1. Management of endometriosis
Tarafdari,
Ob/ Gyn, Fellowship in IVF & Infertility

2. incidence
Endometriosis is defined as the presence of endometrial tissue (glands and stroma) outside the uterus.
6-10% of women of reproductive age
38% in infertile women VS 5% of fertile women
71-87% of women with chronic pelvic pain
No particular racial predisposition
A familial association
Polygenic-multifactorial mechanism of inheritance

3. Disease progression
ENDOMETRIOSIS PROGRESSES IN MOST CASES OF MODERATE AND SEVERE DISEASE.
SPONTANEOUS REGRESSION CAN OCCUR IN UP TO 58% OF MILDER CASES.

4. etiology The pathogenesis of endometriosis Altered endometrial genes
Implantation from retrograde menstruration
Hematogenous or lymphatic transport of stem cells from bone marrow
Coelomic metaplasia
Altered endometrial genes
Increased COX-2 activity
Increased aromatase activity
Progestrone resistance

5. Mechanism of Pain
Chronic inflammatory response TNF-a , IL-1,6, PGs pain
Nerve growth factor especially in rectovaginal lesions increased density of nerve fibers.
Altered uterus innervation severe dysmenorrhea

6. Mechanism of infertility
The mechanism by witch it occurs in early stage is unclear.
An abnormal peritoneal environment due to oxidative stress & inflammatory cytokines may lead:
Affect sperm function & DNA damage
Cause abnormalities in oocyte cytoskeleton function
AMH is decreased in early stage of endometriosis

7. Risk factors Early menarche (before age 11)
Cycles shorter than 27 days
Prolonged & heavy cycles
Single/nulliparous
Non oral contraception

8. Protective factors High pariety Increased duration of lactation
Regular exercise more than 4 hours per week
Smoking

9. Clinical manifestation
The clinical manifestation of endometriosis are variable & unpredictable in both presentation & course.
A significant of women remain asymptomatic.
Endometriosis should be suspected in women with subfertility, dysmenorrhea, dyspareunia, or chronic pelvic pain.
Local symptoms can arise from rectal, ureteral, and bladder involvement.

10. pain
Pelvic pain that is typical in endometriosis is characteristically described as:
Secondary dysmenorrhea
Deep dyspareunia
Sacral backache during menses
In adult women, dysmenorrhea may be especially suggestive of endometriosis if it begins after years of pain-free menses.
Dysmenorrhea often starts before the onset of menstrual bleeding and continues throughout the menstrual period.

11. pain
The pain associated with endometriosis may not correlate with the stage of disease but there may be some association with the depth of infiltration of endometriotic lesions.
Painful defecation during menses and severe dyspareunia are the most predictable symptoms of DIE.

12. CLINICAL EXAMINATIONS
Recommended that pelvic examination be performed at the time of menses when tenderness is easier to detect.
The vulva, vagina, and cervix should be inspected for any signs of endometriosis, although the occurrence of endometriosis in these areas is rare(e.g., episiotomy scar).
The uterus is often in fixed retroversion, and the mobility of the ovaries and fallopian tubes is reduced.
Other possible signs of endometriosis include uterosacral or cul-de-sac nodularity, cervical displacement due to uterosacral scarring , painful swelling of the rectovaginal septum, and unilateral ovarian (cystic) enlargement.

13. DIAGNOSIS
The definitive diagnosis of endometriosis only can be made by histology of endomeriotic lesions removed at surgery.
Neither biomarkers nor imaging studies have been able to supplant diagnostic laparoscopy for diagnosis.
During diagnostic laparoscopy, the pelvic and abdominal cavity should be systematically investigated for the presence of endometriosis.
The visual appearance of lesions during laparoscopy is variable.
Classical lesions: black powder-burns lesions
Non-classical : red or white lesions
CA125 as a diagnostic marker for endometriosis has limited value.

14. Laparoscopic view of peritoneal lesion
Characteristic findings include typical (“powder-burn,”“gunshot”) lesions on the serosal surfaces of the peritoneum.
These are black, dark brown, or bluish nodules or small cysts containing old hemorrhage surrounded by a variable degree of fibrosis.
Scarring of perotoneum causes adhesions
Endometriosis can appear as subtle lesions ,including red implants (petechial, vesicular, polypoid, hemorrhagic, red flamelike), serous or clear vesicles, white plaques or scarring, yellow-brown discoloration of the peritoneum, and subovarian adhesions.

16. ASRM CLASSIFICATION
Is not a good predictors of pregnancy after treatment
Does not correlate well with the symptoms of pain
& dyspareunia & infertility.

17. Thanks for your attention