Does Endometriosis Cause Infertility?

Does Endometriosis Cause Infertility?

Endometriosis In Infertile Women

Endometriosis, a disease in which endometrial tissue that normally lines the inside of the uterus — the endometrium — grows outside the uterus throughout the pelvis, most commonly involving the ovaries, fallopian tubes and the tissue lining the pelvis. Rarely, endometrial tissue may spread beyond pelvic organs.

Although endometriosis negatively impacts fertility it does not usually completely prevent pregnancy.

Fortunately, effective treatments are available. A combination of surgery, ovulation induction with intrauterine insemination, and in vitro fertilisation (IVF) treatment can help women with endometriosis to conceive.

How many women have endometriosis?

Endometriosis is the second most common gynaecological disease after fibroids. Endometriosis has been estimated to affect 10 to 15 percent of women of reproductive age (ages between 15 to 49). Infertile women are 6 to 8 times more likely to have endometriosis than fertile women. Of women with endometriosis, 30 to 50 percent are estimated to have infertility.

What are the symptoms of endometriosis?

The most common symptoms of endometriosis are pain, especially during menstrual periods and sexual intercourse and infertility. However, 20–25% of patients have no symptom. The severity of endometriosis symptoms increases with age, the incidence peaks in women in their 40s. The symptoms of endometriosis do not always correlate with its laparoscopic appearance.

Endometriosis: Who Is at Risk?

Endometriosis is more common in women who:

  • Trouble getting pregnant,
  • Are in their 30s and 40s,
  • Periods with heavy bleeding,
  • Have periods longer than 7 days,
  • Have cycles shorter than 28 days,
  • Started their period before age 12,
  • Have a mother or sister who had endometriosis,
  • Pain in pelvis and a heavy feeling in the lumbo-sacral column and/or legs usually worse during a period,
  • Pain/cramping during or after sexual intercourse,
  • Any cyclical pain affecting other organs, haemoptysis (the spitting of blood that originated in the lungs or bronchial tubes),scapular or thoracic pain, and acute abdomen,
  • Nausea,
  • Lethargy, chronic fatigue,
  • Pain with bowel movements or urination. It may be difficult to differentiate the diagnosis of pelvic pain due to endometriosis from that due to irritable bowel syndrome (IBS),interstitial cystitis, fibromyalgia, and others.

Can endometriosis be mistaken for fibroids?

The symptoms of endometriosis can be like the symptoms of uterine fibroids and are often difficult to distinguish. Severe menstrual pain, severe cramps and heavier bleeding during periods can be caused by endometriosis, as well as fibroids, that are benign growths of smooth muscle tissue of the womb. Also, endometriosis and uterine fibroids can occur together and can both negatively affect fertility.

What Causes Endometriosis?

The reason why endometrial tissue grows outside of the uterus is not known, but there are several theories. Genetic factors and heredity may play a role on the development of endometriosis. One of the theories is that menstrual blood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity. Cells could also move to the pelvic cavity other ways, such as during a cesarean section delivery.

How endometriosis cause infertility?

Although it is known that endometriosis reduces the chance of conception, the mechanisms by which endometriosis causes infertility are not fully understood, but it probably depends partly on the stage of the disease. While mild disease causes inflammatory processes, advanced disease causes anatomical disruption in addition to this inflammatory response. The inflammatory process impairs ovarian, peritoneal, tubal, and endometrial function, and leads to defective egg production, fertilization, and/or implantation.

What is an endometrioma (chocolate cyst)?

Endometrioma is the formation of a cyst within the ovary with ectopic endometrial tissue lining. They are called chocolate cysts because their dark brown, tarry appearance that looks like melted chocolate is likened to chocolate. This is one of the most common manifestations of endometriosis.

What does the Endometriosis Stages Mean?

Endometriosis is surgically staged based on intraoperative disease findings using the American Society of Reproductive Medicine (rASRM) staging system.

Endometriosis is classified into one of four stages (I-minimal, II-mild, III-moderate, and IV-severe) based upon the location, extent, and depth of the endometriosis implants, presence and severity of ovarian adhesions and tubal adhesions and the presence and size of endometrial implants in the ovaries (endometrioma- Large, fluid-filled "chocolate" cysts that form on, and even encapsulate, the ovaries).

What are the stages of endometriosis?

  • Stage I-minimal endometriosis: 1-5 points. Minimal presence of ectopic tissue, the implants are small (1-5 mm) and may be identified during an infertility evaluation, it is uncertain if early-stage disease is the cause of infertility in these women.
  • Stage II-mild endometriosis: 6-15 points. The implants are more, and they are deeper than in Stage I.
  • Stage III-moderate endometriosis: 16-40 points. There are many deep endometrial implants and endometrioma-chocolate cyst in at least one of the ovaries.
  • Stage IV–Advanced disease or severe endometriosis: > 40 points. This is the most widespread form and is associated with distorted pelvic anatomy and adhesions (deep ovarian endometriomas, major pelvic adhesions with obliteration of normal pelvic organ relationships).

The changes in stage III and IV can impair oocyte release or pick-up, alter sperm motility, cause disordered myometrial contractions, and impair fertilization and embryo transport. The chemical and immunologic mechanisms likely contribute as well.

