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Endometriosis is a condition in which the tissue lining the inside of the uterus is found outside the uterus, on other organs or tissues. It is commonly found on the ovaries and the membranes surrounding the abdominal organs. Approximately 35% of women seeking treatment for infertility are diagnosed with endometriosis. Endometriosis can lead to infertility by causing pelvic adhesions or blockage in the fallopian tubes.
The exact cause of endometriosis is still unknown. The most widely accepted theory is that during menstrual periods, the tissues lining the uterus pass through the woman’s fallopian tubes and implant in the abdominal cavity, where they continue to grow.
Endometriosis affects approximately 10% of women, making it a relatively common health issue. This tissue can be found in the organs within the abdomen (ovaries, fallopian tubes, peritoneum, intestines, urinary bladder) as well as outside the abdomen (vagina, umbilicus). The presence of these endometrial lesions can lead to bleeding and certain symptoms.
The accumulation of tissues outside the uterus can cause severe menstrual pain, chronic pelvic pain, and particularly, fertility problems (infertility). While endometriosis may remain asymptomatic or cause no issues in some women, it can also result in serious and varied symptoms.
Endometrioma, also known as a chocolate cyst, refers to the cystic structure formed by endometriosis in the ovaries. Diagnosis is made through ultrasound and measurement of certain tumor markers in the blood. After diagnosis, the treatment should be determined based on the individual. The approach to treatment can vary for each person, and the idea of removing every endometrioma has been abandoned in recent years.
Surgical intervention is an effective treatment modality for women experiencing pain. Laparoscopic surgery is preferred over open abdominal surgery due to better outcomes and patient comfort. Laparoscopy is now considered the gold standard for endometriosis treatment. During surgery, endometriomas should be removed, adhesions should be released, and all identified endometriotic lesions should be eradicated. The operation should be performed using minimally traumatic techniques to preserve ovarian capacity.
In patients without any complaints, surgical treatment should not be considered. Surgical intervention may be considered when cysts are larger than 5 cm. Prior to surgery, ovarian capacity should be evaluated through ultrasound and AMH measurement, and in women with low ovarian capacity and no children, surgery should be avoided as much as possible. In cases where patients present with a desire for pregnancy and adequate ovarian reserve is determined, laparoscopy is appropriate in unilateral cyst cases, followed by waiting for a spontaneous pregnancy for 6-12 months based on the woman’s age. If ovarian reserve is poor, the woman is over 38 years of age, or the cyst is bilateral, the best approach is usually to undergo in vitro fertilization (IVF). Studies have shown that there is no significant difference in pregnancy rates between women who have had their cysts removed and those who have not.
Endometriosis can be one of the causes of infertility in women struggling to conceive. In some of these women, the scar tissue caused by endometriosis can lead to blockages in the fallopian tubes or the formation of hydrosalpinx. In others, the endometriomas (chocolate cysts) formed in the ovarian tissue can affect both ovarian reserve and occasionally impair egg quality.
There is no definitive cure for endometriosis. In women who desire to conceive, cysts larger than 5-6 cm can be surgically removed through minimally invasive laparoscopic procedures. However, these cysts can recur after a certain period of time. Therefore, there is no strict rule that every endometrioma cyst must be removed. Patients can consider undergoing IVF with cysts that do not significantly harm the ovaries and still achieve pregnancy.
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