Endometriosis And Infertility

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Endometriosis is a debilitating and chronic condition in which tissue similar to the lining of the uterus grows outside of uterus, affecting an estimated 10% of reproductive-aged women. It is also a major cause of infertility, affecting up to 50% of women with endometriosis.

In this write-up, we will help you know how endometriosis may affect fertility, the ways it can affect natural conception, the possible treatment options at all the three stages of endometriosis and also what you should do next!.

Let’s delve more deeper into endometriosis and infertility!

Endometriosis affects mainly the reproductive age group (3-10%) and even commoner in the infertility population (20-40%). The presence of endometrial cells outside of the uterus, known as endometriosis, can cause pain and infertility.

There are main 3 theories to explain how the disease develops.

  • 01
    The most accepted one is the retrograde flow of the menstrual debris, cells and blood into the abdomen and pelvis through the fallopian tubes.
  • 02
    Genetics play a role in the development of endometriosis, because first degree relatives of affected women are at 6-7 times greater risk of developing endometriosis compared to the general population.
  • 03
    Endometriosis is associated with a dysfunction in the immune system. Impaired immune response in few women may result in ineffective removal of the endometrial cells from the pelvic area that may result in endometriosis. A number of substances are involves in the pathophysiology of the disease such as cytokines,interleukins, TNF and natural killer cells which produce inflammation, scarring and cause fibrosis and adhesions.

Symptoms:

  • 01
    Endometriosis cause pain by involving the surrounding organs and cause inflammation, bleeding and scarring of lesions.Pain can be associated with menses(dysmenorrhea) and/or intercourse(dyspareunia). Pain can be intermittent or continuous (chronic pelvic pain) depending on the extent and the location of the disease.
  • 02
    Endometriosis causes infertility by disturbing tubal and ovarian anatomy that may result in the prevention of egg catching by the fallopian tubes. It may interfere with egg quality and embryo development as well as affect implantation by changing the endometrial receptivity.
  • 03
    It causes dyschezia, IBS, rectal bleeding during menses, altered bowel habits.
  • 04
    If it involves distal organs like lungs then cause catamenial hemoptysis, shoulder tip pain.

Clinical diagnosis of endometriosis is based on the presence of pelvic pain spectrum that can present as excessive menstrual pain, pain during intercourse and pain that’s radiating in thighs ,buttocks or legs. It can be dull and sometimes deep and aching. Rarely it leads to nausea and vomiting as well. When it involves bowels then patients can present with irritable bowel symptoms, dyschezia, catamenial rectal bleeding and painful bowel movements due to narrowing of bowel lumen. Surprisingly, severity of the disease does not correlate with symptoms, patients with advanced disease may not have any symptoms, while those with mild disease may have excruciating pain.

Physical examination may reveal certain findings that may suggestive of the disease. In most cases, the diagnosis of endometriosis is made by exclusion of other causes of pelvic pain. Surgical diagnosis is the gold standard which include confirming the lesions that are typical for endometriosis or taking the biopsy.

Pelvic ultrasound or MRI (Magnetic Resonance Imaging) can identify the staging of disease.

Endometriosis is classified into four stages (I-IV) based on the severity of the lesions and adhesions (scarring), which can only be determined by surgery, mainly laparoscopy. Stage I-II are defined as minimal-mild endometriosis and stages III-IV are moderate-severe.

Once the diagnosis of endometriosis is confirmed either clinically or surgically, the treatment options depend on the desire to become pregnant or not. If pregnancy is not planned and the main complaint is pain, medical treatment is typically used as the first line management.

Medical treatment of endometriosis has concentrated to suppress the growth of old and prevent the development of new lesions. Some of these medications are progesterone, birth control pills (BCP) and GnRH agonists (i.e. Lupron type drugs). These drugs are equally effective, as they all have benefits and side effects.

Surgical treatment of endometriosis can be the first option in cases of severe pain that is not responsive to medical treatment, presence of chocolate cysts in the ovaries (endometriomas), presence of tubal blockage and adhesions with distortion of pelvic anatomy and when atypical symptoms are present in adjacent organs from endometriosis.

Endometriotic lesions can be removed completely by surgery or ablated depending on the location, depth of invasion and severity. Adhesions (scarring) can be treated during surgery (mostly laparoscopy) and tubal and ovarian anatomy can be restored back to normal. Endometriomas (endometriosis cysts) can be removed completely with the surgical treatment specifically if they are more than 5 cm in size.

Surgical treatment of endometriosis has been shown to improve both pain symptoms and fertility potential. Patients can achieve a spontaneous pregnancy within the first year after surgical treatment and those who do not become pregnant in 1st year of surgery may need IVF treatment.

In patients who have severe endometriosis and completed family and not been responsive to medical management, removal of the uterus, both ovaries and the fallopian tubes, and all visible endometriotic lesions is the definitive treatment and effective in controlling pain more than 90% of the time.

In vitro fertilization (IVF) is an effective treatment option for patients with all stages of endometriosis and results in the highest success rate compared to natural conception. Women with advanced endometriosis involving ovaries have decreased ovarian reserve and IVF becomes the best and sometimes the only option to achieve a pregnancy.

Patients with endometriosis have a lower success rate overall with IVF treatment compared to patients with infertility caused by tubal disease, and severity also plays a significant role in the final outcome with IVF treatment.

Regardless of the patient’s age or the stage of the disease, it is reasonable to advise patients with endometriosis not to put off getting pregnant until later in their reproductive years. It is also highly recommended to seek expert opinion from our infertility specialist, Dr. Ripal Madnani when future fertility is desired in all women with endometriosis.

