Chicago, Illinois Area Endometriosis Treatment
At Oak Brook Fertility Center in the Chicago, Illinois area, we provide the latest in endometriosis treatment to help couples achieve the beautiful gift of a child. With care and understanding, our team of fertility specialists provides vital guidance, support, and treatment to overcome fertility obstacles. With the establishment of the Institute for the Study and Treatment of Endometriosis, of which Oak Brook Fertility Center is affiliated, we are leading the way when it comes to endometriosis treatment.
- What is Endometriosis?
- Changes in the Immune System
- Treatment Methods
- Our Approach
- Management of Infertility in Women with Endometriosis
- Management of Chronic Pelvic Pains
- How to Prevent Recurrence
- Recurrent Endometriosis
- Medical Treatment
- New Treatment Methods
What is Endometriosis?
Endometriosis is a disease affecting women which is characterized by the growth of the uterine lining (endometrium) outside of the uterus. The uterine endometrium during the first half of the menstrual cycle increases in thickness and, during the second half, acquires a spongy-like consistency to facilitate embryo implantation. If there is no pregnancy, the uterine endometrium sheds, along with the menstrual blood, during the menstrual period. With endometriosis, the same cyclic changes that would typically only occur within the uterus now also occur outside the uterus. As the endometrial tissue has grown outside of the uterus, elements of the cycle follow the tissue. This causes bleeding into the abdomen or other organs, inflammatory reaction, development of adhesions (scar tissue), or the appearance of cysts filled with blood which, over time, acquire a consistency of liquid chocolate (chocolate cysts).
Symptoms Their Frequency and Intensity
The cyclic changes associated with endometriosis described above are responsible for symptoms of the disease that include:
- Painful menstrual periods
- Pain during or after urination
- Pelvic pain unrelated to menstruation
- Heavy, prolonged menstrual periods
- Pain during and after sexual intercourse
Pain during or after bowel movements
Endometriosis - common sites
The frequency and intensity of these symptoms varies and there is no direct relationship between the symptoms and the severity of endometriosis. Some women have advanced endometriosis and few, if any, symptoms; others have severe symptoms with only minor endometriosis. The intensity of symptoms is most likely related to the local inflammatory reaction and production of substances, such as prostaglandins and cytokines, by the endometriotic cells and cells of the immune system.
Endometriotic lesions, although benign, may spread like cancer from the reproductive system to other organs and sometimes even to distant locations away from the pelvis. We have seen women with endometriosis of the bladder, bowel, liver, lungs, arms, thighs, and even brain. If endometriosis spreads outside of the pelvis, it can cause generalized symptoms and/or symptoms of pain or bleeding in other organs. In general, any symptom or change in the body that undergoes cyclic changes coincidental with the menstrual cycle should be suspected of being endometriotic in origin. If you believe you are experiencing symptoms of endometriosis, contact our Chicago, Illinois area fertility center to schedule a consultation with one of our board certified physician.
Changes in the Immune System
For more than 30 years, staff of the Institute for the Study and Treatment of Endometriosis (Endometriosis Institute), which is affiliated with the Oak Brook Fertility Center, has been in the forefront of endometriosis research. Our studies indicate that during the menstrual period, blood and fragments of shed endometrial tissues are transported through fallopian tubes into the abdomen in all women. In healthy women, these misplaced cells are programmed to die (undergo apoptosis) and are removed by the cells of the immune system (macrophages). In about 10 percent of women, apoptosis and the ability of macrophages to remove misplaced endometrial cells is impaired. The misplaced cells are then allowed to survive and implant. Typically they implant on the peritoneal surfaces (lining of the abdomen), in the anterior and posterior cul-de-sacs (anterior is between the uterus and urinary bladder - posterior is between the uterus and rectum), on the ovaries, and on other abdominal organs. Following implantation, endometrial cells divide, multiply, and form typical endometriotic lesions. Changes that lead to the development of endometriosis may be transmitted genetically from mother-to-daughter, or may be acquired as a result of environmental effects on the immune system.
