{"paper_id":"f1ea57a8-4974-415c-af54-ae9df705c5b6","body_text":"*Corresponding author email: shaistazubair212@gmail.comSymbiosis Group\nSymbiosis Group\nSymbiosis www.symbiosisonline.org \nwww.symbiosisonlinepublishing.com\nPrevalence of Endometriosis in Infertile and Sub-\nFertile Women\nShaista Zubair1*, Hafsa Sheikh2, ShereenZulfiqarButta3, SamiaShuja3\n1Specialist Obstetrics and Gynecology Oasis Hospital, Abu Dhabi United Arab Emirates.\n2College of physician and surgeons of Pakistan\n3Jinnah Postgraduate Medical Centre Karachi Pakistan\nSOJ Gynecology, Obstetrics and Women’s Health Open AccessResearch Article\nReceived: February 02, 2017; Accepted: February 09, 2017; Published: October 06,2017\n*Corresponding author:  Shaista Zubair, MRCOG.UK, MRCPI. Ireland, FCPS, MCPS, Specialist Obstetrics and Gynecology, Oasis Hospital Abu Dhabi, United Arab \nEmirates, Tel:+971 7401617; E-mail: shaistazubair212@gmail.com\nIntroduction\nEndometriosis is defined as the presence of endometrial-like \ntissue outside the uterus, which induces a chronic, inflammatory \nreaction. While some women with endometriosis experience \npainful symptoms and/or infertility, others have no symptoms \nat all. The exact prevalence of endometriosis is unknown but \nestimates range from 2 to 10% within the general female \npopulation but up to 50% in infertile women. [1]although \nAbstract\nIntroduction: Endometriosis is defined as the presence of \nfunctioning endometrial tissue at a site outside the uterus. It is a \ncommon and debilitating condition, diagnosis has traditionally been \nby laparoscopy.\nObjective: To determine the frequency of endometriosis in \ninfertile and sub- fertile women.\nStudy design: Descriptive cross – sectional study was carried out \nat the Department of Obstetrics and Gynecology, Jinnah postgraduate \nMedical Centre, Karachi, Pakistan (tertiary care hospital listed in WHO \ndirectory). \nMethods:  Patients of reproductive age were selected on \nconvenient sampling technique, with history of infertility and \nsub-fertility with normal semen analysis of husband. Those with \nsuspicious of cyst, Polycystic Ovary Syndrome and contraindication to \nlaparoscopy were excluded.\nResult: The frequency of endometriosis in women with infertility \nand sub-fertility was found to be 10(20%). We found no association \nbetween demographic features age, parity and socio-economic class) \nand occurrence of endometriosis.\nConclusion: Through this study we conclude that women with \nhistory of sub-fertility and infertility at a risk of endometriosis and \nmust be subjected to diagnostic laparoscopy after excluding male \nfactor contribution. Endometriosis is a progressive disease and the \nlonger the diagnostic delay more advanced is the disease at the time of \nlaparoscopy. Hence an early diagnostic laparoscopy in the evaluation \nof infertile women helps to diagnose endometriosis in its early stages \nand also reduces the numbers of patients of unexplained infertility. \nKey words: Endometriosis; Infertility; Sub-Fertility; Laparoscopy\nendometriosis can be diagnosed incidentally in asymptomatic \nindividual, it more commonly present with chronic or cyclical \npelvic pain, sub-fertility or adnexal masses.[2]\nWithin this restricted case definition, the relation between \nendometriosis and infertility status is complex. At baseline, \nthe prevalence of infertility (defined as attempting to become \npregnant for > 1 year without success) was greater among \nwomen with laparoscopic confirmation (20%) than among those \nwho were diagnosed without laparoscopic confirmation (4%) \npotentially resulting in over sampling those with asymptomatic \ndisease, approximately twenty percent of all infertile women are \nfound to have endometriosis. [3]\nEndometriosis is assumed to be one of the causative factors \nof infertility, although the mechanism remains to be elucidated \nmechanical factors distorting the pelvic anatomy and /or \nchanges in the biochemical and cellular environment in the \nperitoneal cavity are possible contributing factors impairing \nfertility. Laparoscopy is a widely used diagnostic and therapeutic \nmeans of treating endometriosis associated infertility. [4]Timely \ndiagnoses by early laparoscopy can reduce the complication \nand mortality that resulted due to delay in diagnosis of these \ndiseases.