Endometriosis is one of the most common gynaecological conditions affecting 6% to 12% of women in the reproductive age group. It can be found in 35% to 45% of women who are trying to conceive and experience infertility. Infertility is one of the most common problems associated with endometriosis. Here is an introduction to the basics of endometriosis and how it can impact fertility.
What is endometriosis?
Endometriosis is a chronic gynaecological disorder characterized by the presence of endometrial tissue (lining of the uterus) outside the uterine cavity. The pelvis is the most commonly affected region, although endometriosis can also be found outside the pelvis.
What are the different types of endometriosis?
Endometriosis can be divided into three different types, classified according to their severity and histopathology:
- Superficial endometriosis on the peritoneum lining the pelvis
- Ovarian disease characterized by endometrioma (cysts)
- Deep infiltrating endometriosis which may affect the bowel or the bladder
What is adenomyosis?
Adenomyosis is a benign disease often co-existing with endometriosis. It is characterized by endometrial invasion into the myometrium. It is associated with abnormal uterine bleeding, pain and infertility (up to 28% reduction in the likelihood of pregnancy). It is diagnosed via ultrasound, MRI or surgical visualization. Medical treatment can be used for management of adenomyosis related infertility.
How does endometriosis affect fertility?
Endometriosis causes infertility through several mechanisms:
- Inducing local inflammation and progesterone resistance within the uterus affecting its receptivity to embryos
- Impairing the release of eggs from the ovary
- Reducing the ovarian reserve of eggs in cases of endometriotic ovarian cysts
- Causing distortion of the anatomy of the pelvis which affects fertilization and embryo transport
What are the symptoms and signs of endometriosis?
The most common symptoms of endometriosis are:
- Severe or painful periods
- Pain that is unrelated to their menstrual cycle
- Painful intercourse
- Difficulty becoming pregnant
- Changes or pain in bowel function during periods
- Some may have no pain and their only presenting feature is their inability to become pregnant
How is endometriosis diagnosed & staged?
The diagnosis of endometriosis can sometimes be made via ultrasound, which can detect ovarian and severe disease. This requires a specialized endometriosis ultrasound scan which is only available at specialized centers. However, ultrasound does not detect superficial endometriosis. The definitive diagnosis requires a laparoscopy (keyhole surgery) to visualize & ultimately treat the disease.
Staging is performed at the time of the laparoscopy. The most common classification system used is the one provided by the American Society for Reproductive Medicine (ASRM).
- Stage I: minimal disease
- Stage II: mild disease
- Stage III: moderate
- Stage IV: severe disease
What are the available treatments for endometriosis related infertility?
The available treatments for endometriosis related infertility are surgery and Assisted Reproductive Technologies (ART) such as in vitro fertilization (IVF). The decision for either or a combination for both is highly case dependent and requires consultation with a gynecologist or fertility specialist with a particular interest in endometriosis related fertility.
Surgery for Women with Endometriosis
Surgery for severe endometriosis can be challenging, requiring advanced laparoscopic skills & experience in this field. When endometriosis involves the bowel, a combined surgical procedure with a colorectal surgeon is performed. Choosing the right specialist is critical for optimal outcomes.
Assisted Reproductive Technology (ART) in Women with Endometriosis
There are different options for women with endometriosis, depending on the type and severity of the disease. A tailored treatment plan is necessary for optimal results. These include:
- Egg freezing after surgery for ovarian endometriomas
- IVF after surgery
- Embryo freezing
- Medical treatment prior to IVF such as with gonadotrophin-releasing hormones agonist (GnRha) especially in women with adenomyosis.
- Endometriosis is common in women of the reproductive age group and can affect fertility
- Endometriosis is a complex, variable and chronic disease which may manifest in different clinical presentations
- Some women with endometriosis may be asymptomatic, while others may experience dysmenorrhea (painful periods), non cyclical pelvic pain, dyspareunia (painful intercourse), pain during defecation and changes on bowel habits
- Laparoscopy is the gold standard for the diagnosis and treatment of endometriosis
- Women with infertility should be investigated for endometriosis and referred to a gynecologist with experience in endometriosis and infertility
- The optimal treatment plan for endometriosis associated infertility is a tailored approach for each woman