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Endometriosis and Your Fertility
a blog by David Kreiner, M.D., F.A.C.O.G.
I don’t have to tell you that endometriosis can be a very painful illness and that it can cause infertility. It is often a reproductive lifelong struggle in which tissue that normally lines the uterus migrates or implants into other parts of the body, most often in the pelvic lining and ovaries. This leads to pain and swelling and often times difficulty conceiving.
If you have endometiosis, you are not alone. Five to ten percent of all women have it. Though many of these women are not infertile, among patients who have infertility, about 30 percent have endometriosis.
Endometriosis can grow like a weed in a garden, irritating the local lining of the pelvic cavity and attaching itself to the ovaries and bowels. Scar tissue often forms where it grows, which can exacerbate the pain and increase the likelihood of infertility. The only way to be sure a woman has endometriosis is to perform a surgical procedure called laparoscopy which allows your physician to look inside the abdominal cavity with a narrow tubular scope. He may be suspicious that you have endometriosis based on your history of very painful menstrual cycles, painful intercourse, etc., or based on your physical examination or ultrasound findings. On an ultrasound, a cyst of endometriosis has a characteristic homogenous appearance showing echoes in the cyst that distinguish it from a normal ovarian follicle. Unlike the corpus luteum (ovulated follicle), its edges are round as opposed to collapsed and irregular in the corpus luteum and the cyst persists after a menses where corpora lutea will resolve each month.
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. Patients with mild endometriosis will not have a cyst and will have no physical findings on exam or ultrasound. It is thought that infertility caused by mild disease may be chemical in nature perhaps affecting sperm motility, fertilization, embryo development or even implantation perhaps mediated through an autoimmune response.
Moderate and severe endometriosis are, on the other hand, associated with ovarian cysts of endometriosis which contain old blood which turns brown and has the appearance of chocolate. These endometriomata (so called “chocolate cysts”) cause pelvic scarring and distortion of pelvic anatomy. The tubes can become damaged or blocked and the ovaries may become adherent to the uterus, bowel or pelvic side wall. Any of these anatomic distortions can result in infertility. In some cases the tissue including the eggs in the ovaries can be damaged, resulting in diminished ovarian reserve and reduced egg quantity and quality.
The treatment for endometriosis associated with infertility needs to be individualized for each woman. Surgery often provides temporary relief and can improve fertility but rarely is successful in permanently eliminating the endometriosis which typically returns one to two years after resection.
There are no easy answers, and treatment decisions depend on factors such as the severity of the disease and its location in the pelvis, the woman's age, length of infertility, and the presence of pain or other symptoms.
Treatment for Mild Endometriosis
Medical (drug) treatment can suppress endometriosis and relieve the associated pain in many women. Surgical removal of lesions by laparoscopy might also reduce the pain temporarily.
However, several well-controlled studies have shown that neither medical nor surgical treatment for mild endometriosis will improve pregnancy rates for infertile women as compared to expectant management (no treatment). For treatment of infertility associated with mild to moderate endometriosis, ovulation induction with intrauterine insemination (IUI) has a reasonable chance to result in pregnancy if no other infertility factors are present. If this is not effective after about three - six cycles (maximum), then I would recommend proceeding with in vitro fertilization (IVF).
Treatment for Severe Endometriosis
Several studies have shown that medical treatment for severe endometriosis does not improve pregnancy rates for infertile women. Some studies have shown that surgical treatment of severe endometriosis does improve the chances for pregnancy as compared to no treatment. However, the pregnancy rates remain low after surgery, perhaps no better than two percent per month.
Some physicians advocate medical suppression with a GnRH-agonist such as Lupron for up to six months after surgery for severe endometriosis before attempting conception. Although at least one published study found this to improve pregnancy rates as compared to surgery alone, other studies have shown it to be of no benefit. The older a patient is, the more problematic post surgical treatment with Lupron will be as it delays a woman’s attempt to conceive until she is even older and less fertile due to aging.
Unfortunately, the infertility in women with severe endometriosis is often resistant to treatment with ovarian stimulation plus IUI as the pelvic anatomy is very distorted. These women will often require IVF in order to conceive.
As endometriosis is a progressive destructive disorder that will lead to diminished ovarian reserve if left unchecked, it is vital to undergo a regular fertility screen annually and to consider moving up your plans to start a family before your ovaries become too egg depleted. When ready to conceive, I recommend that you proceed aggressively to the most effective and efficient therapy possible.
Women with endometriosis and infertility are unfortunately in a race to get pregnant before the endometriosis destroys too much ovarian tissue and achieving a pregnancy with their own eggs becomes impossible. However, if you are proactive and do not significantly delay in aggressively proceeding with your family building, then I have every expectation that you will be successful in your efforts to become a mom.