2007

Evaluating and Managing Pelvic Pain While Preserving Fertility

Points to Remember

• Endometriosis is a cause of pelvic pain, infertility, and menstrual irregularities in approximately 10% to 15% of premenopausal women.
• If medical treatment fails to relieve symptoms, laparoscopic surgical removal of adhesions may be indicated.
• Ovarian endometriosis and surgery may endanger fertility because of the risk of destruction of the oocytes in the ovarian cortex.
• A multidisciplinary reproductive endocrinology practice can aid in the development of a complete fertility plan and is more experienced at conservative surgery, thus preserving fertility.

The Challenge

Approximately 10% to 15% of all premenopausal women and 25% to 35% of infertile women experience pelvic pain and menstrual irregularities caused by endometriosis (Figure). There is a strong genetic component to endometriosis. A woman faces a 7-fold chance of developing endometriosis if her mother had endometriosis. Medical treatment consists of suppressing the menstrual cycle with oral contraceptives or more powerful medications. If this fails, the disease implants and adhesions often require open or laparoscopic surgical removal to relieve the symptoms. However, surgery poses the risk of infertility if excessive ovarian tissue and follicles are removed and adhesions form.

Figure. Endometriosis and distribution of adhesions. Pelvic pain and menstrual irregularities are common symptoms of endometriosis, an abnormal distribution of endometrial tissue in the reproductive tract. Severity of symptoms is not always related to the severity of the disease.

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Treatment Options

Reproductive endocrinology specialists confirm a suspected diagnosis of endometriosis through laparoscopic examination and tissue biopsy. If a woman has completed childbearing or has no desire to bear children and wants to keep her pelvic organs, the focus of the pelvic examination is to determine areas of the pelvis that are most affected and to surgically remove the deposits.

If the woman desires to bear children - or the endometriosis is in locations too difficult to reach surgically - medical therapies may be used in conjunction with surgery. These therapies include continuous oral contraceptives or the use of injectable GnRH analogs to reduce estrogen production and thereby restrict growth of adhesions. Medical therapy alone does not seem to markedly increase fertility.

Focus on Fertility

At Mayo Clinic, the multidisciplinary reproductive endocrinology team strives to preserve or improve fertility in several ways:

• Decreasing the amount of diseased tissue in the pelvis so natural fertility can return
• Using multiple methods to remove disease - through surgery, cautery, laser, and harmonic scalpel - to help minimize the chances of blocking or scarring to the fallopian tubes
• Precisely resecting ovarian adhesions to conserve ovarian tissue and follicles as well as reduce pain
• Working collaborations to help patients coordinate in vitro fertilization and maximize the number of oocytes (eggs) harvested