March 2012 eNews
Endometriosis: What You Need to Know
by Sunita Kulshrestha, MD, FACOG
Endometriosis is a common chronic condition affecting millions of women in their reproductive years. It is thought to affect up to 10% of all women and from 20-50% of women who experience infertility or pelvic pain.
Endometriosis is characterized by the formation of endometrial implants (cells that line the uterine cavity) outside of the uterus. It is most commonly found on the ovaries, and the peritoneum (inner lining of the abdominal cavity) but can also be found on the tubes, bladder and bowel. The exact cause of endometriosis is unclear but the most commonly accepted theories include retrograde menstruation (flow of menstrual blood from the uterus back through the tubes into the pelvis), and an altered immune system so that these cells are unable to be cleared from the pelvis. Risk factors include a family history of endometriosis (3-10 fold increased risk of having endometriosis), lack of previous pregnancy, history of infertility or pelvic pain, early age at onset of menses, short menstrual cycles, prolonged menses, Caucasian race, and a low body mass index.
The symptoms of endometriosis can include pelvic pain, including pain with menstruation (dysmenorrhea), pain with intercourse (dyspareunia), chronic pelvic pain and pain with bowel movements or urination. The pain tends to be progressive. However, many women with endometriosis do not have pelvic pain. The degree of pain is not related to the extent of disease.
Endometriosis has been strongly linked to infertility. The reduction in fertility is related to anatomic distortion of the pelvis related to adhesions (scarring). Adhesions can prevent the passage of the egg to the tube or can block the tubes. Additionally, the endometriotic implants can release chemical mediators that may have hostile effects on sperm, sperm-egg interaction, tubal transport, ovarian function/ovulation and implantation.
A patient's history, physical exam and imaging studies (such as ultrasound or CT scan or MRI) can be indicative of endometriosis. Some patients with endometriosis have endometriomas (fluid and tissue filled ovarian cysts) that can be felt on an exam or seen on an imaging study. However, endometriotic implants or adhesions can not be seen on such studies. The definitive approach to diagnosis of endometriosis is through a laparoscopy, a minimally invasive procedure in which a thin telescope attached to a camera is inserted into the pelvis. Laparoscopy can be used to diagnose and treat endometriosis through burning, vaporizing or excising implants and adhesions, removing or draining cysts, and restoring normal anatomy. Endometriosis is staged (Stage I-minimal, Stage II-mild, Stage III-moderate and Stage IV-severe) based on a variety of characteristics determined at the time of surgery.
The treatment of endometriosis is based on whether the patient's goal is to treat pain or infertility or both. For the treatment of pelvic pain, the patient can pursue medical or surgical management. Medical options for management of pain include the use of analgesics such as non-steroidal anti-inflammatory pain medications, and hormonal treatment including the use of birth control pills, progesterone containing compounds, GnRH analogs (lower estrogen levels and create a pseudomenopause) and androgens (male hormones). These medications however have not been shown to benefit fertility or treat anatomic distortion from endometriosis. Additionally these medications can prevent pregnancy while they are being taken.
A woman's age, duration of infertility, presence of pelvic pain, and stage of endometriosis are factors that determine the best course to treat endometriosis-related infertility. Options include surgical management (see above) or the use of the assisted reproductive techniques, IUI (intrauterine insemination) and IVF (In-vitro fertilization). Several studies have shown that fertility is enhanced in women with minimal or mild endometriosis treated with IUI and IVF. Whereas without treatment, spontaneous pregnancy rates are about 2-5%/month, pregnancy rates with IUI with either clomiphene citrate or FSH injections, can reach 10-15%/cycle. Moderate to severe endometriosis, with anatomic distortion is best treated by IVF. IVF can bypass any issue related to scarring or tubal obstruction and IVF pregnancy rates are equivalent to patients who pursue IVF for other reasons. Pregnancy rates in IVF are based on several factors including embryo quality and a woman's age and can be as high as 40-50%/cycle.
If you have been diagnosed with endometriosis, are seeking to become pregnant and have had difficulty conceiving, please contact us at 703.698.7355 or 800.552.4363, or request an initial consultation by clicking here.