[5]Laparoscopy remains the gold standard in evaluating \nan infertile female. [6] Infertility is the most frequent indication \nfor laparoscopy to detect endometriosis. Without a diagnostic \nlaparoscopy and hysteroscopy in selected patients infertility \nwork up remains incomplete. [7]\nConsidering the current burden of endometriosis, the \ndiagnostic challenges faced by gynecologists and the paucity \nof local data, the study aimed to calculate the frequency of \nendometriosis in women who underwent diagnostic laparoscopy \nin infertility and sub-fertility.\nMaterial and Method\nThis hospital based descriptive cross sectional study was \ncarried out at the department of Obstetrics and Gynecology, \nJinnah postgraduate Medical Centre Karachi Pakistan from \nNovember-2006 to September 2007.A total of fifty patients via \n\nPage 2 of 4Citation: Shaista Z, Hafsa S, Shereen ZB, SamiaShuja (2017) Prevalence of Endometriosis in Infertile and Sub-Fertile Women. SOJ \nGynecol Obstet Womens Health 3(3):1-4. DOI: http://dx.doi.org/10.15226/2381-2915/3/3/00126\nPrevalence of Endometriosis in Infertile and Sub-Fertile Women Copyright: \n© 2017 Shaista Z, et al.\nnon probability convenient sampling technique were selected \nfrom outpatient department.\nThe women of ages 18-40 years, with history of primary \nand secondary infertility the mean parity of patients was 2.50± \n1.5(range: 0-3) included whose husband semen analysis were \nnormal and women with normal luteal phase progesterone >30 \nnmol/L were included. Socioeconomic status was based on the \nfamily basic earning.\nWomen with any an adulatory disorders e.g. Polycystic \novarian syndrome etc. Were excluded.\nAll the laparoscopies were done using standard procedure in \nGynecology operation theatre. The presence of classical powder \nburn, blue/ black implant, vesicular hemorrhagic lesions, \nnodular, discolored lesions. Chocolate ovarian cyst, sub ovarian or \nperitoneal adhesions were all taken as evidence of endometriosis.\nEndometriosis thus diagnosed was scored and classified \naccording to revised American Fertility Society Classification.\nData was analyzed by using SPSS version 20. Age and parity \nwas presented as mean +/- SD. Other variables like endometriosis \nand factors were presented as frequency and percentages. Data \nwas stratified with respect to age, parity, type of infertility and \nsocioeconomic status. Post-stratification Chi-square test is \napplied to observe the significance. P-value≤0.05 is taken as \nsignificant.\nResult\nOut of all women presenting with infertility and sub-fertility a \ntotal of 50 women underwent diagnostic laparoscopy. Of these, a \ntotal of 10(20%) women were found to have endometriosis based \nTable1: Descriptive statistics of study population\n(n=50)\nmean(SD) range\nAge 28.7(5.45) (20-40)\nParity 2.50(1.5) (0-3)\nfrequency percentage\nType of infertility\nPrimary 35 70%\nSecondary 15 30%\nEndometriosis\nYes 10 20%\nNo 40 80%\nStages of endometriosis\nStage-I 2 20%\nStage-II 4 40%\nStage-III 2 20%\nStage-IV 2 20%\nTotal 10 100%\non laparoscopic evidence. The mean age of patients was 28.7 ± \n5.45 years (range: 20-40years) and the majority of patients fell \nbetween ages 20 to 30 years. The mean parity of patients was \n2.50± 1.5 (range: 0-3).\nThe majority of patients in the study presented with primary \ninfertility 35(70%) and rest of them presented with secondary \ninfertility15 (30%). Frequency of each stage of endometriosis \nwere found to be 2(20%) for stage I, 4 (40%) for stage II, 2 (20%) \nfor stage III and 2 (20%) for stage IV. Descriptive statistics of age, \nparity, type of infertility, endometriosis and its stages has been \nsummarized in Table 1.\nAssociation between age, parity, tubal status, type of infertility \nand socio economic status via diagnostic laparoscopy has been \nsummarized in Table 2. Statistically non-significant association \nwas seen between age and endometriosis (p-value=0.85)\nTable2: stratification of endometriosis with regards to effect \nmodifiers\nVariables\n(n=50)\nEndometriosis\nTotal P-Value\nYes No\nAge\n20-25 years 4 13 17\n0.85\n26-30 years 4 14 18\n31-35 years 1 9 10\n36-40 years 1 4 5\nParity\nNull Para 8 27 35\n0.86\n1 Para 1 5 6\n2 Para 1 7 8\n3 Para 0 1 1\nTubal Status\nBoth tubes patent 4 25 29\n0.25\nOne tube block 3 3 6\nTube patent covered with \nadhesions 1 4 5\nBoth tubes block 2 8 10\nType Of Infertility\nPrimary 8 27 35\nSecondary 2 13 15 0.7\nSocioeconomic Status\nLower class 3 21 24\n0.16\nLower middle 4 41 45\nUpper middle 2 5 7\nUpper 1 0 1\n\nPage 3 of 4Citation: Shaista Z, Hafsa S, Shereen ZB, SamiaShuja (2017) Prevalence of Endometriosis in Infertile and Sub-Fertile Women. SOJ \nGynecol Obstet Womens Health 3(3):1-4. DOI: http://dx.doi.org/10.15226/2381-2915/3/3/00126\nPrevalence of Endometriosis in Infertile and Sub-Fertile Women Copyright: \n© 2017 Shaista Z, et al.