Endometriosis can be suspected based on characteristic symptoms, physical examination findings, and/or changes on pelvic ultrasound, CT scans, or x-rays. However, other diseases may give similar findings and the only way to diagnose endometriosis is through a surgical procedure called a laparoscopy or laparotomy. The diagnosis needs to be confirmed by microscopic examination of the tissue. Not every lesion having a visual appearance of endometriosis is actually endometriotic and sometimes atypical lesions may be endometriotic in nature. Your laparoscopic surgeon will take a biopsy to confirm through visual diagnosis. Your physician will also likely assign a score for the size, depth, and location of endometriotic lesions. This is the basis for classifying endometriosis as Stage I, II, III, or IV - with Stage I being minimal and Stage IV being the most advanced. Endometriosis is a progressive disease which impairs fertility, tends to come back after treatments, and lasts as long as there is ovarian function. After menopause, endometriosis will subside. Prompt definitive endometriosis diagnosis and staging at our Chicago, Illinois fertility center are extremely important for lifelong treatment, recurrence prevention, and family planning.
Laparoscopy is a minor surgical procedure performed under anesthesia on an outpatient basis. An experienced laparoscopic surgeon should be able to resect or destroy endometriotic lesions with the use of electrical current or laser at the time of laparoscopy. Alternative treatments include various types of hormonal medications, the purpose of which is to suppress ovarian function and stop menstrual cycles. Without menstrual bleeding, endometriotic lesions heal and gradually disappear. Large chocolate cysts and adhesions may need to be removed surgically.
The choice of treatment in endometriosis depends on several factors, including:
- Woman's age
- Severity of symptoms
- Fertility status
- Stage of the disease
- Prior treatments (if any) and treatment response and side effects (if any)
These factors and patient-specific indications and contraindications, advantages and disadvantages, and risks and benefits of different treatment options need to be thoroughly discussed and considered prior to endometriosis treatment selection. At Oak Brook Fertility Center serving Chicago, Milwaukee, and surrounding areas, we will ensure you have a true understanding of the disease and all available treatment options before any decisions are made.
At the Endometriosis Institute, our objective is to help you select the treatment option that is most appropriate for you. Our overall goal is to remove or suppress endometriosis, to delay its recurrence, to control its progression, and to address its symptoms — all without adversely affecting your fertility or exposing you to undesirable side effects of treatments. We recognize that different women may respond differently to the same treatment, both in terms of the effectiveness and side effects. Indeed, there is no one treatment that would be effective in all women. At the Endometriosis Institute, we always have several ongoing clinical research projects. We also frequently have new medications for clinical trials before they become generally available. Such clinical studies, including medications, may be provided at no charge to you. For more information, please contact Oak Brook Fertility Center and the Endometriosis Institute today.
Management of Infertility in Women with Endometriosis
Causes of Infertility in Endometriosis
There is no single cause of infertility in endometriosis, but rather several factors that decrease the likelihood of conception. In advanced endometriosis (Stage III-IV), endometriomas (chocolate cysts) or pelvic adhesions interfere mechanically with ovulation and egg/embryo transport. In early endometriosis (Stage I-II), the mechanism of infertility is less clear and more complex. Our studies from the Endometriosis Institute and other centers have shown that in endometriosis, the intraperitoneal environment, through a variety of mechanisms, prevents conception. It has been demonstrated that the peritoneal fluid from women with endometriosis contains different biochemical substances with anti-fertility effects. These substances produced by the endometriotic cells or cells of the immune system include several prostaglandins with smooth muscle contracting properties, various cytokines, abnormal autoantibodies, and reactive oxygen radicals. They can prevent ovulation by inducing early LUF (luteinized unruptured follicle) Syndrome; others prevent egg capture by the fimbria of the fallopian tube, interfere with tubal function and its ability to transport gametes and embryos, interfere with hormone production by the corpus luteum, and have embryo-toxic or anti-implantation effects. The anti-fertility effect of the peritoneal environment is, however, variable and depends on the amount of the peritoneal fluid produced and the concentration of these biochemical factors. Consequently, infertility in women with endometriosis is relative, which means that some women are able to conceive.
Chances for Pregnancy
Chances for Pregnancy — Without Treatment
There is no question that chances for pregnancy in endometriosis are significantly decreased. Women with Stage I or II endometriosis have an approximately 2 percent chance for conceiving in any given menstrual cycle (cycle fecundity rate). That chance is less than 1 percent for women with Stage III or IV disease. By comparison, age-dependent cycle fecundity rates in healthy fertile women range between 15 and 25 percent.
Chances for Pregnancy — After Treatment of Endometriosis
After laparoscopic resection of endometriosis, cycle fecundity rate in Stage I-II disease increases to about 4 to 5 percent but only to 1 to 2 percent in Stage III-IV. Medical treatment of Stage I-II endometriosis increases cycle fecundity rate to about 4 to 5 percent, but is less effective in the advanced disease. These percentages are significantly below the expected fecundity rate of fertile women and indicate that not all biochemical and/or anatomical changes associated with endometriosis and contributing to infertility are corrected by the treatment of this disease.
