The pathology and natural history of endometriosis
Endometriosis is a puzzling condition responsible for considerable morbidity. The literature is characterised by a large number of reports but there is surprisingly little agreement on the aetiology and pathophysiology. In particular the relationship between mild endometriosis and subfecundity is uncertain. The aim of the studies described in this thesis was to document the incidence, and symptomatology of endometriosis in the fertile and infertile population, to study the natural history of endometriosis in infertile women and to study folliculogenesis, fertilisation and pathophysiology of periovulatory events in spontaneous menstrual cycles. The relevant literature has been extensively reviewed in the first chapter. By using diagnostic laparoscopy, a large group of fertile and infertile women in the premenopausal age group were studied to document the incidence of endometriosis. Endometriosis was more common in the infertile women. Prolonged usage of combined oral contraceptive pill might have a protective effect against the development of endometriosis. A questionnaire based study of menstrual symptomatology concluded that deep dyspareunia was equally frequent among women harbouring pelvic pathology whether endometriotic or post infective in origin, but congestive dysmenorrhoea was more prevalent among women having mild endometriosis. The study of the natural history of endometriosis suggested that among susceptible women the disease will progress despite treatment with danazol or with diathermy ablation but disease progression was much worse if patients were left untreated. A group of 21 women with primary infertility of more than 3 years duration were extensively studied over two consecutive cycles to study folliculogenesis. The majority of these patients had normal follicular development, and had sonographic evidence of ovulation followed by a normal luteal phase. Furthermore no abnormalities of oocyte maturity and fertilisation were noted in the spontaneous cycles studied. Similarly the endocrine milieu provided by follicular and peritoneal fluids was comparable to a control group. The subfecundity in patients with endometriosis remain essentially unexplained.