الفهرس 
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Abstract
Summary and Conclusions
Infertility is defined as the inability to conceive after one year of unprotected sexual intercourse of reasonable frequency. If no apparent cause of infertility could be elicited, it is then termed ”Unexplained Infertility”.
Endometriosis is defined as the presence of endometrium-like tissue outside the uterine cavity.
Several hypotheses have been proposed to explain the development of endometriosis:
1. Retrograde menstruation
2. Coelomic metaplasia
3. Lymphatic and vascular embolism
However, other factors help to sustain the continuity of this endometrium-like tissue in place. These include hormonal and immunological factors. In addition, there are several risk factors such as, familial, genetic mutations, and environmental toxins.
The commonest symptoms of endometriosis are infertility & subfertility, pelvic pain, dysmenorrehea, dysparunia, dyschesia, & dysuria.
The diagnosis of endometriosis is made primarily by history and clinical examination. Serum markers such as CA-125 & CA19-9, though maybe elevated in endometriosis, yet are nonspecific for endometriosis.
Ultrasonography is deficient in the diagnosis of endometrial nodules less than 20 mm. And in this field, trans-rectal (and to a lesser extent trans-vaginal) ultrasound is primarily used.
The golden standard for diagnosis of endometriosis however, is laparoscopy, where the lesion could be seen directly by visual inspection. However, laparoscopy is expensive and needs high experience. In addition, biopsies have to be taken for histopathological confirmation.
This study was conducted on 203 patients, 95 patients were excluded as they had detectable causes of infertility. This left us with 108 cases with infertility undergoing diagnostic laparoscopy with no detectable causes. The age of these patients ranged between 19-40 years with mean age 28 years and mean duration of marriage 5.4 years.
Regarding the clinical aspect, dysmenorrhea & dysparunia were positive indicators of endometriosis. Also, presence of nodularity or tenderness during the examination of Douglas pouch and/or utero-sacral ligament, and fixation of the uterus were all positive indicators of endometriosis.
Laparoscopic examination showed the presence of endometrisosis in 28 cases (25.9%),the most affected organs were the ovary (14 cases),the utero-sacral ligament and douglas pouch (17 cases) and peritoneal adhesions (2 cases).
The severity and scoring of endometriosis were as follow:
• Grade I (minimal)[1-5]:17 cases
• Grade II (mild)[6-15]: 1 case
• Grade III (moderate) [16-40]: 10 cases
Statistical analysis showed significant correlation between dysmenorrhea and dysparunia, and the presence of endometriosis. The same was also true for nodularity or tenderness in the Douglas pouch and/or utero-sacral ligament.
However, there was no significant correlation between endometriosis of the ovary and the previously mentioned symptoms and signs. Yet, ovarian endometriosis is an important cause of infertility and subfertility.
Thus, we can conclude that:
1. Clinical history and vaginal examination are important indicators for the presence of endometriosis, and shouldn’t be substituted by modern techniques of examination. Yet, it should be mentioned that six of the cases with endometriosis did not show any symptom or sign. Thus, the presence of these symptoms and signs can indicate the presence of endometriosis, but their absence does not negate the presence of endometriosis.
2. Any degree of endometriosis, however low, maybe accompanied with infertility.
3. Laparoscopy is considered the final and golden standard test to diagnose endometriosis.
Finally, we recommend that:
This thesis was based on data collected from cases of unexplained infertility who underwent laparoscopy, without the presence of a control group. This makes it a statistical analysis study (descriptive study). Also, the number of the cases was small. So, another multi-centre study should be performed including a control group of female patients who underwent laparoscopy for causes, other than unexplained infertility, and a larger number of patients.