Endometriosis and Infertility

What is endometriosis?

Endometriosis is a common condition affecting 1 in 10 women. In this condition, tissue similar to the lining of uterus is implanted outside the uterine cavity at ectopic locations. This tissue can be found on ovaries, tubes, peritoneum, bowel and at various other organs. This tissue can form its own hormones and it grows and invades the surrounding tissue which causes adhesions, pain and infertility.

How do I know if I have endometriosis?

Endometriosis may present as painful periods, pelvic, abdominal pain, irregular bleeding, painful sex and infertility or it may be asymptomatic in some cases. As it involves the pelvic organs and pelvic peritoneum, it causes infertility in 30-50% of women. For some women there may be a formation of an ovarian cyst called an endometrioma which can be picked up on ultrasound.

Common symptoms of endometriosis are

• Very painful menstrual cramps
• Chronic pelvic pain, backache
• Painful sex
• Painful defecation / urination
• Bleeding or spotting
• Infertility
• Stomach / digestive problems simulating Irritable Bowel Syndrome (IBS)

The gold standard for endometriosis diagnosis and treatment is laparoscopy.

How does it cause infertility?

For some women with endometriosis, it may be difficult to get pregnant. A few women who are asymptomatic are diagnosed for the first time with endometriosis when they visit for infertility evaluation. Endometriosis impacts fertility by various mechanisms such as

• It distorts the pelvic anatomy
• Adhesions
• Scarring
• Tubal damage
• Inflammation of pelvic organs
• Affects the egg quality
• Interferes with implantation
• Changes the hormonal milieu

How do I know, how bad is my endometriosis?

Endometriosis staging can be done when your doctor does your laparoscopy. They will evaluate the amount, location, depth of endometriosis and can tell you the stage of disease. This way we know about minimal (Stage 1), mild (Stage 2), moderate (Stage 3), or severe (Stage 4) disease. This also helps us with the fertility outcome. Women with advanced disease like Stage 3 or Stage 4 endometriosis where the pelvic anatomy is completely distorted, fallopian tubes are blocked, ovaries are damaged and ovarian reserve is low, may need advanced fertility treatment.

How is endometriosis treated?

For patients who are trying to conceive, treatment will depend on the extent and symptoms of endometriosis. If laparoscopy is done, excision surgery should be done for clearance of endometriosis. The aim of this surgery is to restore the pelvic anatomy and help you restore the normal reproductive functions. After surgery, chances of getting pregnant are improved. Some women with endometriosis conceive spontaneously, while some may need ovulation induction or assisted reproductive technology to help them conceive.

The treatment for endometriosis is case based and it should be individualized for that woman.

Is there a medical treatment for infertility due to endometriosis?

Medical therapy is effective for pain relief in endometriosis, evidence does not support fertility enhancement with medical treatment such as COCs, Progestins, GnRH analogs or Danazol. Surgery combined with medical therapy has shown fertility enhancement in various studies. Infact, fertility treatment may be delayed if medical therapy is given before or after surgery for fertility enhancement. Medical therapy is effective to reduce pelvic pain and painful intercourse. Hormonal suppression may improve quality of life and sexual activity in infertile women with endometriosis which might enhance fertility after completion of the medical therapy.

Is surgery mandatory before assisted reproduction?

There is no evidence that surgery will always increase the chances of pregnancy before starting ART, however, there is also no evidence that surgery decreases chances of pregnancy. Surgery may be advised if you have significant pain or we are unable to reach your ovaries for egg collection or in cases of large endometriomas.

Can I conceive without any treatment after surgery?

Younger women with mild to minimal endometriosis may be a candidate for ‘watchful waiting’ after surgery for endometriosis. Approximately 40 % women may conceive in the first six months after laparoscopic excision of minimal or mild endometriosis.

As already mentioned, it’s a customized case-based treatment but, a woman’s age is an important factor in deciding the specific treatment. Women above 35 years have lower fertility so, decrease in fertility due to endometriosis and age becomes additive. This group of women may need aggressive fertility treatments. And in these cases women are advised to start immediate treatment as longer gap after surgery increases the chances of recurrence.

Women with moderate to severe endometriosis may also need aggressive fertility treatments.

What are different treatment modalities for endometriosis related infertility?

Your doctor may offer one of these treatment modalities depending on your requirements, age and extent of disease.

• Freezing your eggs: some doctors may recommend freezing of your eggs (for single women or embryos for married couples), in case you wish to become pregnant later as endometriosis decreases ovarian reserve.
• Superovulation and IUI – may be an option for women with mild endometriosis, with patent tubes, and partner has good quality sperms.
  • Fertility medications such as Letrozole and Clomiphene may be prescribed.
  • Regular ultrasounds to ensure egg maturity and timing of IUI.
• Advanced options such IVF, ICSI for moderate to severe endometriosis or women who have not responded to other treatments.

How can I improve my chances of getting pregnant with endometriosis?

It is important to live a healthy lifestyle which includes anti-inflammatory diet and pelvic exercises which helps by reducing inflammation in your body.

• Maintain a healthy weight
• Eating a well-balanced diet
• Moderate exercise

Fertility treatment success is age dependant. Higher fertility is seen in younger population, and women aged above 35 years are at greater risk of infertility as well as miscarriage.