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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 and Pain
Endometriosis may cause pain. Classically, the pain of endometriosis is most intense during the menstrual flow (dysmenorrhea) and may involve a wide range of pelvic and abdominal regions. The pain may also be associated with intercourse (dyspareunia) that lasts for several hours after the conclusion of relations (since vaginal penetration commonly results in the movement of pelvic structures most often affected by endometriosis). The cyclic nature of the pain is based on the extraordinary responsiveness of endometrial tissue (wherever located) to the sex steroids, estrogen and progesterone.

During the menstrual cycle, the ovary produces a tremendous amount of estrogen and progesterone in a sequence that promotes the orderly growth of endometrium. If a pregnancy does not occur, then the uterine lining sheds predominantly through the uterine cervix and out the vagina as menstrual flow. If the patient has endometriosis, the endometrial cells that are "shed" in the pelvis have no escape from the body and often cause a dramatic local inflammatory reaction. This inflammation is the most widely accepted cause for the pelvic pain associated with endometriosis.

The pain of endometriosis can range widely from a dull ache to a severe piercing sharp pain. Typically the pain lasts for days starting 1-2 days prior to the onset of the menstrual flow. The pain may be greater in certain locations, but often involves the

  1. * midline pelvis (around and behind the uterus)
  2. * adnexal region (around the ovaries and tubes immediately lateral to the uterus)
  3. * lower back deep in the pelvis (around the rectosigmoid colon or uterosacral ligaments behind the uterus) where it is often thought to be gastrointestinal
  4. * pelvis with radiation down one or both legs or into the groin

Management of the pain associated with endometriosis with medications is reported to be frequently effective. Medical management often takes 3-4 months to become effective and many of these medications can only be given safely for up to 6 months. Therefore, the woman suffering from the endometriosis will often request more aggressive care. Surgery is clearly an alternative with a typically rewarding outcome. I have generally recommended consideration of surgical intervention (operative laparoscopy) at the point when the woman's pelvic pain interferes with her daily activities to such an extent that she would rather have a surgical procedure to try to remove the source of the pain than continue with the pain.

All the medical management options for treating endometriosis include medications that temporarily prevent pregnancy by disrupting ovulation. To be perfectly safe, one should consider contracepting after initiating these medications until a state of anovulation is achieved. Clinical reports comparing the various medications in terms of effectiveness in pain management suggest that they are generally comparable to one another. Many of these medications have significant side effects that the patient may find disagreeable. The medications in use today include

* (1) GnRH agonists:

GnRH agonists essentially turn off the ovary in terms of egg maturation. The dramatic decrease in circulating estrogen is thought to be the primary mechanism of action for GnRH agonists in the treatment of endometriosis.

One should be certain that the patient is not pregnant or able to become pregnant before the ovary is suppressed with a GnRH agonist. The effect of agonist treatment on pregnancy is not known. There is a report in the literature describing an uneventful pregnancy and delivery of a normal baby despite GnRH agonist therapy effectively for the first 3 months of pregnancy (injections at 4 and 8 weeks).

The effectiveness of the GnRH agonists is comparable to Provera and Danazol with respect to treatment of the pain associated with endometriosis. Excellent large studies (prospective, randomized, controlled clinical trials) have demonstrated that GnRH agonists and Danazol have comparable effects on endometriosis in terms of pain and reduction of visible disease (determined by comparing pre and post treatment findings at laparoscopy).

There have been no reports demonstrating a benefit in the treatment of stage I or II endometriosis with GnRH agonists in terms of fertility.

* (2) Progestagens:

Progesterone counteracts the effect of estrogen on the endometrium. The mechanism for this includes a progesterone stimulated reduction in estrogen receptor number (so estrogen in the circulation has fewer cellular receptors to bind resulting in less effect), an accelerated metabolism of estrogen to less active or inactive forms that are rapidly excreted, and an inhibition of some of the molecules formed as a result of estrogen that help in creating the "estrogen effect."

The effectiveness of Provera in providing relief for the pain associated with endometriosis is reported to be comparable to that of Danazol and the GnRH agonists.

There is no apparent benefit of Provera or other medical management in the treatment of stage I or II endometriosis with respect to fertility. In a solid research study (prospective, randomized, placebo controlled clinical trial) there was no significant difference in the pregnancy rates following Provera treatment (100 mg per day) of stage I or II endometriosis compared to placebo (inert tablets without medication).

* (3) Danazol:

Danazol was widely used when introduced into clinical practice in 1972 because it was the only medication available. It is consistently effective in treating pain associated with endometriosis. At this time, Danazol is not used much since equally effective medications are available and the side effects of Danazol can be undesirable.

Side effects of Danazol include weight gain and fluid retention, decreased breast size, acne and oily skin, excessive male pattern hair growth (fascial, chest, back), mood swings, muscle cramps, fatigue, irreversible deepening of the voice, hot flashes, and atrophic vaginitis (with decreased elasticity of the wall of the vagina). Side effects occur in about 80% of women but only 10% of those who take the medication actually discontinue the medication because of the side effects. Most young reproductive age women find these sort of side effects to be highly unattractive and prefer to use one of the other available medications if medical management is chosen for treatment.

Danazol is effective in relief of pain due to endometriosis about 90% of the time, has similar efficacy to GnRH agonists and Progestagens, and the pain will reportedly return in about a third of patients within a year.

There is no known benefit for the treatment of infertility associated with stage I or II endometriosis.


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

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