Endometriosis is one of the most common causes of infertility. According to the ASRM, up to 50% of women experiencing infertility have endometriosis. The condition is diagnosed when there is evidence of normal endometrium (the tissue that lines the uterus and is shed each month during your period) in abnormal places.
Put most simply, endometriosis is the normal endometrium in an abnormal location. During a woman’s period, the endometrium is broken down and the uterus muscle contracts to squeeze the shedding endometrium and blood through the path of least resistance, which is usually through the cervix to the vagina. However, in women with endometriosis the uterus not only pushes the endometrium and blood through the cervix but also pushes some endometrium out through the Fallopian tubes into the pelvis, a process called retrograde menstruation. There are actually other ways to get endometriosis, such as through the lymphatic system, but retrograde menstruation is the leading cause.
Interestingly, retrograde menstruation happens to many women, but their bodies simply absorb the endometrium that lands in the pelvis without any issue. Unfortunately for women with endometriosis, the tissue isn’t absorbed and it can begin to cause problems – namely chronic pelvic pain and in fertility. Of women with chronic pelvic pain, more than 20% have endometriosis. Interestingly, 25% of women with endometriosis never experience any symptoms.
In the infertility world, we‘ve learned to acknowledge the red flag when a client comes to us with both a history of painful periods and difficulty getting pregnant. This usually means a diagnosis of endometriosis is on the horizon.
Currently, we aren’t sure why some women get endometriosis and other women do not. There is a noticeable genetic link in certain cases, but not always, so the definite cause remains a mystery.
Endometriosis is officially diagnosed in one of two ways. The first method uses vaginal ultrasound, which can reveal a cyst of endometriosis on the ovary, called an endometrioma. However, a woman can have endometriosis without any cysts on her ovaries. So, if her symptoms and/or medical history points towards endometriosis, outpatient laparoscopic surgery, performed via a small incision in the belly, is another official way to diagnose it.
During laparoscopy, the woman is asleep by the way, your surgeon can see implants of endometriosis in and around the pelvis with the scope. Implants of endometriosis can be on the ovary, cause kinking or blockage of the Fallopian tube, cause scarring and pain on the bowels, mimic an appendicitis or just about anything else in the abdomen or pelvis. If your surgeon visualizes endometriosis, he/she should be prepared to remove the endometriosis while you are under anesthesia and you are both in the operating room. This visual confirmation allows us to classify her endometriosis in one of four stages:
These stages correlate with fertility statistics. Keeping in mind that healthy couples have about a 20% chance of getting pregnant each month: women with Stage 2 (mild) endometriosis have about a 5% chance of getting pregnant each month, and that chance dips to 2% per month for women with a moderate to severe endometriosis diagnosis (Stage 3 or 4).
The goal of endometriosis surgery for infertility is to treat endometriosis and create a healthier reproductive tract and pelvis, with an added benefit to also decrease pelvic pain. Once that goal is accomplished, additional fertility therapy is often warranted to achieve pregnancy before new endometriosis has a chance to develop after surgery.
There are several known reasons why endometriosis can cause infertility.
Then, because endometriosis is still a bit of a mystery, there are cases where we simply don’t know why a minimal or mild case of endometriosis is affecting fertility, but we do our very best to work around it – or through it.
The methods used to treat endometriosis depend on a woman’s goal. For women who are not ready to get pregnant, a simple birth control pill prescription is often enough to regulate her cycle and eliminate the undesirable symptoms of pelvic pain. This treatment is important for young women who plan to get pregnant someday because the better they control endometriosis, the less likely it is that permanent scarring or anatomical distortions will occur. Other hormonal treatments with medications, such as depot Lupron, can be effective in decreasing pain. In extremely severe cases, a hysterectomy may be recommended. Of course, these treatments for pain are out of the question for women who want to get pregnant.
Pregnancy is one of the best remedies of all for women with endometriosis. It ensures you don’t have a period for nine months (that’s nine months of endometriosis-free life). Then, if you breastfeed (highly recommended), you can probably gain a few more period-free months.
There are two ways to increase your chances of fertility if you have endometriosis.
Have Surgery. Laparoscopic surgery may be sufficient in order to get pregnant without further assistance. Surgical removal of endometrioma cysts in the ovaries or scar tissue around the Fallopian tubes can be very effective to enhance fertility. Even if there is no distortion of the anatomy in the pelvis, removing implants of endometriosis throughout the pelvis reduces the volume of endometriosis, which in turn decreases inflammation in the pelvis, which in turn increases fertility. If there are cysts of endometriosis in the ovary your surgeon must be skilled to only remove the abnormal tissue and preserve all of the normal ovary. In other words, removing an entire ovary because there is a cyst of endometriosis may do more harm to your fertility compared no surgery. Keep in mind though, that every period you have after your surgery provides an opportunity for endometriosis to return and build up again. So, if you don’t get pregnant sooner, rather than later, you may need surgery again.
Use Fertility Medication. For younger women, we typically recommend pairing surgery with fertility meds, so you benefit from quicker conception and fewer periods. We also recommend moving to more aggressively with the meds. It’s a win-win. If you are older, we often recommend moving right to IVF because time is of the essence.
Proceed With In Vitro Fertilization (IVF). As mentioned above, women of advanced maternal age are advised to skip straight to IVF without spending valuable time, energy and money on treatments that may not work. For younger women, there’s a hot and heavy debate amongst fertility specialists as to whether or not patients should have surgery first and then schedule IVF, or whether they should proceed directly to IVF from the get-go.
The first school of thought is that the successful removal of endometrial tissue will reduce pelvic inflammation, increasing the chances for successful implantation of the transferred embryo. The second school points out that with surgery comes the risk of damage to adjacent normal ovarian, resulting in a decrease of eggs that are available during an IVF cycle.
Here at NCFMC, we make individual recommendations based on our patients’ symptoms and by what we can or cannot see via ultrasound. If we feel the cysts are minor enough that we can access the normal ovarian tissue during an IVF egg retrieval – and the patient’s pelvic pain is not an issue – we recommend IVF without surgery.
If, on the other hand, the endometrial cyst is so large that we have trouble seeing the normal ovary via ultrasound (which is necessary for retrieving the eggs), or if a patient is in severe pain, we recommend having surgery first and then proceeding with IVF.
In any case, the ultimate hope is that IVF will result in a live birth, which will provide patients with a year or more of being endometriosis-free (9 months of pregnancy + a few months without periods during breast feeding). We’ve found that timing a second child closely after the first increases a woman’s chances of experiencing natural conception if endometriosis was the cause of infertility.