Endometriosis in adolescence: A long-term follow-up fecundability assessment

Twenty-eight patients were identified from a prospective cohort of 52 adolescents (ages 12 to 18 years) with operative diagnosis of endometriosis between July 1993 and December 1995. All patients presented with chronic pelvic pain unresponsive to conservative medical management. Diagnosis of pregnancy was made by sonographic identification of intrauterine pregnancy, positive serum human chorionic gonadotropin or pathological confirmation of products of conception. Patients were categorized as fertile or sub-fertile by having > 12 months of unprotected intercourse without conception. Follow-up was done for 8.6 years.Staging of endometriosis was performed according to the American Society for Reproductive Medicine standards. Stage I = 14.3%; Stage II = 39.3%; Stage III = 42.8%; Stage IV = 3.6%. Fecundability rates in each stage were statistically significant: Stage I (75%), Stage II (55%), Stage III (25%), Stage IV (0%) (p < .05). Rates of spontaneous abortion were not statistically significant.In our cohort, even at the earliest point in the natural life cycle of endometriosis there is an inverse relationship between stage of disease at diagnosis and fecundability.Recent studies [1] have given us more insight into the pathophysiology of endometriosis. Fragments of functional endometrium reflux through the fallopian tubes and reach the essentially hostile environment of the peritoneal cavity. Proteolytic activity, activated macrophages and natural killer cells all combine to degrade and digest the regurgitated tissue fragments. Occasionally whole fragments of endometrial tissue succeed in evading the peritoneal defense lines, perhaps by their sheer number, perhaps by an intrinsic defect in the defense system. Microtraumas to the peritoneum will expose the extracellular matrix; successful endometrial tissue implantation may occur, and the cyclic angiogenesis that occurs in the female reproductive tract, will allow survival and growth of the ectopic endometrial tissue.