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Dr. Eric Daiter

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Dr Eric Daiter has served Monmouth and Middlesex Counties of New Jersey as an infertility expert for the past 20 years. Dr. Daiter is happy to offer second opinions (at the office or over the telephone) or new patient appointments. It is easy, just call us at 908 226 0250 to set up an appointment (leave a message with your name and number if we are unable to get to the phone and someone will call you back).


"I always try to be available for my patients since I do understand the pain and frustration associated with fertility problems or endometriosis."


"I understand that the economy is very tough and insurance companies do not cover a lot of the services that might help you. I always try to minimize your out of pocket cost while encouraging the most successful and effective treatments available."

NJ Center for Fertility and Reproductive Medicine - Infertility Tutorials

Pelvic Factor Infertility: Endometriosis
Endometriosis is the presence of endometrial glands and stroma (normal components of the tissue that normally lines the uterine cavity) outside the body of the uterus. Most often, endometriosis is located in the pelvis near or on the reproductive structures. However endometriosis can occur in virtually any tissue of the body, including distant sites like the lung, the knee and the skin.

The two major clinically important problems associated with endometriosis are infertility and pelvic pain. A common area of misunderstanding relates to whether these symptoms are linked to each other. The presence of infertility or pain can occur independent of each other. That is, a patient can have incapacitating pain due to endometriosis and normal fertility. Also, a patient can have infertility associated with endometriosis with absolutely no pain at all. This fact frequently surprises couples but is commonly seen by infertility specialists.

There are no reliable nonsurgical diagnostic tests for endometriosis. The diagnosis of pelvic endometriosis requires surgery. Ultrasonography shows no specific pattern for pelvic endometriosis, but is often helpful in diagnosing persistent nonfunctioning ovarian cysts that may represent endometriomas. Although some specialists seem to think that they can diagnose an endometrioma with certainty using ultrasound, there are abundant scientific reports confirming the nonspecific nature of the ultrasound for this purpose. MRI also has no specific findings, with a reported sensitivity and specificity of only about 60% for discovery of endometriosis. Blood tests for CA 125 may be elevated with endometriosis, but are also elevated with a tremendous number of other pelvic inflammatory processes so an elevated CA 125 in a reproductive age woman has little value (unless possibly used as a tumor marker when following a patient with known cancer).

Endometriotic lesions depend upon stimulation by estrogens. The lining of the uterus (endometrium) is one of the most complex tissues in the body in that it continuously changes (grows, modifies its structure, alters its own production of molecular messengers) in response to stimulation by circulating sex steroids. Endometriosis is rarely found in low estrogen environments, such as prior to puberty, after menopause, or following surgical "castration." Endometriosis discovered after menopause is almost always associated with hormone replacement medication containing estrogens.

The incidence of endometriosis is not known, since the only reliable way of determining its presence is through surgery or at autopsy. Surgical incidence is biased by the selection process bringing the patient to the operating room. No large cadaver study examining autopsy specimens for endometriosis has reported data that has been widely accepted. Despite this uncertainty, widely used numbers for the incidence of endometriosis include 3-10% of all reproductive age women and 25-40% of all women with an infertility problem.

The finding that endometriosis is very often found in areas near the end of the tube and in the cul de sac behind the uterus (as well as other dependent regions of the pelvis) has suggested that retrograde flow (from the uterus through the tube into the pelvis) of menstrual blood and cellular material during menses is an important variable in determining which women will develop endometriosis.

There are three main theories for the mechanism causing endometriosis. Each theory has many supporters. It may be that each of these three may accurately describe one of several possible mechanisms.

In the 1920s a physician named John Sampson devoted a great deal of time to the study of endometriosis and is widely credited with the initial suggestion that retrograde flow is the primary path for this tissue to grow in the pelvis. His reasoning was based on the distribution of implants that he observed. Additional support for this theory has been collected over the years and includes

  1. * virtually all women undergoing laparoscopy at the time of menses can be seen to have blood flowing from the fimbriated end of their fallopian tubes (retrograde flow)
  2. * the most common sites for endometriosis at both laparotomy and laparoscopy are in dependent portions of the pelvis and close to the ends of the tubes
  3. * when recovered surgically and grown in culture endometrial fragments within menstrual blood have the potential to survive and grow
  4. * a higher incidence of endometriosis is observed in women who have obstructions to the normal downward flow (out through the vagina), forcing a greater percentage of flow through the tube in a retrograde fashion
  5. * there is an increased risk of endometriosis if the woman has a shorter intermenstrual interval, longer duration flow or larger volume of flow
  6. * in female monkeys where the uterus has been surgically transposed (turned around) so that the flow is predominantly into the abdomen rather than out the vagina there is a higher incidence of endometriosis

One interesting question regarding this information is "if virtually all women have retrograde flow of endometrial cells into their pelvis during each menses then why don't virtually all women have endometriosis?" The answer to this question is not known, however, there are several proposed theories. The most widely accepted theory concerns the immune system. Basically, the immune system can be thought of as a housekeeping mechanism that rejects or destroys any tissue that is "foreign." It can also regulate where a tissue will be allowed to grow within the body.

When the immune system is activated an inflammatory response occurs and these inflammatory cells help to reject the abnormally placed tissues. If there is a problem with the immune response then tissue might be allowed to grow in abnormal locations, that is, to form implants such as endometriosis. In theory, if the amount of tissue is very large it may overwhelm the available normally functioning immune response and result in the growth of this tissue in abnormal locations. Therefore, endometriosis may occur either when a defective immune system is presented with a normal amount of retrograde flow or a normal immune system is presented with a large amount of tissue.

The presence of endometriosis in sites distant from the adnexae (ovaries and tubes) has led to alternative theories. The two other theories commonly considered propose that

  1. * vascular spread of tissue (via the blood vessels or lymphatics supplying the uterus) from the uterus to distant sites allows tissue to be transported to areas like the lungs or the knee, and
  2. * metaplasia (change from one normal type of tissue to another normal type of tissue) of the coelomic epithelium (type of tissue lining the pelvic structures where endometriosis is commonly found and from which uterine endometrial cells are normally derived) allows endometrial tissue to replace other types of tissues outside the uterus. This theory is supported by the finding of endometriosis in some men who have received estrogen treatments, where no endometrial tissue normally exists.


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Eric Daiter, M.D. - Edison, NJ - E-Mail: - Phone: (908)226-0250

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