Endometriosis can affect the fertility of a woman in different ways. The most common way is by causing damage to the reproductive organs, leading to scarring, adhesions, and inflammation that can interfere with the quality of eggs, the release of an egg, the ability of the sperm to reach the egg, and placing the fertilised egg in the uterus. This damage can also lead to blocked or damaged fallopian tubes, which are mandatory for the fertilization of the egg by the sperm. Additionally, endometriosis can cause hormonal imbalances that hinder ovulation and escalate the risk of miscarriage.

Endometriosis can affect the natural conception in several ways. Endometriosis can cause pain during sex, a condition called dyspareunia making it difficult to have regular sex. It can cause irregular menstrual cycles, making it harder to decide the optimal time for conception. In some cases, endometriosis can cause a decrease in the number and quality of eggs by releasing harmful substances, further reducing the chances of natural conception.

Moreover, Endometriosis can lead to the formation of ovarian cysts, which can damage the ovarian tissue and affect the production of eggs. This can also reduce the number and quality of eggs available for fertilization, which can reduce the chances of natural conception.

The severity of endometriosis is often classified based on the extent and severity of the tissue growth. Here are some options available for minimal, mild to moderate, and severe endometriosis.

Minimal endometriosis:

Minimal endometriosis is the mildest form of endometriosis, in which there are only a few small patches or vesicles of endometrial tissue outside of the uterus. Women with minimal endometriosis may not feel any symptoms, and the condition may be explored by chance during a pelvic Laparoscopy or ultrasound

  • 01In most cases, women with minimal endometriosis can still conceive naturally without any intervention. However, if they are facing infertility, there are various treatment options available.
  • 02One option is to use fertility medications such as clomiphene citrate or letrozole, which can stimulate ovulation and improve the chances of conception. These medications can be used in combination with planned intercourse or intrauterine insemination (IUI), in which sperm are directly placed into the uterus (if the tubes are open) to increase the chances of insemination.
  • 03Other option is laparoscopic surgery, which can be used to remove any endometrial tissue outside of the uterus. This can reduce inflammation and scarring, and may increase the chances of conception.
  • 04Basically, women with minimal endometriosis have good chances of conceiving naturally or with minimal intervention. However, if they are facing infertility, they should put heads together with a fertility specialist to choose the best course of action.

Mild to moderate endometriosis:

In this stage, the endometrial tissue growth is more extensive and may be causing mild to moderate pain and discomfort. There are several options to treat moderate endometriosis, which has not yet caused severe scarring or organ damage. The treatment options include:

  • 01

    Pain Management:

    Pain management is often the first preferred treatment for endometriosis if it is a chief complaint. Over-the-counter pain relievers like ibuprofen or naproxen can help reduce the mild to moderate pain. If the pain is more severe, stronger prescription pain medications may be required.

  • 02

    Hormonal Therapy:

    Hormonal therapy can help to control the symptoms of endometriosis and fall-off the growth of endometrial tissue. This includes birth control pills, progestin-only pills, or a hormonal intrauterine device (IUD). Gonadotropin-releasing hormone (GnRH) agonists, which put down the estrogen production, can also be used to shrink endometrial tissue. This option can be suggested if fertility is not the main concern.

  • 03

    Laparoscopic Surgery:

    Laparoscopic surgery is a minimally invasive surgical procedure. It can be used to remove endometrial tissue, scar tissue, or adhesions. This surgery can be helpful for women who experience severe pain or infertility due to endometriosis.

  • 04

    Fertility Treatment:

    Women with mild to moderate endometriosis who have problem conceiving may take advantage of fertility treatments such as superovulation with intrauterine insemination (IUI) or in vitro fertilization (IVF). Fertility treatments can help to bypass any blockages or damage to the reproductive organs caused by endometriosis.

Severe endometriosis:

In this stage, the endometrial tissue growth is extensive and may be causing extreme pain, discomfort, and other symptoms. Treatment options may include:

  • 01

    LAPEX Laparoscopic Excision Surgery for Endometriosis:

    LAPEX is the best option to treat Severe Endometriosis. This minimally invasive surgical procedure includes removing all visible endometrial tissue, nodules, scar tissue, and adhesions from the affected areas.During laparoscopic excision surgery, the surgeon will then carefully remove the endometrial tissue, adhesions, and any other affected tissue.

Laparoscopic excision surgery has been shown to be effective in reducing pain and improving fertility outcomes in women with extreme levels of endometriosis. In fact, some research has shown that women who undergo laparoscopic excision surgery have higher rates of conception than those who undergo other types of surgery or medical treatments.

The decision whether to pursue natural conception or in vitro fertilization (IVF) will depend on various factors, involving the severity of the endometriosis, the woman’s age, and the presence of any other fertility factors.

For women with mild or moderate endometriosis, natural conception is still an option although it may take longer and require more monitoring to achieve pregnancy. In these cases, fertility treatments such as intrauterine insemination (IUI) may be offered to increase the chances of conception.

For women with severe endometriosis, usually the IVF is considered the best option. IVF includes retrieving eggs from the ovaries and fertilizing them with sperm in a laboratory setting. The resulting embryos are then implanted back into the woman’s uterus. IVF can be helpful for women with severe endometriosis because it bypasses any blockages or damage to the reproductive organs caused by endometriosis. It also allows for more precise control over the timing of conception and can increase the chances of success.

Meet our IVF specialist in Abu Dhabi, Dr Ripal Madnani, who stays with you throughout your journey to parenthood! Book Your Appointment Now

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