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Endometriosis and its affect on infertility explained by Dr. Norbert Gleicher.
What Is Endometriosis?
Endometriosis is a very common gynecological condition affecting women in their reproductive years. The cause of endometriosis is still controversial, and the condition involves endometrium (cells making up the internal lining of the uterine cavity), for unknown reasons, growing outside the uterus, most commonly on fallopian tubes, ovaries, bowel, and the pelvic tissue linings.
Like the endometrial lining in the endometrial cavity of the uterus, this extra-uterine growth is affected by the patient's monthly hormonal cycle, first thickening and then shedding the superficial layer with her menstrual cycle. However, within the peritoneal cavity, the resulting bleeding does not have an exit route. The woman's immune system sees the bleeding as an "open wound," and treats it as such, causing scarring, in a process similar to the healing after a skin cut. Over time, accumulation of scar tissue, therefore, causes adhesions and sometimes severe pain if close to nerve fibers. When impacting the fallopian tubes, endometriosis can also negatively impact fertility and outcomes of infertility treatments.
How Is Endometriosis Diagnosed?
Endometriosis is one of the great mimics in medicine: Very mild endometriosis can cause considerable symptoms while very severe stages of the condition may be symptom-free. This can be a challenge because a patient may be suffering from endometriosis-induced infertility without anybody realizing that she suffers from endometriosis.
Even the gold standard for diagnosis of endometriosis, laparoscopy, can be inaccurate because endometriosis is often only microscopic in size. Endometriosis, therefore, can be relatively easily overlooked, or its severity may be underestimated even during laparoscopy.
How Common Is Endometriosis?
Reported rates of endometriosis vary greatly, but the consensus is that approximately 5-10% of all women suffer from this condition. Endometriosis is, however, much more common amongst women with infertility.
Endometriosis and Infertility
Does Endometriosis Cause Infertility?
Whether or not so-called "mild" endometriosis affects fertility has remained controversial. At CHR, we strongly believe that endometriosis, even when mild, can negatively affect fertility. Even more importantly, endometriosis affects fertility adversely in many different ways, though its effects on normal tubal function appear to be the most important.
Investigations attempting to explain why patients with endometriosis are often infertile suggest that:
- Their fallopian tubes may function abnormally, due to adhesion or scarring (so-called tubal infertility)
- Ovarian function may be adversely affected, possibly resulting in sub-par egg quality
- Endometriosis may release toxic substances which may harm embryos and/or their implantation capacity
- Patients with endometriosis may be at a higher risk for miscarriages, lowering their live birth chances
Finally, there may be an immunological factor involved in endometriosis. Norbert Gleicher, MD, CHR's Medical Director, was the first to report on the possible association of autoimmunity and endometriosis, suggesting that endometriosis, indeed, may be an autoimmune disease. It is now widely accepted that the immune system, indeed, plays an important role in endometriosis-associated infertility.
How Does Endometriosis Affect IVF Success Rates?
Endometriosis appears to affect IVF adversely, from reducing the number of eggs at the time of retrieval to poorer egg quality, and lower implantation and pregnancy rates. However, most endometriosis patients will still be able to conceive with IVF.
Can "Unexplained Infertility" Be Endometriosis?
Endometriosis often initially presents as "unexplained infertility," a diagnosis CHR does not believe in. Many studies in the literature point to similar patient profiles in women with endometriosis and unexplained infertility. They also present with similar immune profiles.
In most cases of so-called "unexplained infertility," we, however, can pinpoint a real cause of infertility by performing appropriate diagnostic tests, even though correct diagnosis of endometriosis can be difficult.
How Is Endometriosis Treated?
CHR Publications on Endometriosis
- Human Reproduction The article argues that unexplained infertility, a frequent diagnosis in infertility setting, is unsustainable as an independent diagnosis, pointing out that this "diagnosis" only means that proper diagnostic workup has not been completed. Endometriosis, tubal infertility, POA and immunological infertility are the most frequent "real" diagnosis behind unexplained infertility.
- British Journal of Obstetrics and Gynaecology The article points out the frequency of autoimmune findings in patients with endometriosis, and hypothesizes an immunological etiology to endometriosis, potentially suggestive of immunological treatment approaches to the disease.
There is no permanent treatment for endometriosis. All available endometriosis treatments are temporary, raising the possibility, even likelihood, that endometriosis will return once treatment stops. This fact is probably best documented by the fact that the best treatment for endometriosis is considered to be pregnancy. Pregnancy, of course, stops all menstrual periods, and with it, the above-noted bleeding from endometriotic lesions. It, therefore, interrupts the process of endometriosis.
Medications do the same. However, since those drugs also interrupt the menstrual cycles, for all practical purposes, they are contraceptive. Therefore, an infertility patient, wishing to conceive, cannot be treated with such drugs. These medications are helpful only in clinically symptomatic patients, where pain management is the primary goal of treatment.
In such cases, endometriosis is also frequently treated surgically. As fertility specialists we, however, are always concerned about the surgical treatment of endometriosis: especially if surgery involves the ovaries, we often see that such surgery ends up removing the last vestiges of functioning ovarian tissue, and puts the patient into menopause. CHR, therefore, rarely recommends surgery before patients have completed their families.
What Are The Infertility Treatments for Women with Endometriosis?
Endometriosis infertility treatment requires special expertise. Such need for special expertise is not limited to surgery for endometriosis. Fertility treatments often involve increases in estrogen levels. Estrogen, however, can "feed" endometriosis, and make it worse. Finding the right balance between advantages and risks of different infertility treatments, therefore, is always of utmost importance in endometriosis.
Key Facts about Endometriosis
Speak with a CHR Doctor, or Get a Second Opinion
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Written by Norbert Gleicher, MD
Last Updated: December 31, 2013