Chances for Pregnancy —- With Fertility Drugs
Several studies have shown that in untreated Stage I-II endometriosis, fertility drugs combined with intrauterine insemination during the so-called controlled ovarian hyperstimulation/artificial insemination (COH/AIH) cycle, increase cycle fecundity rates to about 11 percent. There is no improvement in endometriosis during the COH/AIH cycles but ovulation and sperm transport problems are corrected, which may explain the increase in fecundity rates above those reported after resection or suppression of the disease.
Chances for Pregnancy — With IVF/ET
When fertility drugs are combined with in vitro fertilization/embryo transfer (IVF/ET) procedures, cycle fecundity is even higher than with COH/AIH — in excess of 35 percent. It appears that in endometriosis during the IVF/ET cycle, replacement of the adverse intraperitoneal environment with controlled 'in vitro' conditions of the laboratory corrects the majority of anti-fertility effects of the disease. At our fertility clinic based in the Chicago, Illinois area, we work to determine the endometriosis treatment that is most appropriate for each woman.
A recent report from our Endometriosis Institute compared cycle fecundity rates using COH/AIH vs. IVF/ET in women with untreated endometriosis. The study consisted of 313 women with endometriosis and infertility - 202 of whom underwent 648 cycles of COH/AIH and 111 of whom underwent 139 cycles of IVF/ET. Also included was a subgroup of 56 women who failed COH/AIH and underwent 68 IVF/ET cycles.
Figure 1 demonstrates cycle-specific and cumulative fecundity rates in these groups. Cycle one to six fecundity in the COH/AIH group was 15%, 12%, 8%, 7%, 7%, and 0%, respectively, with the six-cycle cumulative fecundity of 41%. There was a plateau effect after five cycles and there were no pregnancies during the sixth cycle. Cycle one to three fecundity in the IVF/ET group was 47%, 27%, and 33%, respectively, with the three-cycle cumulative fecundity of 73%. There was no evidence of a plateau. First cycle fecundity with IVF/ET (47%) was significantly greater (p<0.05) than the cumulative fecundity after six COH/AIH cycles (41%).
In patients who underwent IVF/ET after failed COH/AIH, cycle one to three fecundity was 39%, 27%, and 14%, respectively, with the three-cycle cumulative fecundity of 62%. There was no significant difference between this group and the primary IVF/ET group but the cycle and cumulative fecundity rates were higher than in the COH/AIH group.
When pregnancies with cryopreserved embryos were considered and when couples with a significant male factor were excluded, both cycle and cumulative fecundity rates were higher. For IVF/ET including cryopreserved embryos, cycle one to three fecundity was 50%, 30%, and 33%, respectively, with the three-cycle cumulative fecundity of 77% (Figure 2). For the IVF/ET group without male-factor, the numbers were 46%, 31%, 50%, and 81%, respectively.
Cycle and cumulative fecundity rates in the COH and IVF groups analyzed according to the stage of endometriosis are demonstrated in Figure 3 and according to the age of the wife in Figure 4. First cycle fecundity in Stage IV endometriosis was 10% with COH/AIH and there were no conceptions during subsequent cycles (Figure 3).
With IVF/ET, Stage IV fecundity during three cycles of observation was comparable to that of Stages II and III. Cycle and cumulative fecundity in women over 38 were below other age groups with COH/AIH (Figure 4). With IVF/ET, there were no significant differences.
Not analyzed in our studies but of considerable significance is the effect of ovarian stimulation on the progression of endometriosis. Ovarian stimulation for either COH/AIH or IVF/ET increases two-to-tenfold peripheral blood concentrations of estrogens produced by the ovarian follicles. It is well known that estrogens stimulate progression of endometriosis in a direct proportion to their concentration and length of exposure. Therefore, IVF/ET, with fewer cycles of ovarian stimulation required to achieve pregnancy, carries a lower risk of endometriosis recurrence than COH/AIH. There is no question that IVF/ET is a more complex and costly procedure than COH/AIH. The cost of one IVF/ET cycle is approximately equivalent to the cost of six COH/AIH cycles but the probability of pregnancy is higher with one IVF/ET cycle than with six COH/AIH cycles, as demonstrated by our studies.
