Endometriosis and Fertility

Endometriosis happens when the endometrial tissue that lines the uterine cavity grows outside of the womb. It affects 10% of women of reproductive age and can cause symptoms including infertility, pelvic pain, cramps, abnormal menstrual bleeding, pain with sex, pain with bowel movements, fatigue and bloating. However, many women who have endometriosis do not experience any symptoms.

Approximately 30% to 50% of women with endometriosis experience infertility. Because endometriosis does not cause symptoms other than infertility in many women, it is often first diagnosed during an infertility evaluation.

Endometriosis can cause fertility problems in many ways:

  • Adhesions and blockage of fallopian tubes: Adhesions are a type of scar tissue which distorts normal anatomy in the pelvis and can interfere with the egg and sperm meeting in the fallopian tube and/or subsequent transport of the embryo to the uterus.

  • Endometrioma cysts in the ovaries: can damage the ovary and interfere with ovulation

  • Egg quality and quantity: endometriosis is known to cause decreased egg quality and ovarian reserve by damaging the ovaries

  • Pain during sex: can reduce the frequency of intercourse. Most treatments for pelvic pain interfere with ovulation and therefore prevent pregnancy.

  • Inflammation: as the immune system attempts to clear endometriosis lesions in the pelvis there is chronic inflammation which can interfere with ovulation and embryo implantation

  • Progesterone receptors: found in the endometrium of endometriosis patients are altered and may affect embryo implantation

  • Adenomyosis: is when endometrial tissue grows into the muscle layers of the uterus, it is a similar condition to endometriosis and may co-occur in some patients.

  • Miscarriage: risk of miscarriage is increased by about 60% in women with endometriosis.

 Stages of Endometriosis

The severity and extent of endometriosis may be staged, usually following laparoscopic surgery.

Generally, women with minimal or mild (stage 1 or 2) endometriosis are more likely to conceive than women with moderate and severe (stage 3 or 4) disease. Women with more extensive endometriosis may benefit from starting with more advanced fertility treatments.

Natural Fertility

Most women diagnosed with endometriosis can try to conceive naturally for six months before seeing a fertility doctor. However, women older than 35 years and those with more advanced endometriosis stages which may affect the fallopian tubes should see a fertility specialist earlier.  

Fertility Treatment Options

The most effective treatment for endometriosis-related infertility depends on female age, the stage of disease, and ovarian reserve.

Intrauterine Insemination (IUI)

Intrauterine Insemination (IUI) is often coupled with fertility medication which induces ovulation of two to three eggs and can be attempted in women with minimal or mild endometriosis. During the IUI procedure sperm is injected into the womb just prior to ovulation.

Clomid (clomiphene), Femara (letrozole and injectable gonadotropins are the most common fertility medications used during IUI cycles. Most pregnancies with IUI happen in the first three to four cycles.

Learn more about IUI: https://www.westcoastfertility.com/intrauterine-insemination-iui

In Vitro Fertilization (IVF)

In vitro fertilization (IVF) involves stimulating the ovaries with fertility medications, retrieving eggs, fertilizing them in the laboratory, then transferring embryo(s) into the womb.

IVF is considered the first-line treatment for women aged over 35, those with moderate or severe endometriosis, and those with low ovarian reserve.

IVF success rates in women with endometriosis are similar to those in women with unexplained infertility. However, women who have endometriosis and low ovarian reserve generally achieve somewhat lower live birth rates.

Special monitoring may be required because fertility medications can temporarily trigger symptoms of endometriosis.  Endometriosis symptoms generally improve during pregnancy.

Learn more about IVF: https://www.westcoastfertility.com/in-vitro-fertilization

Surgery

Surgery is often performed to confirm the diagnosis of endometriosis and to treat pain. Surgery may also help increase the chances of pregnancy in some patients with mild and moderate endometriosis.  For women with severe endometriosis, surgery generally does not improve the success rates of IUI or IVF.

Laparoscopy is a minimally invasive approach used to diagnose and remove endometriosis. This procedure is performed under general anesthesia. The abdomen is first inflated with air, then the surgeon makes several small incisions to insert a laparoscopic camera and surgical instruments. Endometriosis lesions and scar tissue are then gently removed. Following surgery, several months of healing are generally advised before starting other fertility treatments.

Surgery can have complications including new adhesions that make pregnancy more difficult. Additionally, excising endometrioma cysts from the ovaries can damage surrounding healthy tissue and further lower the ovarian reserve. Therefore, great caution is advised in women who are seeking pregnancy and are considering surgery for endometriosis. Surgery is best performed by highly experienced gynecologic surgeons who specialized in minimally invasive surgery for endometriosis. Young women who have endometrioma cysts may consider egg and embryo freezing prior to undergoing surgery on their ovaries.  

For most infertility patients the risks of surgery outweigh the potential benefits.  Patients are advised to consult about the pros and cons with a surgeon and a fertility specialist to make a fully informed decision.

Summary

Endometriosis can contribute to infertility by multiple mechanisms including poor egg quality, pelvic adhesions, and ovarian cysts that interfere with normal fertilization and implantation.

Based on factors such as age, ovarian reserve, and the stage of endometriosis a fertility specialist may advise you to try getting pregnant naturally for up to six months. Fertility treatments such as IUI and IVF help many patients to achieve a pregnancy. Laparoscopic surgery for endometriosis may improve pelvic pain and fertility in some patients but carries risks.