Specialised healthcare in the Instituto Bernabeu endometriosis unit

Comprehensive, personalised healthcare in order to improve quality of life by reducing pain and preventing potential complications as well as improving and preserving fertility.

Specialised healthcare in the Instituto Bernabeu endometriosis unit
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What is endometriosis and what are its symptoms?

Endometriosis is an illness in which tissue from the uterus (endometrium) grows outside the uterine cavity. It affects between 10 and 15% of women in childbearing years and can affect up to 50% of women who have fertility issues. Its cause it still unknown and its affect on fertility is variable. For example, cases include those in which there are significant endometrial lesions but which do not affect fertility and others in which less significant lesions cause reproduction issues.

On occasions, endometriosis does not only the make the tissue from the uterus that we call endometrium grow outside it. It can also occur in the form of cysts on ovaries (that cause endometriomas), in the fallopian tubes or in any other part of the body, except the spleen. Such endometrial implants respond to hormones in the same way as the endometrium and, as such, during menstruation they can grow month after month and even lead to slight bleeding or intense pain.


Endometriosis can cause different symptoms.  Menstrual cramps are the most common (dysmenorrhea). Also, abundant bleeding during periods and, depending on where the implant is situated, constipation or diarrhoea, hematuria (urinating blood) during periods and painful sexual intercourse .

Without a doubt, one of the symptoms that women affected by endometriosis worry most about is issues falling pregnant. The reproduction issues it can cause range from repeat pregnancy loss,  embryo implantation issues, ovulation abnormalities and obstruction of the fallopian tubes, amongst others.


The most commonly used classification is the one established by the American Society of Reproductive Medicine in 1996:

  • Stage I: minimal.
  • Stage II: mild.
  • Stage III: moderate.
  • Stage IV: severe.

There are two basic issues with this classification system. The first is that there is no link to the fertility issues the patient may have and the second is that this system requires surgery in order to make a classification. Therefore, nowadays, we tend to classify endometriosis as follows:

  • Superficial: detected mainly following surgery.
  • Endometriomas: presence of cysts on ovaries.
  • Severe: severe endometrial implants detected through surgery or in ultrasounds.

How can you determine if you have endometriosis?

One of the problems for patients and for medical staff is the fact that the intensity of pain, where it is situated and its duration does not always appear to coincide with what shows up on an ultrasound  scan . The patient can often feel misunderstood and frustrated when nothing provides for a conclusive diagnosis and there appears to be no way of getting rid of the pain.

In the Endometriosis Unit in Instituto Bernabeu, we are pioneers in using the very latest in diagnosis methods through the analysis of new, reliable biomarkers (immune system indicators):  cytokines. In a simple blood sample, we take a look at the indicators in the endometriosis inflammatory process, thus generating a precise diagnosis and obtaining highly useful information in terms of the stage and seriousness of the illness. This means that, in most cases, we are able to avoid diagnosis through surgery and the effects that this can have on fertility.

What do we do in the IB Endometriosis Unit?

Correct evaluation and treatment of endometriosis often calls for a multi-disciplinary approach by gynaecologists with experience in diagnostic imaging technology and skilled laparascopists with experience in assisted reproduction.

Years ago, treatment almost always involved surgery. Today, however, we believe that we need to be cautious when dealing with the ovaries since removing endometrial tissue involves removing important follicles from the ovary. This leads to a reduction in ovarian reserve.


In the past, the established diagnosis of endometriosis was anatomical-pathological, i.e. the implant had to be removed and, after analysis, confirmed. Nowadays, this aggressive process, which often worsens the couple’s reproductive situation, is no longer necessary.

There has now been a paradigm shift in how endometriosis can be diagnosed. The European Society of Human Reproduction has already established that this diagnosis can be based on the patient’s symptoms alone.

Although questionnaires have not been shown to improve the diagnostic delay in the diagnosis of endometriosis, they are considered a useful tool for the patient to consult a doctor if she suspects endometriosis.

At Instituto Bernabeu we have high-resolution ultrasound scanners that allow us to make an accurate diagnosis. It is true, however, that many of our patients come to us with a perpetuated diagnosis. With our experience, we can better establish the degree of involvement of the disease and its prognosis.