We conclude from our studies that one cycle of IVF/ET offers a better probability of conception than six COH/AIH cycles in women with endometriosis regardless of age and stage of the disease. In women over 38 or with Stage III/IV endometriosis, in those with a significant adhesive or tubal disease, or in couples with a significant male factor, IVF/ET should be the first line of treatment in the management of infertility. If an adverse effect of prolonged ovarian stimulation on the progression of endometriosis is considered and if there is an intent to limit the number of the stimulation cycles, this recommendation may be extended to all women with endometriosis and infertility. If COH-AIH is performed, the number of attempts should be limited to not more than three to four.
Management of Chronic Pelvic Pains
About 60 percent of women with endometriosis seeking medical attention at our Chicago, Illinois are fertility center do so because of chronic pelvic pains or other pain symptoms related to their menstrual cycles. Laparoscopic diagnosis and treatment in this group of women is usually delayed by an average of 6.35 years from the beginning of symptoms, as demonstrated by one of the studies performed at our Endometriosis Institute. This is interesting considering that a comparable 'diagnostic delay' in women with endometriosis and infertility is only about half as long.
The Cause of Symptoms
Endometriotic implants cause a local inflammatory reaction which irritates nerve endings and sends noxious stimuli along the nerve pathways to the spinal cord and into the central nervous system (CNS) where they are interpreted as burning, dull, achy sensations or as sharp, stabbing, or crampy pains. The local inflammatory reaction is mediated by the increased production of substances, such as a variety of cytokines and prostaglandins, originating from the endometriotic implants and cells of the immune system. These substances also stimulate development of scarring and nodules around the endometriotic implants which may compress peripheral nerves compounding pain symptoms with signs of peripheral neuropathy. Pain symptoms are usually elicited when the nodules are compressed during pelvic examination or sexual intercourse. Endometriotic (chocolate) cysts may compress on other pelvic organs, causing pain and pressure during urination or bowel movements. If there is bleeding from the endometriotic lesions, which frequently happens during the menstrual period, a woman may notice blood in the urine or stools or in secretions from other organs affected by endometriosis, e.g. blood in the sputum with endometriosis of the lungs. Because of increased systemic cytokine and prostaglandin production by the circulating immune cells, some women with endometriosis may experience generalized symptoms such as low-grade fever; crampy, generalized aches and pains; and nausea, vomiting, and diarrhea usually around the time of the menstrual period.
Other Causes of Pelvic Pains
Pelvic organs in the female, in addition to the reproductive system, include the urinary and gastrointestinal systems, pelvic nerves, and musculoskeletal system. All of these organs are in close proximity and it is often impossible to tell which symptoms originate from which organ. Furthermore, it is not unusual that endometriotic implants are totally asymptomatic. It is therefore of primary importance to determine whether endometriosis and not a disease of another organ is actually the cause of pelvic pain symptoms. Several diagnostic tests and consultations with other specialists may be of help here. However, the patient herself may be able to observe a relationship between pain symptoms and different body functions, or physical activities which may suggest a disease of a specific organ. If the cause of the symptoms is still unclear, a trial of ovarian suppression with a drug such as Depot Lupron may help differentiate endometriosis-related pelvic pain from pelvic pains of other causes.
Laparoscopic surgery for chronic pelvic pains and suspected endometriosis at our Chicago, Illinois area fertility clinic serving those from Milwaukee, Oak Brook, and surrounding areas are performed by a surgeon with the necessary skills and expertise in the resection of such lesions and in an operating room equipped with the latest instruments for such a surgery. Endometriotic implants should be resected, vaporized, or fulgurated and care should be taken to perform as complete as possible resection of deep infiltrating endometriotic nodules which are usually the cause of pelvic pains. To reduce pain transmission, nerve interruption procedures such as uterosacral (US) nerve ablation or presacral neurectomy should also be considered. Adhesions (scar tissues) should be completely resected and measures preventing their reformation should be applied. Endometriotic cysts should be resected with their capsule — using ovarian tissue-sparing technique — rather than be drained. The surgeon should also be prepared to resect endometriotic lesions that may involve other organs such as the bowel or bladder. Appendectomy should also be performed if there are adhesions or if endometriosis involves the appendix.
After complete resection of endometriotic lesions, the majority of patients will have a significant improvement in pelvic pain symptoms lasting for several years. Ultimately, however, the disease recurs along with the pain symptoms, especially if there were no preventive measures taken after surgery. If resection of endometriotic implants and/or endometriomas was incomplete, the symptoms may recur earlier or there may be little, if any, symptomatic improvement after surgery.
