| Abstract [eng] |
The growth and proliferation of endometriotic cells outside the uterus, affecting deeper tissues under the peritoneum, is defined as deep endometriosis (DE). The disease is often characterized by nonspecific symptoms, which complicate its diagnosis. Also, women with endometriosis often complain of infertility, which is characteristic of endometriosis, but its relationship with DE is unclear. The aim of this work is to review the literature on the epidemiology, pathogenesis, pathophysiology, clinical manifestations, diagnostics and treatment of deep endometriosis, to describe a clinical case of a patient with this disease and to determine the link between the disease and infertility. The prevalence of deep endometriosis in the general female population ranges from 1% to 6.4%, and among those with endometriosis, this form of the disease is about 20%. The main classification systems for endometriosis are the American Society for Reproductive Medicine (rASRM) classification, the ENZIAN classification, the Endometriosis Fertility Index (EFI) and the American Association of Gynecological Laparoscopists (AAGL) classification. The pathogenesis of the disease is based on several theories: the theory of coelomic metaplasia, the theory of retrograde menstruation, the spreading by blood or lymph, determined by defects in fetal organogenesis or associated with a benign tumor originating from the pouch of Douglas. Deep endometriosis also has a significant genetic basis, and its etiology is determined by many different factors. Three different phenotypes of the disease have been described: ovarian endometrioma, superficial peritoneal endometriosis, and deep infiltrating endometriosis. Histologically, this decease can be divided into well-differentiated glandular, pure stromal or pure glandular or mixed differentiation, and pure undifferentiated glandular structure. Many different factors are involved in the pathogenesis of the disease, the main of which are estrogen dependence and progesterone resistance. Deep endometriosis can lead to infertility, fatigue, dysmenorrhea, dyspareunia, digestive or urinary tract problems, pelvic, lower abdominal, back, and headache. The first-line diagnosic imaging method is transvaginal sonography (TVS), the second-line preoperative diagnostic method is magnetic resonance imaging (MRI), and the gold standard of diagnosis is laparoscopic examination with histological assessment of lesions. The main methods of deep emdometriosis treatment include drug therapy and surgical removal of lesions. Artificial insemination methods are used to treat infertility, mainly in vitro fertilization (IVF). A clinical case of a 28-year-old patient is presented. The woman consulted an obstetrician-gynecologist due to infertility, which has lasted for 4 years. From the anamnesis it is known that laparoscopic cystectomy of the right ovary, magnetic resonance imaging of the pelvic organs and laparoscopic rectal resection, removal of ovarian cysts, excision of the vaginal vault were performed. The patient's partner was diagnosed with asthenospermia. During the consultation, no pathology was observed in transvaginal ultrasound, anti-Mullerian hormone was determined in the blood below the normal limit. In case of infertility of the couple, IVF/ICSI is indicated. During assisted fertilization, an antagonist protocol was applied, the patient was stimulated with alpha gonadotropins 300 IU, and stimulation was applied for 10 days. After ovarian puncture, 12 eggs were obtained, and using the IVF method, 10 were fertilized, of which 3 blastocysts were formed. On the 3rd day after the procedure, 1 embryo was transferred to the uterus, but the patient failed to become pregnant. Later, after 2 months, 2 frozen embryos were transferred to the woman, but the patient did not become pregnant. The couple did not apply for the assisted fertilization procedure again. |
