Endometriosis

Endometriosis is a condition where tissue similar to the lining of the uterus grows outside it, most often on the ovaries, fallopian tubes, and pelvic lining. This tissue responds to your monthly hormones, so it bleeds and inflames with each cycle, but the blood has nowhere to go. Over time that triggers pain, scarring, and adhesions that stick organs together.

It is common. Roughly 10% of women of reproductive age live with endometriosis, and prevalence rises to about 31% among women being investigated for infertility. It's a long-term condition, but it's manageable, and many women with it go on to have children.

There's no single proven cause, but the leading explanation is retrograde menstruation, where menstrual blood flows backward through the tubes into the pelvis and deposits endometrial cells that take root. Genetics, immune differences, and hormonal signals all seem to play a part too.

Some things raise your risk. A close relative with endometriosis, starting periods early, short cycles, heavy or long periods, and never having been pregnant are all associated with higher odds. None of these mean you'll definitely develop it, and many women with no risk factors still do. Endometriosis is a disease of inflammation and hormones, not something you caused.

Pelvic pain is the hallmark symptom, and it often follows the menstrual cycle. The classic pattern is painful periods (dysmenorrhea) that are far worse than ordinary cramps, pain during or after sex (dyspareunia), and a deep, dragging pelvic ache that can last beyond the period itself.

Symptoms vary widely. Some women have severe pain with minimal disease, while others have extensive disease and barely any pain, which is one reason it's often missed for years. For many Indian women, difficulty conceiving is what finally brings endometriosis to light. Bowel and bladder pain, fatigue, and spotting between periods can also occur.

Diagnosis has shifted in recent years. Laparoscopy, a keyhole surgery to look inside the pelvis and take a tissue sample, was long considered the gold standard because it directly confirms the disease. The 2022 ESHRE guideline now supports diagnosing and starting treatment based on symptoms and imaging, without making surgery mandatory first.

Your doctor will start with a detailed history and a pelvic examination. Transvaginal ultrasound is the first-line scan and is good at spotting ovarian endometriomas (chocolate cysts). MRI helps map deeper disease. Laparoscopy is offered when imaging is unclear, when treatment hasn't helped, or when surgery is planned anyway.

Standard Diagnostic Tests in India

• Clinical history and pelvic exam — Reviewing your pattern of pain, periods, and fertility, with a pelvic examination, is the starting point and can guide diagnosis under current ESHRE guidance.
• Transvaginal ultrasound — The first-line imaging test. It detects ovarian endometriomas well and can suggest deeper disease in experienced hands.
• MRI of the pelvis — Used to map deep infiltrating endometriosis and disease involving the bowel or bladder before surgery.
• Diagnostic laparoscopy — Keyhole surgery that directly visualises and biopsies deposits. Historically the gold standard, now offered when imaging is inconclusive or treatment is planned.
• Ovarian reserve testing (AMH) — Often checked when fertility is a concern, especially before surgery on endometriomas, to plan treatment.

Endometriosis can reduce fertility through several routes, but it doesn't make pregnancy impossible. Adhesions and scarring can distort or block the fallopian tubes and trap the ovaries, so the egg and sperm struggle to meet. The chronic inflammation around the pelvis can also harm egg and sperm quality and disturb implantation.

Ovarian endometriomas and the surgery used to remove them can lower the egg reserve. Even so, severity of pain doesn't predict fertility well, and women with mild disease often conceive naturally. Where natural conception is unlikely, IVF bypasses the tubes entirely and is highly effective.

• Tubal and pelvic scarring: Adhesions can block or distort the fallopian tubes and fix the ovaries in place, so the egg and sperm cannot meet naturally.
• Reduced egg quality: Chronic pelvic inflammation can affect the environment around developing eggs and may lower egg quality in some women.
• Lower ovarian reserve: Ovarian endometriomas, and surgery to remove them, can reduce the number of eggs available, lowering reserve.
• Impaired implantation: Inflammatory changes may make the uterine lining less receptive, so embryos can find it harder to implant.
• Disrupted ovulation: Severe disease and large endometriomas can interfere with normal follicle development and ovulation.

Treatment depends on your main goal, whether that's pain relief, fertility, or both, and the two are managed differently. For pain, doctors use anti-inflammatory painkillers and hormonal options such as combined pills, progestins, or GnRH analogues that quieten the disease by suppressing cycles. These ease symptoms but don't improve fertility while you're on them, since they prevent ovulation.

Surgery by laparoscopy can remove or destroy endometriosis deposits and free trapped organs, which may relieve pain and modestly improve natural conception in milder disease. When fertility is the priority and other routes haven't worked, IVF is usually the most effective step. The right plan is always personalised.

IVF works well for endometriosis, and the outlook is reassuring. In a large analysis of the SART database, women with isolated endometriosis had a fresh-cycle live birth rate of 44.7%, similar to or better than women with unexplained infertility, with comparable egg numbers. Outcomes were lower when endometriosis came with other fertility problems.

Practically, you may have a few extra steps. Your doctor may check egg reserve carefully, plan how to handle any endometriomas, and sometimes use a longer hormonal suppression before stimulation. The process is the same in principle as any IVF cycle. Set expectations with your clinic based on your age, reserve, and disease stage.