Dr. abayomi ajayi
Perhaps you’ve been trying to conceive unsuccessfully for some time, and now, after a fertility evaluation and diagnostic laparoscopic surgery, you have been diagnosed with endometriosis.
Or it could be that you haven’t even started thinking about having children yet, but you are experiencing pelvic pain or severe menstrual cramps, and investigations show that you have endometriosis.
Whatever your situation, it is normal to worry about your chances of conceiving. It is a fact that if you have endometriosis, you may have trouble getting pregnant, but getting pregnant with endometriosis is possible, even though it may not come easily.
Endometriosis and infertility are related in specific ways. Apart from the pain, main concern of women diagnosed with endometriosis is the impact it is likely to have on their current or future pregnancy plans. Individually, there are no easy answers regarding the risk to infertility, as mentioned earlier, it varies and essentially depends on how you are actually affected.
Clinically, if you have endometriosis, chances that your fertility may be affected ranges between 30- 50 per cent.
Endometriosis can only be diagnosed with invasive diagnostic laparoscopic surgery. A diagnosis of unexplained infertility gives strong suspicion of mild endometriosis because it is known that up to 25 per cent of women with endometriosis have no symptoms.
Endometriosis doesn’t automatically mean you will experience infertility. If you have endometriosis and less than 35 years old you will often be urged to try conceiving naturally for six months and if you don’t conceive within this time frame, it could be time to consult a fertility specialist. If you opt to go straight to a fertility specialist without consulting your doctor, it is also a reasonable option.
If you’re 35 years or older, you may want to seek counsel sooner than later. As a woman, your natural fertility declines faster as you age and after35, plus a diagnosis of endometriosis, it would be prudent to seek help as fast as you can.
For many and most women with endometriosis pain can interfere with fertility simply because sexual intercourse may be too painful. The pain itself does not interfere with your ability to ovulate or achieve fertilisation; rather, it makes sexual intercourse difficult and sometimes unbearable.
The amount of pain you experience isn’t necessarily related to the severity of your endometriosis. Even though severe endometriosis is associated with increased pain, mild endometriosis may also cause severe pain. It all depends on where the endometrial deposits are located.
More pain doesn’t mean that it will be harder for you to get pregnant compared to a woman without pain. It only impacts on fertility in that you may be less able to have pleasurable sexual intercourse.
If you have endometriosis but not trying to get pregnant, birth control drugs can help lessen pain symptoms, but you can only attempt to get pregnant after stopping use of the pills.
Surgery may be required to remove endometrial lesions or cysts and to reduce pain even in cases of moderate to severe endometriosis. If your case of endometriosis is severe, it would be necessary to examine your uterus and ovaries and critically assess your situation to draw a balance between your welfare (ease of pain) and the impact on your future fertility.
Surgical removal of reproductive organs isn’t a cure for endometriosis and it will not necessarily make the pain to go away. How endometriosis impacts on fertility is still not entirely clear. When endometriosis causes ovarian cysts (which may interfere with ovulation), or endometrial scar tissue blocks the fallopian tubes, the reason for infertility is clearer. However, if you have endometriosis but don’t have endometrial ovarian cysts or blocked fallopian tubes you may still experience reduced fertility.
Endometriosis could make it harder for you get pregnant if there are distortions or blockages of your reproductive organs. This can be caused by scar tissue or adhesions that form as a result of the condition. These adhesions may pull on your reproductive organs, impeding their ability to function normally. Adhesions may also cause fallopian tube blockage, which can prevent the egg and sperm from meeting.
You could also have biochemical signs of increased inflammation, but it is not clear if it is endometriosis that causes the inflammation, or if it is the inflammation that increases endometriosis. How it all relates to infertility is still a bit of mystery.
Endometriosis is a condition that causes endometrial-like tissue to grow outside of the uterus, and it may also affect the endometrium itself. This is one of the reasons why embryo implantation rates are lower in women with endometriosis. However, it’s possible lower embryo implantation rates are not only due to problems with the endometrium but related to poor egg quality as well.
With endometriosis, there is the challenge of poor egg quality to deal with. The quality of embryos that you would produce as a woman with endometriosis tends to develop slower than average. You may therefore need to pool embryos in multiple cycles and proceed to frozen embryo transfer or sometimes need to use donor eggs especially in women with advanced age.
The location, amount, and depth of endometrial deposits all count towards determining the stage or level of your endometriosis.
There are four stages, from Stage 1 to Stage 4, used to help describe and evaluate the severity of endometriosis. Stage 1 is regarded as mild endometriosis and Stage 4 being severe.
Rule of thumb is that women with Stage 1 or 2 endometriosis are less likely to experience infertility than women with Stage 3 or 4 endometriosis.
The stage of your endometriosis can also help your doctor arrive at a suitable treatment plan. For instance, if you are with Stage 2 endometriosis, you may want to try to conceive on your own for a while. If you are with Stage 3 endometriosis you may opt to proceed directly to IVF treatment.
However, the stage of your endometriosis cannot predict whether fertility treatments will be more or less successful. It is possible to have Stage 2 endometriosis and go through numerous failed IVF treatments. And it’s possible to have Stage 4 endometriosis and conceive on your first cycle.
The most effective per cycle treatment for endometriosis-related infertility depends on your age, stage of disease, infertility risk factors and personal choice.
Your treatment plan will also depend on the stage of your endometriosis and whether endometriosis alone is the cause of your infertility.
If you have Stage 1 or 2 endometriosis, intrauterine insemination (IUI) with fertility drugs may be the recommended starting point.
If fertility drugs with IUI are unsuccessful, then In vitro fertilisation (IVF) is the next recommended step. Depending on the circumstance, IVF may be the first treatment options for you if your likelihood of conceiving is significantly reduced, for instance, if you have Stage 3 or 4 endometriosis and you are over 35.
Other factors such as multiple infertility risk factors (like male infertility or low ovarian reserves), will make IVF the best choice for you.
If you are having severe endometriosis, surgery may improve fertility treatment success rates. On the other hand, repeated surgeries can reverse those gains by causing the extensive formation of adhesions and also jeopardise your egg stock or ovarian reverse.