\nParity showed non-significant difference with (p-value=0.86). \nTubal status distribution presented as, out of 10 patients in 4 \n(14.28%) patients both tubes were patent. 3 cases were with \nsingle tube blockage, where as in one case (25%) both tubes \nwere patent but they were covered with adhesion. Bilateral tubal \nblockade found in 2 cases 18.18% of cases stage VI. Not found \nany significant difference, status of tubes in association with \nendometriosis (p-value=0.25).Structural damage to ovaries \nand tubes is therefore not responsible for infertility in cases of \nminimal and mild diseases, In contrary patients in stage IV had \nbilateral tubal blockade .Structural damage can be the reason \nof infertility in stage III and IV. Type of infertility showed on-\nsignificant association with endometriosis with (p-value=0.70) \n.data also stratified for socioeconomic classes and found to be no \nstatistically significant difference with (p-value=0.16).\nDiscussion\nEndometriosis is a significant health problem for women \nin reproductive age. Endometriosis remains a difficult clinical \nproblem due to its variable presentation, costly diagnosis and \nmanagement. The true prevalence of endometriosis in the \ngeneral population cannot be determined as it is impractical to \nsubject asymptomatic general population to a surgical procedure. \nThe present study found the frequency of endometriosis in \ninfertile and sub-fertile patients to be 20%in our study 50 \npatients were included who presented with either primary or \nsecondary infertility. Whereas laparoscopy was carried out for \ndiagnostic purpose. Which reveal that 20% of such patients \nhave endometriosis associated with infertility. The clinical \nmanifestation of endometriosis is versatile and unpredictable \nin its presentation and course. While the association between \nendometriosis and infertility remains the subject of considerable \ndebate. [8]\nFor a definite diagnosis of endometriosis, visual inspection \nof the pelvis at laparoscopy is the “gold standard” investigation. \nUnless disease is visible in vaginal inspection or else. Whereas it \nis proven by the result of the study that it should be performed in \nall suspected cases to confirm the diagnosis. Current study was \nconducted to discover the frequency of endometriosis in relation \nto infertility and sub-fertility. It is difficult to make a final statement \nabout the incidence of disease even by experienced laparoscopist \nwith vast experience of management of endometriosis 7% of the \ncases are missed and 50% are underdiagnosed. Endometriosis \noccur in 7-10% of women in the general population and up to 50% \nof premenopausal women with a prevalence of 38% range 20 to \n50% in infertile women. [8] The result of our study is not only \nsupported by above mentioned statement but also by another \nstudy conducted by Tarek A et al, in Egypt has similar results.\n[9]This is also supported by study Nakagawak et al, (2005) their \nstudy shows 21% incidence of endometriosis.[10]\nRegarding the age distribution majority of patients with \ninfertility and endometriosis presented between 20 to 30 \nyears of age and same age distribution found in the study of \nNaseerudin et al, 77-78% and only one patient was 40 years old. \n[11] A study conducted in India in 2002 all patients underwent \ndiagnostic laparoscopy to evaluate the cause of infertility .The \nage of the patients varied from 20-40 years. With maximum \nnumber of patients belonging 25-30 years of age. [12]Nazhat \nAlam (2005) whose study shows prevalence of endometriosis in \nprimary infertility 72.27% and in secondary infertility 27.27%. \n[13]Studies conducted in Asia and western world indicate that \nprevalence of is same in both classes of community. [14]\nWhile apparently in our study the prevalence of disease is \nopposite to the conventional belief i.e. The poor socioeconomic \nclass women suffered more , the opposite explanation for this \ndifference is because of majority of the patients coming for their \nproblem belongs to the poor socioeconomic group because of \nthis Centre being a public sector institution. Most of the with \nendometriosis fall in stage I and II in our study which shows \nthat it’s not the distorted pelvic anatomy in cases of minimal \nand mild disease causing infertility it can be due to the changes \nin peritoneal environment .In similar study according to revised \nguideline of American Fertility society shows majority of patients \nin stage I and Stage II 25% and 37.5 %respectively. While there \nwere 12.55 % in stage III and 25.5% in stage IV.