a. Endometriosis is a condition characterized by ectopic endometrial glands and stroma.
b. The etiology of endometriosis is unknown. Possible etiologies are as follows:
(1) Retrograde menstruation
(2) Vascular or lymphatic transport
(3) Transformation of coelomic epithelium into endometrial type glands (coelomic metaplasia)
(4) Immunologic alteration leading to a decreased cellular immunity to endometrial tissue
(2) Dyspareunia, especially with deep penetration
(3) Low back pain
d. Examination: Certain findings should raise a physician’s index of suspicion.
(1) Retro verted uterus
(2) Enlarged ovaries
(3) Fixed uterus or ovaries
(4) Tender, nodular uterosacral ligaments
(1) Laparoscopy should be performed.
(2) Suspicious lesions on the cervix should be biopsied.
(a) Operative laparoscopy to ablate all visible lesions and debulk ovarian endometriomas
(b) Laparotomy: debulking procedure
(a) GnRH agonist (Depo-Lupron, Zoladex)
(b) Oral contraceptives: decidualize endometrial tissue
(c) Danazol: should be used only in cases of persistent pain
(d) Progestational agents (Depo-Provera, Provera)
2. Cervical factor.
a. Scarring: previous cone, LEEP, or cryotherapy
b. Diethylstilbesterol (DES) exposure
c. Clomiphene citrate: antiestrogenic mechanism of action leads to thick cervical mucus
3. Uterine factor.
a. Miillerian anomalies
b. Anatomic abnormalities
(2) Asherman’s syndrome
(3) Adenomyosis: presence of endometriosis within the myometrium; these patients have chronic pelvic pain
(1) Hysterosalpingogram (HSG): needed by all infertility patients
(3) Magnetic resonance imaging (MRI): especially for Miillerian anomalies and myomas
(1) Surgical: See Surgical Therapy for Infertility.
(2) Medical: See Medical Management of Infertility.
4. Male factor infertility.
a. Semen analysis: Physicians should never make a diagnosis based on a single semen analysis.
(1) Normal semen parameters2
(a) Volume: 2.0 mL or greater
(b) pH: 7.2 to 8.0
(c) Concentration: 20 x 106 spermatozoa per mL or greater
(d) Motility: 50% or greater
(e) Morphology: 30% or greater normal forms (0 White blood cells: 1 x 106 per mL or fewer
(2) Specimen collection rules
(a) Three days of abstinence is optimal.
(b) Specimens should be produced via masturbation.
(c) No lubricants may be used.
(d) Specimens should be collected in a sterile specimen container.
(e) Extremes of temperature should be avoided while trans’ porting to the laboratory.
b. See Section 6.2 for further information on male factor infertility. 5. Hormonal dysfunction.
a. Disorders of ovulation
(1) Polycystic ovarian syndrome: LH/follicle-stimulating hormone (FSH) ratio of 3:1 or greater
(2) Hypothyroidism: high TSH
(3) Oligo-ovulation: etiology unknown
b. Luteal phase defect: Defined as a lag of more than 2 days in the histologic development of the endometrium as compared with the actual day of the cycle. It is diagnosed by an appropriately timed endometrial biopsy. It is best to time the biopsy by the LH surge rather than the start of the menses. Luteal phase defects have one of the following etiologies:
(1) Lack of adequate progesterone production
(2) Inability of the endometrium to respond to the progesterone that is present
6-. Pelvic adhesions.
(1) HSG: look for tubal occlusion or contrast loculation
(2) Laparoscopy: direct evaluation of pelvic anatomy
(1) Surgical lysis
(2) Assisted reproductive technology (ART)
7. Ovarian failure.
a. Diagnosis: serum FSH
(1) Less than 15: There is a good chance for successful ART.
(2) Greater than 15 to less than 25: There is a diminished chance for success. Oocyte donation should be discussed with the patient.
(3) Greater than 25: Estrogen replacement should be started and oocyte donation discussed.
8. Unexplained infertility: This is a diagnosis of exclusion. A complete workup should be done before this diagnosis is made.