INFERTILITY AND ENDOMETRIOSIS
The relationship between endometriosis and infertility is like the one of the hen and the egg. There are two schools of thought. According to the first school, the woman developed endometriosis, because she did not became pregnant at a young age. The second school maintains that, even if a young woman wanted to get pregnant, she would encounter difficulties due to the endometriosis.
However, endometriosis is not synonymous to infertility. It is estimated that 60-70% of women with endometriosis are fertile. They can conceive naturally and give birth.
The severity of the disease affects the chances of pregnancy. Women with severe endometriosis find it more difficult to conceive, than those with mild disease. Those with mild disease have more difficulties in conceiving, than healthy women.
A percentage of women, with endometriosis related fertility problems, will get pregnant following medical interventions, either by surgery or by assisted reproduction (IVF or Intrauterine insemination).
Hormonal or complimentary medical treatments do not improve the chances of spontaneous pregnancy in women with endometriosis.
There is no evidence that women with endometriosis are at higher risk of fetal malformation.
It is not well understood how endometriosis can cause infertility, in the majority of cases.
It is easy to understand, when endometriosis is severe, because it causes anatomical damage to the reproductive organs. Significant adhesions may hinder the function of the tube. In cases of blocked tubes (hydrosalpinges), the sperm can not meet the egg to fertilize it.
Other theories have been suggested:
- Bad quality of the egg because of toxic actions of the endometriosis
- Various chemicals can impede the movement of the tube and the propulsion of the fertilized egg towards the uterus
- Inflammatory factors activate the white blood cells to attack the sperm
- The ovarian wall may thicken, subsequent to the endometriosis related inflammation, and the egg is trapped inside the ovary.
Surgical treatment increases the chances of natural conception
Many studies have shown that operative laparoscopy in women with endometriosis stage I and II (AFS) improves the chances of spontaneous conception, when the endometriotic implants are destroyed and the adhesions removed.
In cases with ovarian chocolate cysts (endometriomas), surgery improves pregnancy rates. The surgeon must be careful, to remove as little as possible normal healthy ovarian tissue, in order to preserve the ovarian reserves.
In cases of deep infiltrating endometriosis, there is no evidence that surgery increases the chances of spontaneous conception.
It is important not to delay a surgical intervention.
Medical adjuvant treatment prior or after surgery
There is no evidence, that medical adjuvant treatment prior or after surgery, increases the chances of conception in infertile women with endometriosis.
Assisted reproduction increases the chances of conception
In infertile women with endometriosis assisted reproduction increases the chances of conception. Medically assisted reproduction includes in vitro fertilization IVF and intrauterine insemination IUI.
The partner’s sperm is prepared with Percoll or swim up. These techniques select the best sperm. Then, the sperm is placed into the uterus via a fine catheter, during ovulation.
The cycle is monitored with transvaginal ultrasound scans and hormonal measurements. Gonadotrophins can also be used to increased the number of oocytes. When the follicles reach the size of 17mm or more, the oocytes are mature and the insemination takes place.
In women with minimal or mild endometriosis, intrauterine insemination with light stimulation of the ovaries with gonadotrophins, significantly improves the pregnancy rate.
Some studies have shown that after surgery, intrauterine insemination with light stimulation of the ovaries with gonadotrophins, significantly improves the pregnancy rate. This is also an option for women with a chocolate cyst or more advanced stages of the disease. However, in these the effectiveness of the technique is not well documented.
The pregnancy rates are higher after light stimulation of the ovaries compared to a natural cycle.
The administration of FSH (Gonal, Puregon, Follistim, Merional, Menopur, Altermon) is more effective than clomiphene citrate (Clomid, Serpaphar).
If you have not conceived after 3-4 inseminations, the chances of success are reduced and it is better to proceed to IVF without waisting time.
Intrauterine insemination is not option in the following cases
- Blocked tubes
- Severe male factor infertility
- When other treatments have failed
In these cases is better to proceed to IVF.
In Vitro Fertilization
A significant proportion of women with moderate to severe endometriosis will achieve a pregnancy only following IVF.
Women undergo controlled ovarian stimulation, to produce 8-10 eggs. The cycle is monitored with scans and hormonal measurements. The oocyte pick up is performed transvaginally, under ultrasound control, with light sedation.
The eggs are fertilized in a test tube (conventional IVF) or a sperm is injected into the egg, in cases of sperm problems (ICSI).
Egg collection is covered with prophylactic antibiotics, especially in women with chocolate cysts.
IVF seriously helps women with endometriosis to overcome their infertility and become pregnant.
Endometriosis recurrence is not more common after controlled ovarian stimulation.
Medical adjuvant treatment prior IVF
There is some evidence that, administration of GnRh analogues for 3-6 months prior to IVF, increases the chances of pregnancy, in women with endometriosis.
Surgical treatment prior to IVF
There is no strong proof that, surgical treatment prior to IVF increases the chances of pregnancy. The opposite is also true, that an operation will not reduce the chances of pregnancy. Your doctor might advise you, that you are better off having IVF after surgical treatment for endometriosis, in cases of pain or large cysts, when it is difficult to collect the eggs.
Removing deep infiltrating endometriosis prior to IVF, is not associated with higher success rates.
Success rates of IVF in women with endometriosis
It was widely believed for a long period of time, that the success rate of IVF in women with endometriosis was 30% lower, than those with tubal infertility.
Women with endometriosis respond less to the stimulation of the ovaries, they produce less oocytes and less embryos, than women with tubal infertility.
However, analysis of mega data of national IVF registries of many states, has shown that the results of IVF in women with endometriosis are better, than those with tubal disease. Hundreds of thousands of cycles were analyzed and the statistical power of the results is beyond doubt.
From my personal experience of 25 years as an IVF doctor, I have witnessed excellent IVF results in women with endometriosis.
Young women with stage 4 endometriosis, even if they do not produce many eggs, have excellent pregnancy rate.
As women get older, the influence of endometriosis is more marked.
Therefore the sooner a woman with endometriosis undergoes IVF, the higher the chances of a pregnancy.