ENDOMETRIOSIS, INFERTILITY AND OVERCOMING SOCIETAL BURDEN
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Dr. Shivani Samlall, MBBS, is a specialist in Obstetrics and Gynecology with a sub-specialty in Gynecology Oncology, and with over 10 years of medical practice. Dr Samlall can be contacted at drshivanisamlall26@gmail.com.

SOCIETY continues to exert enormous pressure on married couples to have children. Couples are constantly being bombarded with questions from family, friends, neighbours, workmates and even strangers regarding their fertility. Mostly, the women endure the bulk of this pressure. This constant intervention into a couple’s fertility underlines the lack of empathy and knowledge as to the causes of infertility in both men and women.
While there are several causes, this column explores Endometriosis, as a cause of infertility with the intention of bringing awareness to the severe burden of this disease and the impact that it can have on women’s lives.
Let us talk about Gina, a close friend of mine. Gina is not the typical endometriosis patient. In fact, up until a few months before her diagnosis, she recalled never having severe pains during her period. She did indicate that she sometimes had back pains that radiated down her legs, and, years before, she suffered significant delays between her cycles (sometimes extending to 40 days).
After suffering excruciating pains one evening, Gina did several ultrasounds which all yielded different diagnosis. She travelled to Jamaica, underwent laparoscopy, and was diagnosed with Stage IV Endometriosis! At this time, Gina and her husband were hoping to start their family and her doctor advised her to try for one year before doing an in vitro fertilization (IVF).
She recalls the enormous pressure she faced during this time. Separate and apart from the unintended pressures she faced from family members and friends – she felt less of a woman every single time she saw a negative pregnancy test. Gina eventually decided to go ahead with IVF and travelled back to Jamaica for the initial tests. Upon returning home to prepare for the treatment, she found out that she was pregnant! Naturally! Without any fertility treatment. Let us talk Endometriosis.

WHAT IS IT?

Endometriosis is often a painful disorder in which tissue like the lining of the uterus (the endometrium) grows outside the uterus on other organs. During each menstrual cycle, this “endometrial-like” tissue, thickens, breaks down and bleeds. Surrounding tissue can become irritated, eventually developing scar tissue called adhesions (bands that cause tissues and organs to stick together).
Areas of endometrial tissue (implants) can show up on organs including the ovaries (causing chocolate cysts or endometriomas), fallopian tubes, outer surfaces of the uterus, vagina, rectum, intestines, cul-de -sac (space behind the uterus).

How common is endometriosis: Endometriosis occurs in about 1 in 10 women of reproductive age (from first period to menopause). It is most often diagnosed in women in their 30s and 40s.

SYMPTOMS OF ENDOMETRIOSIS
Pain: The most common symptom. Pelvic pain and cramping (especially just before and during periods). The intensity of the pain varies. For some women, the pain can get worse over time and can become debilitating. It can also be in the lower back and the abdomen. Women can also have pain during or after sex, pain with bowel movements or urination.
Heavy bleeding or spotting between menstrual periods.
Others: fatigue, diarrhea, constipation, bloating, nausea, especially during menstrual periods.

WHAT IS THE LINK BETWEEN ENDOMETRIOSIS AND INFERTILITY?
Almost 40 per cent of women with infertility have endometriosis. Sometimes, endometriosis is first diagnosed in those seeking treatment for infertility. Inflammation from endometriosis may damage the sperm or egg or interfere with its movement through the fallopian tubes and uterus. In severe cases of endometriosis, the fallopian tubes may be blocked by adhesions or scar tissue.

Diagnosis of Endometriosis: Although a gynecologist may perform a physical exam, including a pelvic exam, and an ultrasound, the only way to tell for sure is through laparoscopy; during which, a small amount of tissue is removed and sent for biopsy.

Treatment of Endometriosis: Treatment depends on the extent of the disease, the symptoms, and whether the woman wants children. Endometriosis may be treated with medication, surgery, or both. When pain is the primary problem, medication usually is tried first. Besides pain meds, there are also other options for managing pain such as heating pads, hormonal medications to stabilise hormone fluctuations, pelvic-floor physical therapy to help relax muscles, etc.

As in Gina’s case, surgery is sometimes done to relieve pain and improve fertility (by removing as much endometriosis implants and adhesions as possible). Additionally, IVF and other fertility treatments are not always necessary to obtain a pregnancy. Furthermore, surgery does not cure endometriosis. While most women have relief from their pain after surgery, about 40–80 per cent of women have reported the return of their pain within two years of surgery which may be due to the extent of the disease. The more severe the disease, the more difficult it is to remove all the endometriosis at the time of surgery. Taking birth control pills or other medications after having surgery may help extend the pain-free period.

Not many women are as fortunate as Gina, since many are suffering without a diagnosis or as to the cause of their pain and infertility. This is mostly due to the low suspicion of this disease, to the unavailability, especially in the public sector, of laparoscopic services, and to having only one functional pathology lab that is centrally located in the country. My hope is that with March being Endometriosis Awareness Month, more emphasis is placed on recognising the impact of this disease on women’s lives and efforts are made to improve the services so that they are readily available to these women.

Note: This columnist thanks Gina Arjoon for sharing her story. It is Gina’s hope also, that her story can help spread awareness of Endometriosis and that it can serve as an inspiration to women.

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