Endometriosis Treatment

Endometriosis is a condition where individual sections of the endometrium

(lining of the uterus) are present in various internal organs outside the uterus.

At Herzliya Medical Center in Israel, Endometriosis treatment is done individually, as indicated by the results of diagnostic laparoscopy.

The Benefits of Endometriosis

Treatment at HMC:

• Several leading Israeli gynecologists in a single facility
• Minimally invasive methods for diagnosis and treatment – endoscopy, hysteroscopy, and laparoscopy
• Advanced, leading-edge equipment
• Personnel for coordination and monitoring throughout treatment

What is Endometriosis?

Endometriosis is characterized by the abnormal presence of endometrium (uterine tissue) in other surrounding organs of the uterus (periuterine), such as the fallopian tubes, ovaries, and the bladder – in rare cases, endometrium tissue can be found in distant body organs, like the lungs.

Similarly, the ectopic endometrium tissue responds to menstrual hormonal changes the same way it does within the uterus – it’s able to swell and causes bleeding. This may lead to the development of chronic inflammation of pelvic organs and abdominal cavity, and consequently, the appearance of adhesions. As a result of adhesions, the normal anatomical structure of the female reproductive system is disrupted, which may cause chronic pain and in some cases, this can contribute to secondary infertility.

The incidence of endometriosis in women of childbearing age is 3-10% and it is among the most common causes of infertility. Patients undergoing treatment for endometriosis suffer from disorders of reproductive functioning. Nearly one-third of patients were diagnosed with endometriosis at IVF clinics.

Numerous theories attempting to explain the development of endometriosis that includes genetic, fetal and hormonal factors – to name a few. A steadfast theory associated with the cause of endometriosis is attributed to retrograde menstruation of the endometrium within the uterus through the fallopian tubes into the pelvic cavity, reversing the flow of menstrual blood (instead of leaving the body).

Endometriosis and Pregnancy

Endometriosis causes the obstruction of the fallopian tubes, which may prevent pregnancy. Mature eggs enter the uterus after passing through a channel in the fallopian tube. Adhesions in the pelvis lead to deformation of the fallopian tubes, which in turn makes them resistant to the inner channel through which the egg travels. Ovarian cysts that develop after surgeries to remove them, may also obstruct the fallopian tubes. A number of studies investigating the relationship between endometriosis and pregnancy have found that endometriosis triggers the production of antibodies that attack the lining of the uterus. The presence of antibodies, then, negatively impact the egg, which prevents implantation in the uterus and disrupts normal embryogenesis.

Endometriosis Diagnosis at HMC

Diagnosis of endometriosis involves a clinical gynecological examination and ultrasound (US) of the abdomen and pelvis and laparoscopy:

• The US can detect specific signs of endometriosis cysts in the ovaries. It is impossible to emphasize that the US does not screen for ectopic endometriosis in the internal organs
• Laparoscopy enables the specialist to perform diagnostic and therapeutic procedures simultaneously
• During laparoscopy, the specialist is also able to examine internal organs and take tissue samples from suspicious areas. The definitive diagnosis of endometriosis is then made by histopathological examination of samples collected during the laparoscopy

Treatment of endometriosis at HMC

Experts at the IVF Center and Gynecology Department carry out treatment of Endometriosis at Herzliya Medical Center; depending on the severity of the disease, the optimal treatment is applied.

There are four distinguished degrees of endometriosis:

• Minimal
• mild
• moderate
• Severe

This classification is based on the location, quantity, depth, and size of the endometrium, including pelvic adhesions and fallopian tube blockage. However, the severity of the disease does not always correlate with the severity of symptoms, pain or fertility risk. Some women with severe endometriosis may also be asymptomatic.

Laparoscopy at HMC

Indications for laparoscopy and beginning treatment of endometriosis are not universal. The decision to perform laparoscopy in patients with impaired reproductive function, presumably caused by endometriosis is taken individually.

