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Management of endometriosis in woman trying to conceive (04HDC03651)

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(04HDC03651, 9 June 2005)

Obstetrician and gynaecologist ~ Infertility ~ Endometriosis ~ Pelvic inflammatory disease ~ Investigation ~ Diagnosis ~ Treatment options ~ Information ~ Communication ~ Referral ~ Professional standards ~ Standard of care

A 31-year-old woman was referred by her general practitioner to an obstetrician and gynaecologist when she had failed to conceive after a year. The woman complained that the endometriosis from which she suffered was not diagnosed and appropriately treated, and that the care she received was not adequate and did not conform to standard practice.

The woman, who had experienced painful yet regular periods, was concerned about fertility rather than pain issues. The obstetrician and gynaecologist assessed the clinical picture as a whole and, on the basis of radiological investigations and laparoscopy, concluded that the woman was suffering from very early stage endometriosis. This condition, which can exhibit symptoms varying from chronic pain to no symptoms, and which can cause infertility, is not uncommon among women of child-bearing age.

There was a possibility of pelvic inflammatory disease, which was communicated to the woman. However, the decision was made to treat for endometriosis with Danazol, a drug that is successful in treating endometriosis but which significantly affects fertility for the period of treatment. It was held that the diagnosis was appropriate, but the use of Danazol should be considered only where pain management is required and where fertility is not an issue. Given the woman's desire to conceive, it would have been more appropriate to have monitored the endometriosis to see if the woman could conceive anyway, to have intervened surgically, or to have referred the woman to a fertility specialist to discuss assisted reproductive options in light of the unilateral tubal block.

Although it was clear from the obstetrician and gynaecologist's notes that she had considered all the management options, she did not effectively communicate to the woman the options and the reason behind her decision. The evidence was not firm enough to support a breach finding, but the obstetrician and gynaecologist was reminded of the need to clearly and comprehensively discuss all treatment options with patients.