Endometriosis and Fertility

March 8, 2017
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Endometriosis is often a painful disorder, in which tissue that normally lines the inside of the uterus — the endometrium — grows outside the uterus. Endometriosis most commonly involves ovaries, bowel or the tissue lining the pelvis. Rarely, endometrial tissue may spread beyond the pelvic region.

In endometriosis, displaced endometrial tissue continues to act as it normally would — it thickens, breaks down and bleeds with each menstrual cycle. Because this displaced tissue has no way to exit your body, it becomes trapped. When endometriosis involves the ovaries, cysts called endometriomas may form. Surrounding tissue can become irritated, eventually developing scar tissue and adhesions — abnormal tissue that binds organs together.

Endometriosis can causes pain— sometimes severe — especially during your period and often also cause infertility.

It is a very common disorder, 5-10% of all women have endometriosis. The large majority of cases of endometriosis are mild. Most of these women are not infertile but 30-40% of infertile women have endometriosis.

Diagnosis of endometriosis
The only way to be sure whether a woman has endometriosis, is to perform a surgical procedure called laparoscopy that allows us look inside the abdominal cavity with a narrow scope and directly visualize endometriosis implants or endometriomas.

However the disease can strongly be suspected based on the woman’s history of very painful menstrual cycles, painful intercourse, etc., or based on the physical examination of the woman or ultrasound findings.

Symptoms
Common signs and symptoms of endometriosis may include:

– Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before and extend several days into your period and may include lower back and abdominal pain.
– Pain with intercourse. Pain during or after sex is common with endometriosis.
– Pain with bowel movements or urination. You’re most likely to experience these symptoms during your period.
– Excessive bleeding. You may experience occasional heavy periods (menorrhagia) or bleeding between periods (menometrorrhagia).
– Infertility. Endometriosis is first diagnosed in some women who are seeking treatment for infertility.

The severity of pain is not necessarily a reliable indicator of the extent of the condition. Women with any stage of endometriosis (mild, moderate, or severe) can have severe lower abdominal and pelvic pain – or they might have no pain or symptoms whatsoever.

Infertility
The main complication of endometriosis is impaired fertility.

Although mild endometriosis is associated with infertility in some women, a cause and effect relationship between mild endometriosis and infertility has not been established.

Severe endometriosis causes pelvic scarring and distortion of pelvic anatomy. The tubes can become damaged or blocked and the ovaries often contain cysts of endometriosis (endometriomas) and may become adherent to the uterus, bowel or pelvic side wall. Any of these anatomic distortions can result in infertility.

In the case of endometriomas, the eggs in the ovaries can be damaged, resulting in reduced egg quantity quality and – especially after surgical excision of the cyst – in decreased ovarian reserve.

Treatment of endometriosis
Treatment for endometriosis associated with infertility needs to be individualized for each patient. There are no easy answers, and treatment decisions depend on factors, such as the severity of the disease and it’s location in the pelvis, the age of the woman, length of infertility, and the presence of pain or other symptoms.

 

General approach to infertility:

Treatment for mild endometriosis
Several well-controlled studies have shown that neither medical or surgical treatment for mild endometriosis will improve pregnancy rates for infertile women, compared to no treatment.

For treatment of the infertility associated with mild to moderate endometriosis, controlled ovarian hyperstimulation with intrauterine insemination (IUI) is often attempted and has a reasonable chance to result in pregnancy if other infertility factors are not present.

If IUI is not successful by about 3 cycles or you are over 35 years old or you have a low ovarian reserve, in vitro fertilization (IVF) is the best option and should not be postponed.

Treatment for severe endometriosis
Several studies have shown that MEDICAL treatment for severe endometriosis does not improve pregnancy rates for infertile women. However, SURGICAL treatment of severe endometriosis does improve the chances for pregnancy as compared to no treatment. However, pregnancy rates remain very low after surgery – some studies have reported pregnancy rates of 1.5-2% per month.

Medical suppression with a GnRH-agonist such as Lupron, Synarel, or Zoladex for up to 6 months after surgery or before fertility treatment appears to be beneficial improving pregnancy rate.

Unfortunately, infertility in women with severe endometriosis is usually resistant to treatments such as IUI. If the pelvic anatomy is very distorted, artificial insemination is unlikely to be successful and these women very often require IVF in order to conceive.

Pregnancy success rate with IVF for women with severe endometriosis is usually good if the woman is relatively young (under 35) and if she produces enough eggs during the ovarian stimulation (more than 5).

If you have endometriosis and you wish to conceive, DO NOT WAIT, age is crucial to improve your chances of success. Consult us as soon as possible and we will guide you through the right treatment choice tailored on your specific case.

 

– Dr Roberta Corona

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