Endometriosis and Fertility
What is Endometriosis?
Endometriosis is a medical condition where endometrial tissue (the lining of the uterus) is found growing in other areas of the pelvis. For some people, endometriosis can cause pelvic pain, especially during menstruation and can cause severe discomfort with sexual intercourse. The presence of abnormal menstrual pain may lead a physician to suspect endometriosis if the pain is worsening over the course of several months or years. During a pelvic exam endometriosis may sometimes be suspected by palpating tender nodules behind the uterus or by visualizing a persistent ovarian cyst on ultrasound that has certain echogenic characteristics (an “endometrioma”). Many times the only symptoms of endometriosis is infertility. The diagnosis can only be confirmed or excluded by undergoing a laparoscopy. Endometriosis is staged based on the depth of the lesions and the extent of the involvement of the pelvis. Stage 1 and 2 are termed “minimal” and “mild” endometriosis, while stages 3 and 4 are “moderate” and “severe” disease. The prevalence of endometriosis has been calculated to be 3-10% in the general population of reproductive age women. However, it is found in 40% of infertile patients.
How Endometriosis Affects Fertility
Many experts agree that endometriosis impairs infertility. One mechanisms for this effect is the inflammatory response incited by the endometriosis lesion. White blood cells, the warriors in the body’s defense system, try to eradicate the abnormally located endometrial tissue and release substances into the pelvic cavity which are toxic to sperm, eggs, and embryos. In addition, as the body tries to heal the inflamed areas it may inadvertently scar the fallopian tubes and/or ovaries causing them to adhere to other pelvic structures, and thereby interfere with the ability of the egg to reach the fallopian tube where fertilization can take place.
Gonadotropin Injection Superovulation
Another common method for treatment of infertility in patients with endometriosis who have at least one open fallopian tube is gonadotropin injection superovulation (e.g. hMG/FSH). Up to 3 months of such treatment is routinely offered. Studies have shown good pregnancy rates using this treatment for patients with mild to moderate endometriosis.
For patients who fail to conceive within one year of surgical ablation of moderate to severe endometriosis, the most successful therapy is In-Vitro Fertilization (IVF). A study that compared IVF to re-operation for endometriosis found that only 24% of the re-operated patient achieved a pregnancy by 9 months post operatively while 70% of the IVF patients were pregnant by their second cycle. IVF is the treatment of choice when tubal adhesions are present.
Treatment Options for Endometriosis
There are a number of treatment options for infertility attributable to endometriosis. The easiest treatment from the patient’s perspective is to have the endometriosis lesions surgically eradicated during the initial diagnostic laparoscopic procedure. Common methods to treat these lesions include laser vaporization, electrocautery and mechanical removal. In cases of moderate or severe endometriosis, it has been well established that surgical ablation of endometriosis lesions and adhesive scar tissue improves fertility by restoring the correct anatomical relationship of the fallopian tubes and the ovary. Even when the stage of endometriosis is only minimal or mild, improvement in fertility following the surgical ablation of these lesions has been demonstrated in a well controlled clinical trial reported in the New England Journal of Medicine in 1997. The additional use of medications such as Danazol, or a GnRH agonist such as Lupron or Synarel to suppress any residual endometriosis has been advocated by some. However, numerous studies have failed to show that these medication improve fertility rates beyond that of surgery along. This may be in part, due to the fact that patient’s must avoid becoming pregnant while on these medications. Yet the optimal time to achieve a pregnancy may be immediately following the surgery (when the fallopian tubes have just been flushed and before any scar tissue has had a chance to re-form). However, post- operative medication is sometimes recommended when pelvic pain is an overwhelming component of the disease, since medication can improve the chance of pain relief.