Based on numerous factors, leading experts of the Center for IVF at HMC in Israel recommend diagnostic laparoscopy to patients according to the following criteria:

• Presence of large cysts in the ovaries, or tumors
• The severity of symptoms like intense pain and no effective treatment from drug therapy
• Signs indicating endometriosis development in other organs
• Long-term infertility of unknown cause
• Other infertility aspects – duration, previous experience and ineffective attempts to treat infertility

Laparoscopy is a complex, but minimally invasive diagnostic technique with the use of an optical instrument inserted into the abdomen through a small incision. Only qualified and experienced surgeons perform this procedure.

Other Treatments of Endometriosis

Conservative treatment of endometriosis involves the use of hormone replacement therapy (HRT), which suppresses the secretion of ovarian function and reduces estrogen levels in the blood. Ectopic endometrium responds to changes in the concentration of estrogen in the same way as the normal endometrium. To achieve regression, a patient with ectopic endometrial prescribed oral contraceptives, progesterone, or a gonadotropin-releasing hormone, prescribed for a period of 3 to 6 months.

Surgical treatment of endometriosis involves laparoscopy, performed under general anesthesia. After the procedure, a 1-2-day hospital stay is necessary for rehabilitation. Rehabilitation usually proceeds quickly and without complications. During laparoscopy, the surgeon carefully examines the presence of endometriosis and performs ablation where necessary. The main objective is to remove the ectopic endometrium to the greatest extent while maintaining the integrity of the pelvis.

Infertility Treatment for Endometriosis

Endometriosis is one of the most common causes of infertility. For this reason, it is imperative that endometriosis is diagnosed in its early stages. If the diagnosis of endometriosis is confirmed, it is necessary to assess the degree of severity in order to determine the particular internal organs present among the ectopic foci of the endometrium.

In patients with mild endometriosis, it is recommended to start treatment for infertility with ovulation induction drugs followed by insemination. Pre-course therapy is performed as well as hysterosalpingography (X-ray of the uterus and fallopian tubes). It should be emphasized that in such situations, treatment by hormonal therapy of endometriosis is not performed.

The effectiveness of the aforementioned method of endometriosis has no fundamental influence. On average, the likelihood of pregnancy (due to ovulation induction and insemination) is 20% for each procedure respectively. If after several months the patient does not achieve a positive result, the feasibility of diagnostic laparoscopy or selection of an alternative IVF procedure should be sought. The success of the IVF procedure is independent of the Fallopian tubes.

Numerous clinical studies have focused on severe endometriosis and pregnancy. Results indicate that the most complex approach, regulative hormone therapy for endometriosis for a period of 3-6 months, followed by IVF is effective.

Also in this situation, it is possible to perform resection surgery of ectopic endometrium and reconstructive surgery of the pelvic organs.

In general, the effectiveness of IVF for patients is reduced in endometriosis patients, fewer pregnancies result in comparison to patients undergoing IVF due to other causes (of obstruction to the fallopian tubes). The presence of endometriosis has a negative impact on the quality of eggs.

Currently, there is no consensus as to how suitable surgery is to remove endometrial ovarian cysts are as part of infertility treatment. However, it is reasonable to assume that the risk of ovarian trauma during surgery is much higher than the potential benefit of cyst resection.

Specialists at the IVF Center at HMC believe that the indications and suitability for this operation be considered individually. In most cases, major resection of the cyst with a diameter greater than 4 cm is attainable. In some patients, before surgery is necessary, it is beneficial to perform a diagnostic laparoscopy to determine the characteristics of the cysts.

Many patients are wary of hormone therapy as part of treatment for infertility because they believe high levels of estrogen may be a cause of endometriosis. However, scientific research indicates that the rapid growth of ectopic endometrium and recurrence of endometriosis caused by infertility treatments are very rare. Conversely, successful pregnancy alleviates the symptoms of the disease and contributes to its regression. Patients with endometriosis will still need monitoring and preventive gynecological examinations.

Complications of severe endometriosis experienced during pregnancy are extremely rare but possible. Bleeding, which develops due to the rupture of endometrial cysts or adhesions are a possible side effect.

At the Center for IVF at Herzliya Medical Center, infertility treatment for patients with endometriosis is performed by reputable experts with extensive experience in the field of reproductive medicine. The use of modern technology, an individual approach, and sensitivity to each patient’s needs are essential to successful treatment.