Alternative Approaches to the Management of Pelvic Pains
As mentioned earlier, local inflammatory reaction caused by endometriosis stimulates pelvic nerves and activates neural pathways from the pelvic organs to the CNS. In some women, CNS sensitivity to these signals is increased with increased perception of pelvic pains and a vicious circle where a relatively minor irritation, associated with minimal endometriosis, results in a progressively increasing and disproportionately high perception of pelvic pains. In such patients, endometriosis may be a relatively minor health problem while pelvic pains become a chronic, overwhelming condition leading to clinical depression and other health problems. Several approaches may be tried to control pelvic pains and to break this vicious circle. Non-steroidal anti-inflammatory drugs (NSAID) are prostaglandin synthetase inhibitors which decrease the inflammatory changes associated with endometriosis and improve pain symptoms in most patients. They can be used alone or with other pain medications. Tricyclic antidepressants control depression which frequently is associated with chronic pains and, at the same time, inhibit pain transmission in the spinal cord. Other approaches to the management of chronic pain, such as peripheral nerve blocks, bio-feedback, acupuncture, reflexology, hypnosis, and visualization, may also decrease transmission and perception of pain stimuli and some patients may find them acceptable and effective.
How to Prevent Recurrence
Recurrence of endometriotic lesions is stimulated by estrogens, the female hormones produced by the ovaries. During the normal menstrual cycle, blood levels of estradiol (the main estrogen) fluctuate between 40 and 400 pg/mL. These levels are necessary to achieve pregnancy but they also contribute to the recurrence of endometriosis. Estradiol levels between 70 and 100 pg/mL are adequate for normal body functions, do not reactivate endometriosis, and will prevent menopausal changes. There are two methods to prevent or delay recurrence of endometriosis in a woman who is not planning to conceive: 1) By changing the hormonal environment from estrogenic to strongly progestational using certain types of birth control pills, and 2) By maintaining blood estradiol levels between 70 and 100 pg/mL using GnRH analogs and add-back regimens.
In women with recurrent endometriosis and recurrent pelvic pains, several options of treatment may be considered. Clinical response to prior surgery and medical treatments as well as frequency and intensity of side effects of these treatments should be the guidelines in treatment selection. If there was a good and lasting response after surgical resection, another laparoscopic surgery may be considered. It should, however, be kept in mind that repeated surgeries cause adhesions and destruction of healthy ovarian tissue and may adversely affect fertility.
Medical treatment at our Chicago, Illinois area Endometriosis Institute can suppress endometriotic lesions and decrease the size of endometriomas. Pain improvement is observed in over 80 percent of patients but the effect is gradual over a period of six months of typical treatment. Because all medications used in the treatment of endometriosis change the hormonal status of the patient, there may be a variety of side effects. GnRH agonists are the most commonly used hormones. They include Depot Lupron, Zoladex, and Synarel. They lower estradiol levels to less than 20 pg/mL, causing menopausal symptoms and changes. After endometriosis is suppressed, the GnRH agonist may be used for a longer period of time with estrogen add-back to control the symptoms and changes of menopause. Danocrine is an anabolic steroid that lowers the estradiol level only to 40-60 pg/mL, suppressing the menstrual cycle and endometriosis without severe menopausal symptoms. Increase in appetite and weight gain are the major side effects. Birth control pills, especially those with strongly progestational properties when given as a long-cycle regimen, may control pelvic pain symptoms but generally have only a limited effect on endometriosis. Their side effects, however, are tolerable by most patients. Progestogens alone can control pelvic pain symptoms in some women. Their effect on endometriosis and their side effects are similar to those of birth control pills.
New Treatment Methods
Several new hormonal preparations are being tested for their effectiveness in controlling endometriosis and pelvic pains. Our Chicago, Illinois area Endometriosis Institute has recently completed a clinical study on a new drug, Abarelix, which is a GnRH antagonist. Abarelix is more effective than GnRH agonists and seems to have fewer and less bothersome side effects. It should be approved for clinical use within the next year or two. We currently are investigating a new approach to the management of endometriosis and pelvic pains. This is based on a local intravaginal — rather than systemic — administration of the hormones such as intravaginal Danocrine. We are expecting a similar clinical effect as with oral administration but without systemic side effects. In the future, we anticipate that a new class of medications - the immunomodulators - will become available to treat endometriosis and pelvic pains more effectively.
Contact Oak Brook Fertility Center / Endometriosis Institute
If you would like to learn more about endometriosis and available treatments at our Chicago, Illinois area Endometriosis Institute serving Milwaukee, Oak Brook, and surrounding areas, contact us today.