Endometriosis and infertility: The link established
THIRUVANANTHAPURAM: Endometriosis is a very common debilitating disease that occurs in 6 to 10% of the general female population; in women with pain, infertility, or both, the frequency is 35–50%. About 25 to 50% of infertile women have endometriosis, and 30 to 50% of women with endometriosis are infertile.
Endometriosis is defined as the presence of endometrial-like tissue (glands and stroma) outside the uterus, which induces a chronic inflammatory reaction, scar tissue, and adhesions that may distort a woman’s pelvic anatomy.
Endometriosis is often seen as a reproductive disease and while endometriosis can impact the ovaries, uterus and fallopian tubes, it can also be found on the bowels, bladder, appendix as well as other organs.
In rare cases, the disease can be found in distal sites such as the lungs. Endometriosis is primarily found in young women, but its occurrence is not related to ethnic or social group distinctions.
Symptoms of endometriosis
- Painful cramps during menstruation (dysmenorrhea)
- Pain during intercourse (dyspareunia)
- Pain with ovulation
- Urinary symptoms, such as frequent urination, especially around the time of menses
- Bowel symptoms, such as pain with bowel movements, constipation or diarrhoea, especially around the time of menses
- Lower back pain or leg pain, especially around the time of menses
- Fatigue
- Infertility
The associated symptoms can impact the patient’s general physical, mental, and social well being.
How does endometriosis affect fertility?
Endometriosis can affect fertility in a number of ways. Most obviously, as the disease progresses and pelvic damage increases to organs such as the Fallopian tubes through distortion or adhesions, the passage of sperm and eggs through the pelvis will be increasingly impaired. Similarly, there appears to be a change in the pelvic environment, most likely resulting from the endometriosis-related inflammation. These inflammatory substances and cells impair the function of both eggs and sperm, fertilization, embryo development and implantation. There is also increasing evidence that the quality and quantity of eggs in women with endometriosis is affected, though it is not certain whether this is a direct effect of the disease. Egg quantity (the ovarian reserve) can be measured through a pelvic ultrasound or a blood test, called an AMH.
While it makes sense that endometriosis in the ovary can have this effect, the current evidence points to a reduction in egg numbers and quality even if the disease is outside of the ovary. Similarly, the current evidence suggests that the uterus in women with endometriosis seems to function differently. There appears to be a reduction in implantation and potentially also an increased chance of miscarriage in women with endometriosis.
Some of the treatments for endometriosis, whether they be medical or surgical, can also affect fertility. Almost all medical treatments for endometriosis will interfere with ovulation and therefore stop you from falling pregnant while you are on this treatment. While none of these treatments has long-term effects on fertility, any delay in conception, particularly over the age of 35, will naturally reduce the chances of conception.
Finally, but most importantly, the pain associated with endometriosis can affect all aspects of relationships, whether directly related to sex or not. Women with endometriosis are more likely to report an altered body image, describe reduced desire, arousal and pain. From a woman’s perspective, endometriosis is a disease surrounded by taboos, myths, delayed diagnosis, hit-and-miss treatments, and a lack of awareness, overlaid on a wide variety of symptoms that embody a stubborn, frustrating and, for many, painfully chronic condition. It affects these women and girls during the prime of their lives. These individuals’ physical, mental, and social well-being is impacted by the disease, potentially affecting their ability to finish an education, maintain a career, with a consequent effect on their relationships, social activities, and in some cases fertility.
Endometriosis can only be diagnosed through laparoscopy and confirmation of the disease can be achieved through pathological biopsy.
Treatment of endometriosis
Endometriosis should be viewed as a chronic disease characterized by pelvic pain and associated with infertility. It requires a life-long personalized management plan with the goal of maximizing medical treatment and avoiding repeated surgical procedures.
The treatment for endometriosis is essentially chosen by each individual woman, depending on symptoms, age, and fertility. For many women, adequate treatment requires a combination of treatments given over their lifetime. The current treatments include medical, surgical, or a combination of these approaches.
Effective, evidence-based treatments of endometriosis-associated infertility include conservative surgical therapy and assisted reproductive technologies. Patients with endometriosis who are interested in fertility may gain limited benefits for medical therapy. Although theoretically advantageous, there is no evidence that the combination of medical and surgical treatments can significantly enhance fertility, and it may unnecessarily delay further fertility therapy.
The two treatment options of choice, in this case, include surgery or in vitro fertilization and embryo transfer. However, the management of endometriosis, especially the more severe/advanced forms, requires a multidisciplinary approach.
Endometriosis is a disease which is rooted in very real, highly complex hereditary, epigenetic, and molecular underpinnings – a truly multi-factorial, physiological disease. Women with endometriosis may struggle with the emotional distress brought on by the unrelenting symptoms of pain and infertility and a multidisciplinary approach with psychological support is essential for these women.
Dr Sneha Ann Abraham
Infertility Specialist
KIMS Hospital
Thiruvananthapuram
(The views expressed by the author are her own)