They may also negatively impact the ovarian follicles. Compared with women who have mild endometriosis or tubal factor infertility, women with advanced endometriosis have abnormal follicle development and reduced fertilization potential of oocytes.

How is endometriosis treated?

The right treatment to be chosen for you may differ depending on your symptoms and whether you want to become pregnant or not. Endometriosis can be treated in different ways.

Pain killers – These medicines can relieve the pain caused by endometriosis temporarily but do not eliminate endometriosis implants.

Birth control pills – They can help to reduce pain symptoms, but you cannot use if you are trying to get pregnant.

Medicines that stop monthly periods – hormone therapy with agents such as danazol or gonadotropin-releasing hormone agonists for suppression of endometriosis does not improve fertility or pregnancy rates but only relieves pain and suppress endometriotic implants.

Surgery: In women who do not relieve with these medications or who choose to have surgery to treat endometriosis different options of surgery can be offered.

  • Laparoscopy –Endometriosis implants or ovarian endometrioma (chocolate cyst) can either be to resected or ablated.
  • Hysterectomy – If no other treatments work hysterectomy-surgery to remove the uterus can be considered. Sometimes, the ovaries and fallopian tubes can also be removed.

Can a woman with endometriosis get pregnant?

Infertility may be caused by endometriosis alone or endometriosis combined with other factors, both male and female. After infertility evaluation if performing primary surgery for staging and treatment of endometriosis or repeat surgery to treat pain symptoms are needed or not decided. Choice of infertility therapy is based on the combination of findings from the infertility evaluation and surgical staging.

Endometriosis is a chronic disease that requires life-long management with the goal of maximizing medical treatment and avoiding repeated surgery. Primary laparoscopic surgery is indicated for staging and treating of endometriosis, improving fertility, and reducing pain. Indications for repeat surgical treatment are mainly severe recurrent pain symptoms that impair quality of life or treatment of a symptomatic endometrioma. Repeat surgery does not improve fertility.

How is infertility is treated in women with endometriosis?

Infertility therapy is guided by the combination of findings from the infertility evaluation, the symptoms of the woman and surgical staging of endometriosis as well as patient age.

In infertile women with symptoms suggestive of endometriosis:

  • In women with symptoms suggestive of endometriosis such as pain, dysmenorrhea, dyspareunia etc. operative laparoscopy improves pregnancy rates and reduce pain symptoms.
  • In women who have previously undergone primary surgical treatment of endometriosis, repeating surgery for the treatment of infertility does not improve fertility, although it can reduce pain.

In infertile women with no symptoms suggestive of endometriosis:

  • For infertile women with endometriosis who have no symptoms surgical treatment to improve fertility is not indicated, even if the endometriosis has not been previously removed.
  • In women with infertility and an asymptomatic presumed endometrioma, IVF treatment and observation of the endometrioma rather than surgical removal is recommended.

In women with no other infertility factors (normal fallopian tubes and whose partner has normal sperm):

  • Women with minimal to mild endometriosis (Stage I/II),and age younger than 35 years and who desire a trial of natural conception, six months of timed intercourse is advised. If conception does not occur within six months, then ovulation induction with clomiphene citrate and intrauterine insemination IUI is offered.
  • For women ≥35 years of age with Stage I/II endometriosis IVF treatment is recommended as it shortens time to pregnancy and offers the option of freezing excess embryos for future use. If IVF treatment is not possible (e.g., financial restraints) then three to five cycles of clomiphene or an aromatase inhibitor such as letrozole with IUI can be offered.
  • Women and/or those with advanced endometriosis (Stage III/IV) including those with endometriomas benefit from IVF treatment.

In women with other infertility factors: Women with other infertility factors as significant male factor component, decreased ovarian reserve are offered IVF treatment.

What is the impact of endometriosis on IVF outcomes?

IVF is commonly the primary option to be considered in women whose infertility is associated with endometriosis and whose ovarian reserve is compromised and/or who are over 35 years of age.

Mild endometriosis (i.e., Stage I/II disease) does not appear to negatively impact IVF results. Stage III/IV disease negatively impacts outcomes probably related to be decreased ovarian reserve. The impact of diminished ovarian reserve becomes more pronounced in women of older age whose declining egg quality is associated with greater embryo aneuploidy.

Younger patients with an impairment of the ovarian reserve due to severe endometriosis, have diminished oocyte yield but not a reduction in embryo quality and pregnancy outcomes. The serum AMH levels should not be adopted as a criterion for discouraging these patients from undergoing IVF/ICSI treatments.

Does endometrioma effect IVF outcome?

Women with endometrioma undergoing IVF have similar IVF outcomes compared with those without the disease, although their ovarian reserve is reduced, and cycle cancellation rate is higher.

Surgical treatment of endometrioma do not alter the outcome of IVF treatment compared with those who did not receive surgical intervention. Surgical intervention may have potential detrimental impact on ovarian reserve.

Fertility Preservation in Women with Endometriosis

As endometriosis can be associated with ovarian depletion and infertility, fertility preservation therapies such as embryo, oocyte, and ovarian tissue freezing have been proposed for women diagnosed with endometriosis.

Women who may benefit from this approach include those with bilateral endometriomas, prior ovarian surgery, and young age at diagnosis.

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