1. Duration of symptoms (years)
Does the duration of pelvic symptoms play a role in the prevalence of infertility in women with endometriosis? Somjate Manipalviratn1, M.D., Pamela Stratton1, M.D., Mary Lou Ballweg2, B.A., Ninet Sinaii3, Ph.D. 1Reproductive Biology and Medicine Branch, NICHD, NIH 2The Endometriosis Association, International Headquarters 3Biostatistics and Clinical Epidemiology Service, CC, NIH
Background:
The most common symptoms of endometriosis are pain and infertility. One quarter to half of infertile women have endometriosis and 30-50% of women with endometriosis are infertile.1 Similarly, others have shown that endometriosis may account for more than 50% of women with chronic pelvic pain.2 Moreover, among those who fail medical treatment for chronic pelvic pain, almost 70% have endometriosis.3
Objective:
To examine if women with pelvic pain reporting surgically diagnosed endometriosis and a longer pelvic symptoms report a higher prevalence of infertility than those with a shorter duration.
Study Design:
Cross-sectional study of self-reported survey data
Materials and Methods:
In 1998, the Endometriosis Association surveyed its members on symptoms of endometriosis, including pelvic symptoms and fertility. Women with surgically diagnosed endometriosis who had attempted pregnancy were included in this analysis. Pelvic pain symptoms include dysmenorrhea, pain at the time of ovulation and pain at other times in menstrual cycle. Symptom duration was defined as the difference between age at diagnosis and pelvic symptoms onset. Symptom duration was then categorized as <5, 5-10, and > 15 years. Data were analyzed using chi-square test for trend and logistic regression when adjusting for age at time of survey.
Results:
Of 4428 respondents with surgically diagnosed endometriosis, 2594 (58.6%) reported attempted pregnancy. Of those, 1800 (69.4%) reported infertility, had a mean age at the time of survey of 37±6.8 years and reported a mean age of 29.9±6.4 years at the time of endometriosis diagnosis. 15.5% of women had pelvic symptoms for > 20 years. There is a significant trend for higher prevalence of infertility with increasing symptom duration (Figure 1). Those reporting infertility were more likely to have onset of symptoms during adolescence (< 20 years old) than later (OR 1.27, 95%CI: 1.06,1.52)
Of 2556 women reporting pregnancy data, 1507 (59%) achieved pregnancy. Of those with infertility, about half reported at least one pregnancy. Among women achieving pregnancy, but not abortion compared to those without. Live birth was also less common. (Table 1)
Figure 1: Prevalence of infertility according to the duration of pelvic symptoms.
Table 1: Pregnancy outcomes according to self-reported fertility status.
Conclusions:
Women with longer duration and earlier onset of pelvic symptoms of endometriosis were more likely to have fertility problems. Those reporting infertility had a higher frequency of adverse pregnancy outcomes.
References:
1. The Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility. Fertil Steril 2006;86 Suppl 4:S
2. Fauconnier A, Chapson C. Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications. Hum Reprod Update 2005;11:
3. Laufer MR, Goitein L, Bush M, et al. Prevalence of endometriosis in adolescent girls with chronic pelvic pain not responding to conventional therapy. J Pediatr Adolesc Gynecol 1997;10:
Support:
Intramural program, Reproductive Biology and Medicine Branch, NICHD, NIH, Bethesda, MD and Endometriosis Association, International Headquarters, Milwaukee, WI
Fertile N=626 (%)
Infertile N=881 (%)
P-value
Miscarriage
140 (22.4%)
371 (42.1%)
<.01
Abortion
121 (19.3%)
163 (18.5%)
.69
Ectopic pregnancy
16 (2.6%)
46 (5.2%)
<.05
Live births
511 (81.6%)
563 (63.9%)
Percentage
Duration of symptoms (years)
61.5
67.8
71.8
73.4
P for trend <