The link between endometriosis and infertility is a moot one. Professor Thomas states that "none of the published randomized trials have shown that medical treatment improves fertility", and suggests that "endometriosis should be considered to be coincidental unless it has caused tubal and ovarian damage that requires repair".
Most current drug therapy for endometriosis suppresses ovulation, inducing either pseudo pregnancy (through the contraceptive pill or other progestogens) or, more commonly, pseudo menopause. It is therefore not a suitable treatment if a woman is infertile and wishes to conceive. If she does conceive while on hormone therapy, there is a chance of infant abnormality. Progestogens are also not a good idea as suppression of ovulation can continue for a long time after treatment has ended.
A quantitative overview of commonly used treatments for endometriosis associated infertility concluded that "ovulation suppression is an ineffective treatment" (Fertility & Sterility, May 1993).
Hormone treatment has proved quite effective in temporarily suppressing some of the worse symptoms of endometriosis, but the symptoms usually return once treatment stops (The Lancet, 31 October, 1992).
Even relief from symptoms has to be weighed up against the side effects associated with these drugs. These include hot flushes, depression, changes in breast size, dry vagina, sweating, mood changes, loss of libido, headaches, nausea, muscle pains and a reduction in bone density (which increases the risk of osteoporosis).
Danazol one of the most commonly used drugs and gestrinone, both induce a post menopausal state with the possibility of these sorts of side effects. But they are also both androgens which are similar to male reproductive hormones. Male hormonal side effects such as greasy skin, acne, hirsutism and voice changes (the latter non reversible) can cause additional distress.
Surgery may be offered to women with advanced endometriosis whose symptoms are extreme or who are infertile. The British Journal of Clinical Practice (Symposium Supplement, Autumn 1991) took the view that the only lasting cure for endometriosis was radical surgery with removal of both ovaries.
As for infertility, Prof Thomas points out that there have been no scientific studies of the experiences of surgical treatment of endometriosis on future fertility. Surgery itself can cause adhesions, which could further contribute to the problem.
Conservative surgery involves trying to conserve or improve reproductive capacity while removing endometrial patches and adhesions and repairing any damaged organs.
Radical surgery means a hysterectomy and removal of ovaries. This usually brings on the menopause, which is often more severe than natural menopause because its onset is sudden rather than gradual. Women who go through the menopause much earlier than normal also have an increased risk of osteoporosis and possibly even heart disease and hardening of the arteries. If the ovaries are removed, HRT may be recommended, which could of course reactivate the endometriosis.
A recently developed alternative to conventional hysterectomy is endometrial ablation (removal of the lining of the womb to stop heavy bleeding, using laser, radiofrequency electromagnetic energy or electrocoagulation). This technique is popular in the US and UK. However, a report in JAMA (8 September 1993) highlights four cases of hyponatremia (potentialy life threatening lack of sodium in the blood, possibly leading to convulsions and coma) following endometrial ablation, in which one woman died. The report concluded: "Menstruant women are at high risk for death or permanent brain damage from even modest postoperative hyponatremia. . ..