Increased monthly fecundity rate and cumulative pregnancy rate after surgical removal of minimal to mild endometriosis.
When endometriosis is moderate or severe, involving the ovaries and causing adhesions that block tubo-ovarian motility and ovum pickup, it is associated with subfertility (182,185). This effect was shown in primates, including cynomolgus monkeys and baboons (144,186). Numerous mechanisms (ovulatory dysfunction, luteal insufficiency, luteinized unruptured follicle syndrome, recurrent abortion, altered immunity, and intraperitoneal inﬂammation) are proposed as explanations, but an association between fertility and minimal or mild endometriosis remains controversial (187).
Spontaneous Abortion A possible association between endometriosis and spontaneous abortion was suggested in uncontrolled or retrospective studies. Some controlled studies evaluating the association between endometriosis and spontaneous abortion have important methodologic shortcomings: heterogeneity between cases and controls, analysis of the abortion rate before the diagnosis of endometriosis, and selection bias of study and control groups (80,188,189). Based on controlled prospective studies, there is no evidence that endometriosis is associated with (recurrent) pregnancy loss or that medical or surgical treatment of endometriosis reduces the spontaneous abortion rate (190–192). Some data suggest that miscarriage rates may be increased after treatment with assisted reproductive technology (193).
Endometriosis is associated with anovulation, abnormal follicular development with impaired follicle growth, reduced circulating E2 levels during the preovulatory phase, disturbed luteinizing hormone (LH) surge patterns, premenstrual spotting, luteinized unruptured follicle syndrome, and galactorrhea and hyperprolactinemia (194). Increased incidence and recurrence of the luteinized unruptured follicle syndrome is reported in baboons with mild endometriosis, but not in primates with minimal endometriosis or a normal pelvis (195). Luteal insufficiency with reduced circulating E2 and progesterone levels, out-of-phase endometrial biopsies, and aberrant integrin expression was reported in the endometrium of women with endometriosis by some researchers, but these findings were not confirmed by other investigators (194,196,197). No convincing data exist to conclude that the incidence of these endocrine abnormalities is increased in women who have endometriosis.
Extrapelvic Endometriosis Extrapelvic endometriosis, although often asymptomatic, should be suspected when symptoms of pain or a palpable mass occur outside the pelvis in a cyclic pattern. Endometriosis involving the intestinal tract (especially colon and rectum) is the most common site of extrapelvic disease and may cause abdominal and back pain, abdominal distention, cyclic rectal bleeding, constipation, and obstruction. Ureteral involvement can lead to obstruction and result in cyclic pain, dysuria, and hematuria. Pulmonary endometriosis can manifest as pneumothorax, hemothorax, or hemoptysis during menses. Umbilical endometriosis should be suspected when a patient has a palpable mass and cyclic pain in the umbilical area (56).