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Clinical Research, Diagnosis and Treatment of Endometriosis Combine to Provide Comprehensive Approach to Common Gynecological Disorder

Reproductive medicine specialists at Cedars-Sinai Medical Center are among a handful of clinician/ researchers in the United States who are attempting to dissect the mechanism of human embryo implantation and its link to endometriosis. Their expertise in basic research, combined with their fellowship training in reproductive endocrinology and infertility, provides a comprehensive approach to the diagnosis and treatment of their patients with endometriosis, particularly those who are infertile and hope to become pregnant.

Los Angeles - August 19, 2005 - Marika Collins was single and in her early 30’s when she had her first laparoscopic surgery for endometriosis. “It may have had more to do with where I was then in my life than anything else,” she recalls, “but none of the infertility issues made it onto my radar screen. I didn’t think becoming pregnant was going to be an issue for me.”

Eight years later, Collins had been married for one year and was eager to start a family. 

“I was prepared,” she says, “for the doctor to tell me that my age (38) might make it harder for me to get pregnant or that the endometriosis, which had reoccurred, needed to be taken care of first. But I wasn’t prepared to hear that my chances of getting pregnant were poor. I had no idea that there was a correlation between endometriosis and infertility.”

“Endometriosis affects many premenopausal women who suffer from infertility,” explains Collin’s physician Lee-Chuan Kao, MD, PhD. of Cedars-Sinai Medical Center. “But whether endometriosis causes infertility continues to be investigated from a scientific viewpoint. We’re one of less than a half dozen facilities in the United States trying to dissect the mechanism of human embryo implantation and its link to endometriosis.”

Kao and Margareta Pisarska, MD, are co-directors of the Cedars-Sinai Center for Reproductive Medicine, one of three specialty clinics that provide a comprehensive approach to the diagnosis and treatment of women’s gynecological/reproductive disorders. “Because of our expertise in reproductive medicine, we probably tend to see more women with endometriosis whose focus is fertility than most general obstetrician/gynecologists,” says Kao. Both physicians have completed fellowship training in reproductive endocrinology and infertility and are engaged in research activities in addition to their clinical practices. Kao’s research focuses on gaining a better understanding of the molecular processes involved in human embryo implantation and their relationship to endometriosis. Pisarska is interested in ovarian function and fertility preservation, specifically how ovarian follicles develop and digress.

Endometriosis occurs when tissue similar to the lining inside of the uterus grows outside the uterus, usually on the surfaces of the ovaries, fallopian tubes and other pelvic structures. The symptoms can include very painful menstrual cramps, chronic pelvic pain, pain during or after sex, pelvic mass and infertility. Some women don’t have any symptoms and first learn that they have endometriosis when they experience difficulty getting pregnant. Endometriosis can be treated medically, surgically or with a combination of both approaches depending on a number of factors including the extent of the disease, a woman’s age and her desire to conceive, says Pisarska.

Laparoscopy is the only definitive way to diagnose endometriosis, says Kao. During the procedure, a laparoscope − a tube with a light and a camera in it − is inserted through a small incision in the abdomen, allowing the surgeon to view the reproductive organs, intestines and other surfaces. If surgery is needed, one or two other tiny incisions may be made below the bikini line to allow the surgeon to pass lasers or other small surgical instruments into the abdomen to remove or vaporize the endometrial tissue. The procedure usually lasts about 1½ to 2½ hours and most patients go home the same day.

Laparotomy, another surgical treatment for endometriosis, is a major abdominal procedure in which the surgeon removes the endometriosis and may remove the uterus, ovaries and fallopian tubes. Hormone therapy can also be used to treat endometriosis but because it puts patients in a pseudomenopausal state, says Pisarska, it is not recommended for women who want to conceive.

According to Kao, laparoscopic surgery sometimes has an added benefit for women like Collins who are eager to conceive. “There is a study that was published in 1997 that we generally quote as the ‘Canadian Study’. It showed that women with mild to moderate endometriosis who had laparoscopic surgery increased their chances of conceiving by 28 percent within 32 weeks after surgery.”

Collins second surgery for endometriosis took place in early 2005. After the four-hour operation, she remembers Dr. Kao giving her and her husband some somber news – he had removed as much of the endometriosis as he could but the chances of her becoming pregnant were poor. Even so, Collins put her faith in the Canadian study, hoping that she might be in the “Canadian study camp” as she referred to it.

“Mrs. Collins’ fertility had been complicated with other issues such as her age, reduced ovarian reserve and the extent of her endometriosis,” says Dr. Kao. “So I recommended that she and her husband might need to consider obtaining an egg donor as an alternative option.”

The couple was reluctant to consider Kao’s suggestion, but agreed they would start talking about alternative fertility methods later in the year. But about two months after her surgery, Collins learned that she was pregnant − with twins. “We realize how lucky we are,” she says. We got a gift, a double gift, a gift that we weren’t supposed to get.” The twins (both are girls) are due in late November – the day before Thanksgiving – but doctors advise Collins that she will likely deliver them in early November. The couple hasn’t chosen the girls’ names yet, but has agreed that each will choose one name.

Kao and Pisarska are hoping to raise young women’s awareness of their reproductive health. “What we’d like to see happen,” says Kao, “ is for women to begin taking care of their reproductive health while they’re young, even before they start thinking about having a family. If they’re experiencing pelvic pain or severe pain with their menses, they need to see a physician. They could have a gynecological disease that might affect their future fertility.”