Endometriosis and Its Impact on Fertility

Endometriosis and Infertility

Endometriosis can damage the reproductive organs and be a cause of infertility. Endometriosis is the implantation of uterine lining tissue in areas outside of the uterus. These areas of implantation can be anywhere in the body, but commonly are in the pelvis. Infertility can result from endometriosis, which causes inflammation and scarring to reproductive organs. Endometriosis can be very painful or sometimes nearly painless. The amount of pain often does not match the amount of endometriosis present.  More pain does not necessarily mean more endometriosis is present; and less pain does not mean there is less endometriosis present.

Diagnosis-

Endometriosis diagnosis is usually made by laparoscopy. Women who have stomach pain, pain with sex, or have evidence of large endometrial cysts in their ovaries are often candidates for laparoscopic surgery to diagnosis and surgically treat endometriosis. Even so, many women with infertility do not need a laparoscopy to diagnose endometriosis. If their reproductive assessment is normal through standard tests such as ultrasounds, sonohysterograms and/or hysterosalpingograms, they can often be treated without the need to have a laparoscopy depending on their cause of infertility.

Control of pain and prevention of infertility-

Women who are not interested in fertility and are in pain with the diagnosis of endometriosis can be treated with medications.

These include:

1. Oral contraceptives with both estrogen and progesterone components.
2. Progesterone only birth control pills.
3. Intramuscular progesterone (Depot Provera).
4. Long acting GnRH agonist (Depot Lupron) with addback.
5. Hormonal intrauterine devices (IUD); such as a Mirena®

It is best to consult your OB/GYN or Reproductive Endocrinologist to decide which treatment best suits your circumstances.

Laparoscopy for the infertile patient–

When laparoscopy is chosen for pain or large endometrioma(s) greater than 4 cm, it is imperative to be as conservative as possible. The endometriosis should be either removed or treated with a laser depending upon it’s location. The pelvic anatomy is then returned to normal as much as possible to avoid compromising fertility. Care should always be taken to preserve the ovaries. If the woman does not have pain, endometrial cysts less than 4 cm do not have to be excised as their attempted removal may also remove healthy tissue in the ovary.

Fertility treatments for patients with endometriosis-

Women who have minimal or mild endometriosis have treatment options to become pregnant. These can include therapy with fertility drugs.  Oral and injectable medications with or without insemination of sperm, depending upon evaluation and past failed fertility treatments. If the couple have already tried these simpler treatments and have not been successful or they have stage III or IV endometriosis then they should consider in-vitro fertilization (IVF). Of note, women with endometrioma(s) (endometrial cysts) less than 4 cm do not need to have the endometrioma(s) excised before attempting IVF due to the fear of worsening the woman’s fertility potential if surgery is done.

Take home points-

1. It is important to remember that endometriosis impacts each woman differently.
2. It is best to consult with a doctor who is familiar with both infertility and endometriosis to discuss whether an evaluation is necessary and which treatment is the best fit.
3. We at Michigan Reproductive Medicine do our best to protect and preserve fertility.
4. Some women with endometriosis may find that egg freezing is a good option for them if they are not ready to get pregnant currently, but do not want the endometriosis to hurt their reproductive organs and lower their fertility over time.

This information written by Dr. Manny Singh, MD

About Manny Singh