[15]\nAs endometriosis is a serious gynecological issue but it is \nignored. Although work has been done but still more work need \nto be done. The results of my study will be helpful for other \nhealth care professionals as these results can be used for further \nresearches to identify the pathogenesis of endometriosis and \ncause effect relationship between endometriosis and fertility. \nGeographic preponderance of the disease cannot be judge .The \nreason is that all cases included in the study were Asian in origin.\nConclusion\nBased on information from the literatures and findings of \nthe present study we recommend  recent researches and large \nsample size should be done in order to know the accurate figures \nof the endometriosis and its associated risk factors among sub \nfertile women undergoing diagnostic laparoscopy.\nReferences\n1. Dunselman G.A.J, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe \nT , De Bie B, et al. ESHRE guideline: Management of women with \nendometriosis. Human Reproduction. 2014;29(3):400-412.\n2. Basmaissa, Laura O, Peter JW, Mrinal S, Hamedy S. Endometriosis \nand irritable bowel syndrome: a dilemma for the gynecologist and \ngastroenterologist The Obstetrician &Gynaecologist. 2016; 18(1):9-\n16.\n3. Tanahatoe S, Hompes PG. Lambalk CB. Accuracy of diagnostic \nlaparoscopy in the infertility work up before intrauterine \ninsemination. Fertilsteril . 2003;79(2):361-366.\n4. Osugay, Koga K, T sulsumi O, Yano T . Maruyama M, Kugu K, et al. \nRole of laparoscopy in the treatment of endometriosis associated \ninfertility. Gynecolobstet. 2002:53(Suppl 1); 93-4.\n5. Imtiaz S, Zafar F, shaukata. Laparoscopic Findings in Fertility. Ann K \nE Med Coll. 1999; 5:93-94.\n\nPage 4 of 4Citation: Shaista Z, Hafsa S, Shereen ZB, SamiaShuja (2017) Prevalence of Endometriosis in Infertile and Sub-Fertile Women. SOJ \nGynecol Obstet Womens Health 3(3):1-4. DOI: http://dx.doi.org/10.15226/2381-2915/3/3/00126\nPrevalence of Endometriosis in Infertile and Sub-Fertile Women Copyright: \n© 2017 Shaista Z, et al.\n6. Nair K,Senta F, Kamruddin A. Laparoscopic evaluation of female \nfactors in fertility ,Med Channel. 2002;8:78-80.\n7. Dunselman GAJ, Vermeulen N, Becker C, Calhaz-Jorge C, D-Hooghe \nT , De Bie D, et al. ESHRE guideline: management of women with \nendometriosis. Hum Reprod2014; 29(3):400–12.\n8. Diaa M, EL-Mowafi. Laparoscopic Management of Endometriosis. \nProgress in Obstetrics and Gynaecology. 17TH ed. Philadelphia \n2006; 343-57.\n9. Tarek A, Shokeir, Heshan M. Shalan, Mohammad M, EL, Shafei. Egypt \ncombined diagnostic approach of laparoscopy and hysteroscopy \nin the evaluation of female infertility result of 612 patient. J \nobstgynaecol Res.  2004;30(1):9-14.\n10. Nakagwa K, Ohgi s, Horikawa T . Laparoscopy should be strongly \nconsidered for women with unexplained infertility. National center \nof Child Health and Development Abstract. 2007;33(5):665-670.\n11. Naseeruddin, Khan A, Nudratullah. Prevalence and presentation \nof endometriosis in patients admitted in Nishtar Hospital, Multan. \nJAMC. 2000; 12(3):22-25.\n12. Maiskarv.Desai SK, allahbadiag.Masalwalla M, Kania P . Incidence \nof endometriosis on laparoscopy in 230 consecutive infertility \npatients. J obstetgynaecol India. 2002;52 (2):99-109.\n13. Nuzhatalam (2005) Dissertation, Endometriosis associated infertility \nlaparoscopic evaluation Bahawal Victoria Hospital,Bahawalpur.\n14. Kaun Hung W, Jones GL, Vitonis A, Cramar DW, Kennedy SH, Thumas \nD et al. Characteristics of patients with endometriosis in UK and \nUSA, fertlsteril. 2002;78(4):767-72.\n15. Hussain M, Ashraf M, Jabeen T , Nasir AK, Yasmin H, Noorani KJ. \nLaparoscopic evaluation of endometriosis. J Surg Pak 2004; 9:2-5.","source_license":"CC0","license_restricted":false}