Endometriosis and Fertility
I had never operated on such severe endometriosis cases as the ones I did with my mentor, Dr Farr Nezhat. Dr Nezhat is a pioneer in minimal invasive techniques and we received patients from all around the world to be treated by him in New York. He is the founder of EndoMarch, which is a world renowned walk. The reason: to create awareness about a frequently encountered pathology which has many victims suffering in silence.
What is Endometriosis?
Are they only strong colics with your period? Does it cure itself during pregnancy? Does it mean you can’t have babies? All of these are some erroneous concepts associated with the condition that I try to demistify in this article.
Endometriosis is one of the most common causes of chronic pelvic pain. It affects one out of every 10 women, but many don’t understand the symptoms, which makes it difficult to diagnose. In fact, the time from the beginning of symptoms to diagnosis can take even 6 years!
There is an important genetic factor, so, if your mother or sister have endometriosis, you have a higher chance of having it too. It is important to know that the symptoms can start at any age which means you are never too young to have endometriosis. Many times, the diagnosis is delayed due to the erroneous beliefs of family members that the patient is not the appropriate age or that severe menstrual pain is normal.
This brings me to the first question, What is Endometriosis?
- The cells of the internal part of the uterus (endometrium), should only exist in this area. However, in endometriosis they are implanted in other surfaces, such as ovaries, Fallopian tubes, the external part of the uterus, intestines, etc. Every month, when women with endometriosis get their periods, these tissues do what the are programmed to do, meaning expulsion of blood and inflammatory tissue such as in the uterus, but in the case of endometrial tissue outside of the uterus this stays inside the body and causes symptoms typical of endometriosis.
Like I mentioned, endometriosis can be implanted in many different places, which is why it shouldn’t be a surprise the wide variety of symptoms that are associated with the condition:
- Excessive and irregular mentrual blood, including spotting in between periods
- Painful periods
- Pain with sexual relations, before and/or after
- Pain during defecation (this could be only during your period) which can be confused with irritable bowel syndrome since it can present itself with diarrhea and/or constipation.
- Pain with urination during your period
- Pelvic pain, which can present as crampy pain, spasms or irritation of pelvic muscles and lower back
What is interesting about this condition is that women can have severe endometriosis and be asymptomatic and can have mild endometriosis and have severe pain or other symptoms.
Because of this fact it is common to see in the practice women with severe endometriosis which were never told they had the condition.
Effects of Endometriosis in Fertility
If endometriosis progresses without treatment, it can cause infertility by changing the architecture or even destroying your reproductive organs. This condition not only affects the structure, but chronic inflammation leads to negative effects on the quality and quantity of oocytes. It is common to see young patients in their 30s with endometriosis have oocytes that appear older.
In fact, women with infertility are 6-8 more times likely to have endometriosis. Although 30-40% of women with infertility have endometriosis, the majority of women with endometriosis do not suffer from infertility and it is possible for them to conceive naturally.
Studies indicate that treating endometriosis surgically can increase the chances of conceiving. Having said this, it is important to choose the patients that will benefit from surgery wisely. This should be reserved for patients that have pain and do not improve with conservative medical treatment. The reason is that there are multiple studies that indicate that performing endometriosis surgery in the ovaries to remove what are called endometriomas can reduce your ovarian reserve.
Therefore if you know that endometriosis is an inflammatory condition that affects the quality and quantity of oocytes (eggs in the ovaries) it is better to reserve surgery for selected patients as surgery can potentially worsen the situation.
There are medical treatments as simple as non steroidal antiinflammatories (ibuprofen, naproxen, etc) or hormonal (mostly contraceptives). There are also more complex treatments such as the newly approved Orilissa.
Being a condition that can easily progress despite adequate treatment, it is recommended to do egg freezing around age 30 if the patient does not have a stable partner to preserve the fertility and have a plan B. At this age, it is recommended to freeze at a minimum 15 oocyts.
In case of having infertility associated with endometriosis that is visible on ultrasound (advanced endometriosis) it can be recommended by your doctor to do in vitro fertilization to achieve pregnancy faster instead of performing surgery that can potentially worsen your chances to conceive naturally. During pregnancy, endometriosis symptoms tend to improve temporarily.
Endometriosis can have totally different presentations between patients which is why it is important to individualize the plan always taking into account the reproductive future of the woman. Also, it is important to take into account the partner, as endometriosis with or without infertility can affect both psychologically. Be sure to see a specialist with experience prior to submitting yourself to a surgical procedure or fertility treatments.