26 July 2016

Endometriosis and Fertility

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Sims IVF

Most people who experience fertility issues are sub-fertile, not infertile.  Their chance of conceiving is diminished but not gone.  Subfertility can be unexplained but the two main gynaecological conditions that contribute to it are polycystic ovarian syndrome (PCOS) and endometriosis.

It is estimated, according to US figures that 6-10% of women have endometriosis. 

The key question is:  “Will endometriosis cause a fertility problem?”  In 30-50% of cases the answer is ‘Yes’.  Unfortunately, endometriosis very often goes undiagnosed. 

What is endometriosis?

The endometrium is the lining inside the womb.  It is programmed naturally to grow and shed – and that is what happens when you have your period.  Unfortunately, if endometrial tissue forms outside the womb, in the ovaries for example, there is no way that the tissue can be shed, so it remains and may cause scarring.

What causes endometriosis?

There are many theories, but no clear answers on what actually causes endometriosis.  Retrograde menstruation, the lining moving up the tube to be deposited in the pelvis instead of out through the vagina is one such theory.

How does endometriosis affect your fertility?

In the most severe cases, endometriosis can cause tubal damage and make it difficult for sperm to travel through the fallopian tubes, and so preventing the egg and sperm from meeting. 

Where endometriosis is present in the ovaries, it can cause ovulatory abnormalities and disturb the regularity of the menstrual cycle.

Endometriosis may also cause a decrease in both the numbers and quality of the eggs.

How do you know that you have endometriosis?

First of all, look at your family history – does anyone else in your immediate family suffer from endometriosis?

The most common indicator of endometriosis is pain – during intercourse and your period.

To date, no blood test has been developed to identify endometriosis. 

However, an AMH test can indicate your ovarian reserve (how many eggs are left), though this does not tell the quality of the eggs.

How is endometriosis diagnosed?

There are various grades of endometriosis and they can be identified in different ways.  You can use a scan to identify endometriosis, particularly if it causes cysts in the ovaries.  The best way is by laparoscopy – which involves a camera inserted via the belly button – which allows us to look around the pelvis to identify endometrial tissue.

What can we do about endometriosis?

There are two perspectives on treating endometriosis and it very much depends on your ultimate goal.  The first is the gynaecological approach – which is designed to reduce the impact of endometriosis on your life and to reduce its presence in your body.  This approach, however, may not be sympathetic towards your desire to conceive a child at some point in the future.  Firstly, you may be put on the pill or advised to have a Mirena Coil inserted.  Secondly, you may have a number of operations, which over time could impact your ovarian reserve, affect your fallopian tubes and your womb.  So gynaecologically speaking, the treatments for endometriosis may not be baby friendly…

What are your fertility options?

Treatment of endometriosis, from a fertility specialist perspective, takes a slightly different perspective.  Obviously, we won’t recommend the pill or the Mirena Coil, which prohibit conceiving a child.

There are three main options open to you, depending on the type and severity of your endometriosis.  These are: Ovulation Induction (IUI), surgery, and IVF.

Ovulation Induction Cycles – Ovulation is stimulated using medication.  It is a controversial method for dealing with endometriosis for a number of reasons.  It doesn’t overcome the issue of tubal damage, so you have to be sure that this is not a problem.  In most cases, you have to avoid ovulation induction unless you are also conducting surgery to fix the damage caused by the endometriosis. 

Surgery – When it comes to treatment of endometriosis, from a fertility perspective, surgery has to be very carefully considered.  Our aim is to treat the endometriosis as delicately as possible to ensure that we protect your fertility and most specifically your tubes, ovaries and womb, so that you can conceive a child.  If we keep going back to remove scar tissue, then each time, it is virtually impossible not to impact your fertility – your ovarian reserve may be reduced, for example. 

How can the ovarian reserve be damaged? 

This particularly occurs where endometriomas or chocolate cysts are present. 

There are three ways to treat these cysts:

Use a needle to suck out the core material of the cyst – it is however likely to reform.
Open a window to remove the cyst, which has a better chance of not reforming but can still do so.
Take away the cyst altogether – although – no matter how careful you are, you will decrease the ovarian reserve.  This is the preferred option

IVF – If endometriosis is present, without endometrioma, IVF has a high chance of success.  IVF works very well for most people with endometriosis, because it overcomes the tubal difficulty.  If there are also endometrioma cysts present, the chances of success are lower with IVF. 

So what should you do if you have endometriosis?

It is critical that you speak with a fertility professional to discuss the pros and cons of the various treatment methods.  You have to identify the type of endometriosis that you may have and then work with your specialist, to find the best way to overcome the problem and conceive a healthy baby.

In most cases, there is a successful outcome.  Endometriosis does not mean that you cannot conceive, and in some cases, people conceive naturally with endometriosis.  However, if you find that it is an inhibitor, then get help sooner rather than later. 

Dr. John Kennedy is Consultant Fertility Specialist and Gynaecologist at Sims IVF, based in Clonskeagh, Dublin 14.