Endometriosis and Infertility
Endometriosis and its affect on infertility explained by Dr. Norbert Gleicher from The Center for Human Reproduction in New York, NY. What is endometriosis? Is pregnancy possible with endometriosis?
It is a very frequent condition which can present in a whole variety of ways, with very very little correlation between symptoms and severity of disease. Endometriosis is the presence of endometrial tissue, that is the lining of the cavity of the uterus, outside 0:41of the uterus. The cells that make up that lining are not supposed to be anywhere but in the endometrial cavity. When little islands of these cells for reasons which are not yet understood, are outside of the uterus, sitting on the uterus the tubes, the bowel maybe up to the diaphragm. Every time the women menstruates, those little islands also menstruate and therefore the immune system of the women sees those little islands, which menstruate which bleed, like it would see a little cut in the skin, like an open wound. And the immune system does the same thing to those little islands of endometriosis inside the abdominal cavity, inside the pelvis as it would do to a skin cut, it tries to heal it. And healing creates scar tissue and scar tissue is obviously not something good inside the pelvis and particularly is not something good when it affects the fallopian tubes which have to freely float to catch eggs. Endometriosis is associated with infertility and you can have relatively mild endometriosis and have infertility and be infertile and on the other hand you can have very severe endometriosis and not even know that you have it and have three kids. So, it is a very strange disease and what makes it probably most strange is the fact that we still don’t know why so many women have endometriosis. As a symptomatic disease what characterizes endometriosis are basically three findings. What we call dysmenorrhea, meaning pain during menstruation and by that I don’t mean a little bit of cramping but very disproportional pain. You can have what is called dyspareunia, which is pain during sexual activity and I need to go a little bit into more detail, the pain characteristically happens with deep penetration and the reason for that is that the uterus is kept in place by two ligaments which are called the uterosacral ligaments and with deep penetration those 3are hit. And they are the most frequent location of early endometriosis. And the third sign or symptom is the inability to get pregnant and that is why we very frequently as an infertility center end up seeing endometriosis patients. The diagnosis of endometriosis can be difficult, the principal reason why endometriosis is difficult to diagnose is because it can be 4:08so divergent in its symptoms. Once you suspect endometriosis the ultimate diagnosis can only be made by looking inside and finding endometriosis. Therefore the diagnosis, if you really want to be 100 percent certain, has to be made by seeing those lesions of endometriosis with your eyes and that can only be done through a surgical procedure usually a laparoscopy and sometimes even taking biopsies. Because even the naked eye sometimes can have a hard time finding microscopic lesions. And much of endometriosis can be microscopic. You may not even see microscopic typical lesions you may end up only see scar tissue already being formed without seeing those lesions. The vast majority of my colleagues will agree that even mild endometriosis decreases fertility. We think the most important way, how endometriosis can effect fertility, for a long time has been overlooked and that is the fact that the ovary is the most frequent or maybe the second most frequent location for endometriosis, after the uterosacral ligament. And with endometriosis invading the ovaries endometriosis can have significant effects on ovarian reserve and on ovarian function. And it is almost expected when you see an endometriosis patient in an infertility practice and if you carefully assess her ovarian reserve it is almost expected for these patients to show diminished ovarian reserve and premature ovarian aging. Finally, and probably the most controversial issue, is the association between endometriosis and autoimmunity. Autoimmunity, in and of itself, is a very controversial issue in the reproductive immunology. It is becoming increasingly clear over the recent years that autoimmunity can very negatively affect reproductive success, both in terms of allowing pregnancy to happen and in increasing miscarriages. So, endometriosis therefore, in many different ways can affect female reproductive success and represents a major issue in our specialty. There is a possibility that in mild cases, surgical removal of endometriosis may increase spontaneous pregnancies for a short time period. We did that for the longest time because we had no alternative treatment and what we learned in those days is that yes, we are getting a very short period after the surgery where we see a little peak in pregnancies but the scaring very quickly comes back and usually even worse than it was before. And I think the same thing applies to endometriosis. We don’t have treatment for endometriosis neither surgical nor medical. Whatever we do is temporary and yes, we may get a little window and we may get a few pregnancies through it but in the long run we are not getting a benefit. Therefore I would argue today, in today’s world where IVF, in vitro fertilization, has so greatly improved in results, I would argue against surgery and I would argue very much in favor of taking patients into IVF, rather than exposing them to surgery. Your treatment approach to endometriosis has to be very much individualized to the specific circumstances. The patient with mild endometriosis who may have mild tubal disease needs very different treatment from the patient with stage three endometriosis who has huge endometriomas. Time is of the essence because we never know how quickly endometriosis can or will progress. Number two I would say stay away from the ovaries particularly if there are endometriomas in the ovaries and the patient already shows signs of diminished ovarian reserves. The textbook advice given to patients with endometriosis is always to have surgery and that is correct advice for those who no longer want to have children. But if a woman still wants to have children my strong advice would be to try to delay that surgery for as long as possible because by having surgery you may have removed your last chance of achieving pregnancy. Because every time you operate on a woman with endometriosis you take a lot of ovary and ovarian reserve out even the best surgeons do that because it can’t be avoided. And we all the time see young patients who come to us with high FSH levels who tell us that don’t understand how come suddenly their FSH jumped and then when we ask them that suddenly wasn’t so suddenly it happened after they had surgery for endometriosis. So be quick and be conservative, those are the two principals for infertile women with endometriosis.