Endometriosis and Infertility
Advanced Fertility Center of Chicago
Gurnee & Crystal Lake Illinois
Background
The endometrium is the
tissue that lines the inside of the uterine cavity. Endometriosis is a disease state in
which some of this tissue has spread elsewhere - such as to the ovaries, or elsewhere in
the abdominal cavity.
Endometriosis causes
pain in some women and can also cause infertility.
5-10% of all women
have endometriosis. Most of these women are not infertile.
30-40% of infertile
women have endometriosis.
Diagnosis of
endometriosis
The only way to be
sure whether a woman has endometriosis is to perform a surgical procedure called laparoscopy that allows us look inside the abdominal cavity with a
narrow scope.
Sometimes we strongly
suspect that the disease is present based on the woman's history of very painful menstrual
cycles, painful intercourse, etc., or based on the physical examination of the woman or
ultrasound findings.
Mild endometriosis
Top: Endometriosis of the ovary and peritoneum
Bottom: Brown endometriosis spots on pelvic side wall
Laparoscopic photo album
The large majority of
cases of endometriosis are mild.
Women with any stage
of endometriosis (mild, moderate, or severe) can have severe lower abdominal and pelvic
pain - or they might have no pain or symptoms whatsoever.
Although mild
endometriosis is associated with infertility in some women, many fertile women also have
mild endometriosis. A cause and effect relationship between mild endometriosis and
infertility has not been established. It might be that infertility and delayed pregnancy
predisposes women to developing endometriosis, rather than the endometriosis causing the
infertility.
Therefore, some
experts consider infertility associated with mild endometriosis to really be
"unexplained infertility".
Severe endometriosis
Severe endometriosis
causes pelvic scarring and distortion of pelvic anatomy. The tubes can become damaged or blocked
and the ovaries often contain cysts of endometriosis (endometriomas) and may become
adherent to the uterus, bowel or pelvic side wall. Any of these anatomic distortions can
result in infertility.
In some
cases the eggs in the ovaries can be damaged, resulting in decreased
ovarian reserve and reduced egg quantity and quality.
Treatment of
endometriosis
Treatment for
endometriosis associated with infertility needs to be individualized for each woman. There
are no easy answers, and treatment decisions depend on factors such as the severity of the
disease and its location in the pelvis, the age of the woman, length of infertility, and
the presence of pain or other symptoms. Some general issues regarding treatment are
discussed here:
Treatment for mild
endometriosis
Medical (drug)
treatment can suppress endometriosis and relieve the associated pain in many women.
Surgical removal of lesions by laparoscopy might also reduce the pain temporarily.
However, several
well-controlled studies have shown that neither medical or surgical treatment for mild
endometriosis will improve pregnancy rates for infertile women as compared to expectant
management (no treatment). There are a few more recent studies that did show a benefit to
surgical treatment of mild endometriosis. This is interesting because previous studies
have shown no benefit.
For treatment of the
infertility associated with mild to moderate endometriosis, controlled
ovarian hyperstimulation with intrauterine insemination is
often attempted and has a reasonable chance to result in pregnancy if other infertility
factors are not present.
If this is not
effective after about 6 cycles (maximum), then in vitro fertilization
should be considered.
Treatment for severe
endometriosis
Several studies have
shown that medical treatment for severe endometriosis does not improve pregnancy rates for
infertile women.
Some studies have
shown that surgical treatment of severe endometriosis does improve the chances for
pregnancy as compared to no treatment. However, pregnancy rates remain low after surgery -
some studies have reported pregnancy rates of 1.5-2% per month.
Some physicians
advocate medical suppression with a GnRH-agonist such as Lupron, Synarel, or Zoladex for
up to 6 months after surgery for severe endometriosis before attempting conception.
Although at least one published study found this to improve pregnancy rates as compared to
surgery alone, other studies have shown it to be of no benefit. This is one of many issues
regarding endometriosis that there is not universal agreement about among infertility
specialists.
Unfortunately, the
infertility in women with severe endometriosis is often resistant to treatment with
ovarian stimulation plus intrauterine insemination. If the pelvic anatomy is very
distorted, insemination would probably be futile. These women will often require in vitro fertilization in order to conceive.
Although the studies
of in vitro fertilization for women with severe endometriosis do not all show similar
results, pregnancy rates are usually good if the woman is relatively young (under 40) and
if she produces enough eggs during the ovarian stimulation.
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