Endometriosis.

Although endometriosis is a frequent finding in infertile patients, the cause of their infertility is far from clear. The spontaneous cure rate of infertility in patients with endometriosis has never been assessed accurately, so that reports of medical and surgical treatment of endometriosis suffer from sampling errors and lack of a control group. The uncomplicated stage is distinguished from the complicated stage since they probably differ in physiopathology and consequent therapeutic approach. The specific mechanism by which endometriotic implants cause infertility in uncomplicated endometriosis remains unknown. Some investigators have speculated that prostaglandins produced by the endometriotic implants may interfere with normal reproductive function. 2 groups of investigators have found that human endometriosis is frequently associated with luteinization of an unruptured follicle (LUF syndrome). LUF is also frequently found in patients with otherwise unexplained infertility. Steroid hormone concentrations in peritoneal fluid during the 1st week of the luteal phase have supported the existence of the LUF syndrome. It is possible that the LUF syndrome precedes endometriosis and is a causal factor. The incidence of the LUF syndrome is not related to the stage of endometriosis and therefore contributes to infertility throughout the evolution of the disease. Formation of pelvic adhesions contributes to infertility and makes it harder to overcome. The diagnosis of uncomplicated endometriosis can only be made by laparoscopy, and diagnosis of the LUF syndrome must be made during the 1st week of the luteal phase. The spontaneous cure rate of infertility in patients with uncomplicated endometriosis is not known but may be high. Uncomplicated endometriosis can be treated by bipolar coagulation at laparoscopy or by medication such as danazol, but there is no proof that such treatment is effective except in stopping the spread. Endometriosis frequently leads to development of adhesions in the pelvic cavity and disturbance of tubo-ovarian structures. Hysterosalpingograms and laparoscopy are essential in diagnosis. Conservative surgery is generally accepted as the treatment of choice although some prefer medical treatment or a combination. Preparation of the abdomen for surgery is described as are procedures for resection of endometrioma and reconstruction of the ovary and for dense adhesions fixing the ovary to adjacent tissue, tubal distortion or tubal occlusion, peritoneal endometriosis, and frozen pelvis. Since 80% of pregnancies occur within 1 year of surgery, it is illogical to suppress ovulation after surgery. In a recent series of 61 patients, term pregnancies were achieved in 32 after conservative surgery.