What's New at GIVF
The Fertility Preservation Center for Cancer Patients
Building on its record of being the first clinic in the Washington, DC area to provide elective oocyte preservation - Personal Egg Banking - GIVF is pleased to announce the establishment of a Center to provide fertility treatment for both female and male cancer patients that is fully-integrated with the treatment provided by the patient's oncologist.
Click here to read more.
Virginia Personhood Bill Update
Thank you for voicing your objections to the Virginia Personhood bill. In a surprising move, upon hearing strenuous objections from the voters and physicians, Senate Majority Leader Normant introduced a motion to send the HB1 (Personhood) bill back to the Health and Education Committee for further study. This bill could have jeopardized the ability to undergo IVF treatment in Virginia. The bill has been tabled for this session and will not come back for consideration until the 2013 session. We encourage you to support the advocacy efforts of RESOLVE and ASRM to defeat legislation that limits access to reproductive care. Please consider a donation today.
Donations to RESOLVE can be made here
Donations to ASRM can be mailed to:
American Society for Reproductive Medicine
1209 Montgomery Highway
Birmingham, Alabama 35216-2809
Affordable Options at GIVF
GIVF offers a variety of financial options to make treatment accessible and affordable, including:
Click here to view all of our current affordable options.
RESOLVE Advocacy Day 2012
Join RESOLVE for Advocacy Day, April 25, 2012 in Washington, DC. Click here for more information and to register.
In Recognition of Women's History Month
Barbara McClintock, PhD
A Scientific Pioneer
by Sarah Zornetzer, MS, CGC
in the lab at Cold Spring Harbor, NY
Thinking back 15 years ago... It is 3AM and I am shuffling through a foot or two of snow trying to make it up Libe Slope to visit my fruit flies. I am a junior at Cornell University taking the dreaded Genetics 281 laboratory that is required for all Biology Majors. Its unpopularity is partially due to the odd hours that you need to conduct your experiments which are based on animal life cycle, not the convenience of a student. My laboratory partner and I flipped a coin and I lost, so I get the 3AM shift. Back in my college days I failed to appreciate my genetic predecessors who identified the principles of the experiments keeping me up all night.
Now as a genetic counselor, I can let others stay up all night in the laboratory conducting the experiments while I work during the day. Even though I know I cannot appreciate the labor of the researchers, I sometimes reflect on their accomplishments. Seventy five years before I set foot on the frozen grounds of Ithaca, New York, Barbara McClintock took her introduction to genetics class which was the only genetics course available to undergraduates. After the completion of that course, she received an invitation to attend the only other course at Cornell for genetics which was only open to graduate students. Her love of genetics was born.
Dr. McClintock's work focused on the relationship between plant reproduction and mutations. While still in her 20s she published studies that proved that "normal" exchange of genetic material produced new varieties of corn. Shortly after similar studies were published on fruit flies (the reason for my 3AM stroll), but Dr. McClintock was the first in the field. She is most known for her discovery of "jumping genes" which showed that genetic material is not always stationary and can "jump" to another chromosome. She identified these genetic elements 20 years ahead of biologists who were working with simpler life forms.
Her accomplishments are even more amazing in light of her deterrents. At an early point in her career she was told if she married, she would be fired from her position. Her work was considered too radical and was ignored by many. Disappointed, she started refraining from publishing her work and ceased giving lectures, and only shared her work with a small circle of colleagues. Decades later, once the genetics field caught up with Dr. McClintock's discoveries, she finally was recognized for her amazing work.
Dr. McClintock is one of the great women that we should celebrate during women's history month. In 1944, she became the third woman elected to the National Academy of Sciences. She was the first woman to become president of the Genetics Society of America. President Richard M. Nixon awarded Dr. McClintock the National Medal of Science in 1971. Ten years later, she became the first recipient of a MacArthur Foundation Grant, now known informally as the "genius" grant, which was awarded for her lifetime work. That same year, she was given the Albert and Mary Lasker Award. At the age of 81, she received the Nobel Prize in Physiology or Medicine for her work on "jumping genes." Dr. McClintock was the first woman to receive an unshared Nobel Prize in that category. Dr. McClintock was ahead of her time and is one of the most distinguished scientists of the 20th century.
The Genetics & IVF Institute (GIVF) regularly publishes an informative newsletter featuring the latest infertility news and developments. The newsletter is sent electronically via email. To subscribe, click here.