Endometriosis is usually a painful disease with features of chronic inflammation. It is one of the most common benign gynecological diseases in the reproductive age with a frequency in the general population of about 10%, while in infertile women the percentage varies from 30-50%. The average age of diagnosis is 28 years and it should be mentioned that the diagnosis usually is delayed, because the symptoms are not properly assessed.

Endometriosis has serious consequences, both in the social and professional life of the patients, as well as in their mental balance. The economic burden in the US is estimated at $49 billion annually.

Endometriosis is the condition where endometrial tissue sensitive to the action of estrogen is found outside the endometrial cavity and the diagnosis is confirmed after biopsy.

There are several theories about the appearance of endometriosis:
1. The retrograde flow of blood from the fallopian tubes during menstruation and the implantation of endometrial cells in the peritoneal cavity. But this happens to all women and therefore there should be some individual predisposition.
2. The metaplasia of the visceral epithelium where some peritoneal cells turn into endometrial cells.
3. Mullerianosis where during the fetal period some cells develop in the wrong areas of the body.
4. The theory of hematogenous and lymphogenous spread, which could justify remote foci of endometriosis such as e.g. in the chest cavity.

There are 3 types of endometriosis: superficial foci of endometriosis (15-50%), endometriosis cysts (endometriomas up to 45%), and deep endometriosis (about 20%).

Symptoms of endometriosis

Endometriosis can present with symptoms such as: severe period pain (dysmenorrhoea). Typically in endometriosis, dysmenorrhoea is particularly intense and usually occurs several years after the onset of menstruation. Many women report a persistent hypogastric pain, which is not attributable to another pathological entity. Dyspareunia, i.e. pain on contact, is a major symptom of the disease. Bowel symptoms, painful bowel movements, pain during defecation, pain during urination.

These women often have ovarian cysts, which in this case are called endometriomas and cause infertility in a significant percentage.

Endometriosis is thought to negatively affect fallopian tube function through the formation of adhesions, egg quality, fertilization and embryo implantation. 50% of patients with this disease will need to undergo IVF to be able to have a child.

In particular, there is evidence that endometriosis as a disease has an impact on ovarian reserves. Levels of the markers AMH, the number of small follicles and Inhibin B where they serve to assess fertility are reduced compared to the general population.

Pathophysiologically, endometriotic cysts are believed to contain substances, such as free iron, that may be toxic to the follicles. Also, chronic stretching of the ovarian cortex due to cysts can have negative effects. As it has also been found that there is an overactivity of the primordial follicles, which can lead to their faster exhaustion.

Endometriosis diagnosis

The detailed medical history raises the suspicion of the disease. A thorough ultrasound examination will identify endometriotic cysts as well as foci of endometriosis in other organs, by experienced doctors. The blood test Ca -125 is a useful auxiliary indicator. Magnetic resonance imaging is also used for diagnosis. Confirmation of the disease is achieved after a laparoscopy operation with taking tissues for histological examination – biopsy.

The treatment of endometriotic cysts (>4cm) is their laparoscopic surgical removal. Unfortunately, there are also negative consequences even from the most experienced surgeons and that is the reduction of ovarian reserves after the operation. A statistically significant decrease in AMH and AFC has been found, reflecting a decrease in a woman’s fertility potential. Also, disease recurrence rates of 20% at 2 years and 40% at 5 years have been reported.

Egg freezing

In the past, egg freezing, due to the low success rates of previous techniques, was a solution of necessity and limited to selected cases, such as fertility preservation before the start of anticancer treatment or the unavailability of sperm on the day of egg retrieval in IVF cycles. The introduction of modern techniques, such as vitrification, shows excellent chances of success after oocyte thawing, with pregnancy rates of 35-65%. Egg freezing has also been found to be just as effective as fresh eggs and does not increase the risk of genetic or chromosomal abnormalities. So thousands of women choose egg freezing for social or medical reasons.

Studies show that women with endometriosis who undergo egg freezing have a greater number and better quality of eggs, ideally if they undergo an egg collection procedure at the age of less than 37 years and before surgery to treat endometriosis.

Endometriosis is a disease directly related to infertility. It is also an evolving disease and for these reasons women who would like to have children in the future should be informed by doctors about the effects of the disease and about the possibility of egg freezing when they are diagnosed with endometriosis and before undergoing surgery.