In addition, thanks to our genetics unit we are able to analyse inflammatory mediators called cytokines. Cytokines are proteins produced by various cell types that act as mediators in inflammatory processes and in the immune response. Because of this, they can be considered as biomarkers whose levels can be found to be elevated in case of clinical suspicion of endometriosis.

Likewise, endometriosis has been related to certain variations in genes, which, although it is not yet established which can give a definitive diagnosis, certain variations or polymorphisms can give us information about the reproductive prognosis of endometriosis, such as the variants of the VEGF or APOE gene, which are currently analysed in our IBGenRIF test. 


Adenomyosis is when endometrial tissue is situated within the muscular wall of the uterus (endometriosis in the uterus). This can complicate embryo implantation.

Further to the use of three-dimensional ultrasound equipment in our daily work routine at the clinic, our aim has been to diagnose this little-known pathology.

We are now able to interpret the different images adenomyosis gives in ultrasounds and one of our lines of research work includes establishing how capable the uterus is of correctly implanting embryos based on how severe the adenomysis is.

What tests are carried out in the IB Unit for the treatment of endometriosis?

Endometriosis leads to decreased ovarian reserve as time goes by. We therefore believe it is necessary to first of all carry out a thorough ovarian reserve diagnosis in order to be able to give the patient feedback on the likelihood of falling pregnant in the future. Ovarian reserve is evaluated by means of an antral follicle count,  anti-Mullerian hormone levels and the patient’s age, amongst other factors.

Depending on the severity of the endometriosis, pelvic anatomy may be distorted and this can affect, amongst other structures, the fallopian tubes. In order to look into this, we carry out a sonohisterography test. This has replaced the hysterosalpingography test which requires injecting a fluid into the pelvic area and is a painful procedure.

During the process, and taking into account each patient and all potential benefits, where necessary, a hysteroscopy is a useful procedure in obtaining a direct evaluation of the endometrial cavity and in backing up the information obtained from ultrasound images.


Certain foods can have an effect on the intensity of the illness and symptoms as well as increases and decreases in them. Therefore, the Endometriosis Unit is also given support by our endocrinology and nutrition team in the form of nutritional evaluation and advice. The aim is to make the most of natural resources in the fight against the illness and to hold back the associated symptoms.

In order to improve quality of life and by way of a complementary treatment to the endocrinological and gynaecological healthcare being given, acupuncture can help to relieve pain  and inflammation and we also, therefore, offer this type of specialist treatment.

What issues can be resolved?

Instituto Bernabeu offers personalised solutions and has a number of on-going specific research projects in which conventional treatment has been refractory. We also have two units that specialise in the significant issues that  endometriosis can cause:

Preserving fertility: EGG VITRIFICATION

Egg vitrification is a technique that facilitates the preservation of ‘eggs’ when patients are young. Taking into account the fact that endometriosis can affect fertility as years go by, with vitrification, patients wish to become mothers, have the option of doing so.


When did you have your first period?
 Before the age of 10
 Between the ages of 11 and 15
 Older than 16 years of age

Are your periods painful?
 No, never
 Yes, sometimes
 Yes, always

Do you suffer from pain during sexual intercourse?
 No, never
 Yes, sometimes
 Yes, always

Do you need to take painkillers during your period?
 No, never
 Yes, sometimes
 Yes, always

Have you ever needed to go to hospital due to painful periods?
 No, never
 Yes, sometimes
 Yes, always

Have you had issues falling pregnant?
 No, never
 Yes, it took me at least 6 months
 Yes, I’ve had assisted reproduction treatment

Do any members of your family have endometriosis?
 I don’t know

How many sanitary towels or tampons do you need on the heaviest days of your period?
 Under 6 tampons/sanitary towels a day
 Between 6 and 11 tampons/sanitary towels a day
 More than 12 tampons/sanitary towels a day

Have you been diagnosed with any malformations in the uterus?

Have you been diagnosed with any auto-immune or rheumatological illness?

Have you or any close relative been diagnosed with uterine fibroids?
 I have not, but a family member has


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