Table 2. In our study, we found a definite correlation of USG and laparoscopic evidence of endometriosis with the stage of disease. The presence of bilateral blocked tubes also had statistically significant association with the severity of stage of endometriosis. All patients with minimal and mild (stage I/II) endometriosis were treated by fulguration/cauterization with bipolar cau- tery followed by three doses of GnRH agonist. Moderate and severe (stage III/IV) endometriosis were treated depending on laparoscopic findings, i.e. adhesiolysis, endometrioma cyst wall excision followed by three doses of leupragon (3.75 mg) or goserelin (3.6 mg) at an interval of 28 days.
History and clinical examination can provide us a clue tothe diagnosis to endometriosis.
The primary presentation of endometriosis is pelvic painand/or infertility. 45–82 % of women with chronic pelvicpain have endometriosis, while 2.1–78 % of infertilewomen have the same [5,9]; the incidence of complaintslike chronic pelvic pain and others is more common withinfertile women than with fertile women [10,11].
Transvaginal ultrasound can also help in its diagnosis bytelling us about probe tenderness, which can be used as asurrogate marker for rectovaginal endometriotic nodule,and about endometriomas, which are deep ovarianendometriosis and seen as ground-glass homogeneousopacity that is an indicator of moderate-to-severe disease;
however, it cannot tell about superficial or deep peritonealimplants and about adhesions caused due to endometriosisor about obliterated POD. Laparoscopy is considered itsgold-standard diagnostic tool as it provides direct visual-ization of endometriotic lesions. Their laparoscopic fea-tures are unique and can easily be characterized into earlyor late lesions: early lesions are small, flat patches, flecks,blebs or even polyps of red, brown colour, advancedlesions are black puckered, while healed are white fibroticlesions which can be present on the pelvic surfaces, or canbe on the ovaries, uterus or other pelvic organs. Ovaries arethe most common organs affected by endometriosis, and itcan be superficial or deep involvement, which is importantfrom grading point of view also. Also, a strong correlationhas been observed between depth of lesion[10 mm andchronic pelvic pain [12]. Endometriomas or chocolate cystsare deep ovarian endometriosis. Beyond diagnosis,laparoscopy also provides with an opportunity to treat thedisease, i.e. fulgurate the lesion or to do adhesiolysis asaccording to the severity of disease. ESHRE guidelinesrecommend laparoscopy as gold-standard measure todiagnose endometriosis [13]. Laufer MR et al. and BrosensI et al. even recommend hydroflotation technique toimprove visualization of even early lesions like free-float-ing adhesions and focal microvascularization [14,15]. Ourstudy has shown significant correlation between presenceof endometriomas and grading of the disease. Hughesdonet al. found in a detailed study of 29 ovarian specimenswith endometriomas that in 90 % of cases it was formed bya pseudocyst and part of the ovarian cortex is invaginated[16]. Among 31 cases who had endometrioma in our study,diagnosed on transvaginal USG, 24 cases had stage III andIV endometriosis as confirmed by laparoscopy findingsaccording to rAFS score (1985).
Endometriosis can affect almost each and every organ offemale reproductive system and thence adversely affectsthe reproductive ability of a female. The exact mechanismby which it causes infertility is still controversial. Hor-monal, genetic and environmental factors cause alteredperitoneal fluid composition that is one of the causes andleads to an increased levels of prostaglandins, proteases,cytokines and vascular endothelial growth factor (VEGF)in the peritoneal fluid [17]. It can affect oocyte release, itstravel in the pelvis, sperm movement, embryo quality andfallopian tube function [18].
Meuleman C et al. have reported 47 % prevalence ofendometriosis in infertile women [19], while in our study itis slightly high, 54.98 %.
Valson H et al. in 2016 reported a very high prevalence ofendometriosis among infertile women of about 73.33 % [20],while Mishra VV et al. in 2014 reported it to be 48.38 % [21].
The majority of cases in our study had stage I disease,and most of them were asymptomatic while as severity ofstage increased, severity of symptom presentation increases and also sonographic presentation of endometriomaincreases in a statistically significant manner.
Compliance with Ethical Standards
Conflicts of interest None.
Informed Consent Informed written consent was obtained from every patient to enrol them in this study.
