I. Staging of endometriosis
RAFS staging (1985) score
Stage I (microscopic) – shallow peritoneal and ovarian lesions with a few adhesions. (1-5 points)
Stage II (mild) – deep peritoneal lesions, superficial lesions on both ovaries, adhesions to the right ovary. (6-15 points)
Stage III (moderate)-deep peritoneal lesions, partial closure of the rectal trap of the uterus, and deep lesions of the left ovary. (16-40 points)
Or superficial peritoneal lesions, adhesions on each side of the fallopian tubes, dense adhesions at the left cistern, deep left ovarian lesions.
Stage IV (severe) – superficial peritoneal lesions, deep ovarian lesions, and dense adhesions of the fallopian tubes and ovaries. (>40 points)
Complete closure of the rectal trap of the uterus, dense adhesions of the left fallopian tube ovary, adhesions of the right ovary, deep ovarian lesions on both sides.
Second, the relationship between endometriosis and infertility has been proven.
Due to the majority of pelvic adhesions in EMT, tubal obstruction is caused, resulting in obstruction of ovulation, egg collection or intrafallopian transport of sperm (a commonly accepted etiology).
The peritoneal fluid of EMT can significantly inhibit the motility of sperm, which can prevent fertilization, and also weaken the function of the fallopian tube umbrella, which can weaken the egg collection function of the fallopian tube umbrella, affect follicular development, inhibit ovulation and promote luteolysis, thus leading to infertility.
Treatment of EMT-related infertility
However, none of the treatment methods can completely cure endometriosis. Increasing pregnancy rate, relieving pain and delaying recurrence as much as possible have become the main objectives of treatment.
1. Expectant therapy Patients with endometriosis can have a natural pregnancy. According to statistics, 50% of patients with mild endometriosis who are observed for 5-12 months can have a natural pregnancy, which is comparable to the effect of conservative surgery and medication.
2.Pharmacological treatment The current pharmacological treatment for EMT-related infertility is mainly the application of hormone therapy, including progesterone, pseudopregnancy therapy, pseudomenopausal therapy and gonadotropin-releasing hormone agonist (GnRH-a).
Surgery Surgery can clarify the diagnosis, estimate the degree and type of lesion, remove the lesion, correct abnormal pelvic anatomy, improve the pelvic environment and help pregnancy. Studies have confirmed that surgery can restore fertility faster, but the recovery of fertility decreases with time after surgery.
4.Assisted reproductive technology
(1) IUI (intrauterine insemination), currently many people advocate the use of controlled ovulation (COH) combined with intrauterine insemination (COH + IUI), which can achieve a high pregnancy rate.
(2) IVF-ET (external fertilization and embryo transfer technique), also known as in vitro fertilization (IVF). In 2002, Dmowski et al. compared IUI and IVF, the success rate of IUI in EMT patients was 32-7% (212/648), the success rate of IVF was 79-9% (111/139), and the success rate of IVF in unsuccessful IUI patients was 82-4% (56/68). Therefore, IVF-ET is the preferred method of pregnancy assistance for severe EMT infertility.
(3) Recently, foreign scholars believe that ICSI (intracyto-plasmic sperm injection) can be considered in the treatment of some patients with EMT-related infertility due to the poor quality of oocytes, and the poor quality of embryos is due to the low implantation rate. The low implantation success rate is mainly due to the poor quality of embryos, which is caused by the poor quality of oocytes due to EMT.
In order to achieve a higher pregnancy rate, long-term GnRH-a treatment is usually given prior to IVF to control the natural LH peak, to improve the condition of the pelvic affected genitalia in EMT patients, to improve egg “production”, quality, fertilization rate, embryo quality and implantation rate, and ultimately to achieve a satisfactory pregnancy rate. The use of GnRH-a has been shown to improve the outcome of IVF, and 6 months of GnRH-a treatment prior to IVF in patients with stage III-IV EMT with infertility has been shown to improve ovarian ovulation, embryo transfer and pregnancy rates, and reduce the incidence of preterm abortion.
The GnRH-a+IVF-ET regimen is also applicable to patients with EMT after surgical treatment. Therefore, it is indisputable that the use of GnRH-a improves the pregnancy outcome of IVF.
IV. Principles of EMT-related infertility treatment
The author proposes the following principles for the treatment of EMT-related infertility: First, a comprehensive infertility examination should be performed to exclude other infertility factors. For patients with unexplained infertility, especially those with suspected stage I or II EMT, laparoscopy is the first choice of examination. Laparoscopy is the gold standard for the diagnosis of EMT and is also the treatment. Patients with mild lesions, asymptomatic or mild symptoms of infertility can be treated with laparoscopic luminescence test and, if necessary, release of tubal adhesions and distortions to promote early conception, or with COH+IUI protocol. In patients with definite diagnosis of stage III-IV endometriosis-related infertility, or patients with stage I or II EMT with severe clinical symptoms (e.g. painful intercourse, dysmenorrhea), surgery can be considered after excluding other infertility factors.
There is no significant difference between open surgery and laparoscopic surgery to improve the pregnancy rate, and the procedure can be determined on a case-by-case basis. Laparoscopic surgery is generally preferred because of its minimal injury, quick recovery and relative safety. The pregnancy rate at 24 weeks after surgery has been reported to be high. For young patients, observation for six months may be considered and guidance may be given, and if pregnancy is still not achieved, a GnRH-a+IVF-ET regimen is recommended to help pregnancy.
For patients with high-risk factors (age 35 years or older; infertility for more than 3 years, especially primary infertility; severe EMT, pelvic adhesions, incomplete excision of lesions), because of the increasing rate of spontaneous abortion with age and decreasing fertility, GnRH-a may be considered for 3-6 months followed by assisted reproductive techniques such as COH/IUI or IVF-ET, or direct assisted reproduction. In conclusion, the choice of treatment should be based on the specific situation, taking into account the patient’s age, duration of infertility, family history and pelvic pain, and timely communication with the patient to design an individualized treatment plan to improve the pregnancy rate.