Endometriosis and Fertility
With the bloom of Daffodils in early spring, it is the beginning of Endometriosis Awareness Month. It is time to shine some light on endometriosis and its sister condition, adenomyosis. If you have Endometriosis, you are not alone - it affects 1 in 10 women and those assigned female at birth; however, this figure may be higher as the condition remains underdiagnosed. Care teams routinely provide fertility treatment to women affected by this condition. Let’s explore some of the key issues about this condition to raise awareness.
What are Endometriosis and Adenomyosis?
Endometriosis is a benign condition where cells similar to the cells of the womb's lining (endometrium) become implanted outside the lining of the womb. This can be in the ovary (forming chocolate cysts or endometrioma), around the womb, within the muscle layer of the womb, fallopian tubes, in the lining of the pelvis and abdomen (peritoneum), vagina, bowel or bladder. While the awareness about Endometriosis has increased in the last few years, little is known about its sister condition- adenomyosis. Adenomyosis is a condition where cells similar to the cells of the lining of the womb implant within the wall of the womb (muscle layer). It is also called Endometriosis of the womb.
With every menstrual cycle, the lining of the womb and the endometriosis tissues change in response to the hormones. Whilst the cells of the lining of the womb are shed out in the form of menstrual blood, there is no outlet for the endometriosis tissue. As a result, the endometriosis lesions cause inflammation, pain and scarring. In adenomyosis, the muscle layer of the womb reacts to these uninvited guest cells of the lining of the womb and enlarges in size along with cyst formation.
Although the exact cause is unknown, any female in the reproductive age group between menarche (the first menstruation during puberty) and menopause can develop Endometriosis.
What are the symptoms of Endometriosis?
Symptoms of Endometriosis and adenomyosis may vary and coincide with symptoms of other gynaecological conditions. Some women have no symptoms, whereas others might have severe symptoms affecting their quality of life. Some of the symptoms are:
- Menstrual pain that limits your routine activity without pain killers
- Pelvic pain or pressure just prior to menstrual period
- Long-term pain all the time in the lower part of the tummy, back, during bowel movements or the top of the legs
- Cyclical pain on opening bowels or emptying the bladder or in the upper part of the abdomen under the ribs just prior to or during periods
- Heavy menstrual bleeding
- Painful rectal bleeding or the presence of blood in the urine just prior to or during periods
- Cyclical cough, chest pain, or coughing of blood just before or during periods
- Cyclical scar swelling and pain just prior or during periods
- Pain during or after sexual intercourse
- Difficulty getting pregnant
You may find it useful to record your symptoms using a pain & symptom diary, which can support your discussion with your GP or gynaecologist.
How can one diagnose Endometriosis?
A pelvic ultrasound scan is a reliable first-line investigation to screen for Endometriosis and Adenomyosis. Usually, this is an internal vaginal scan performed to check the ovaries, the muscle layer of the womb, the junction between the lining of the womb and muscle layer of the womb, the area behind the womb. A scan may not always detect endometriosis lesions at every site involved.
MRI is a second-line tool in cases where advanced Endometriosis affecting the bowel and bladder is suspected and where it is difficult to differentiate between adenomyosis and fibroids.
Keyhole surgery (laparoscopy) is the gold standard investigation to diagnose Endometriosis and also has the advantage of treating Endometriosis. This is indicated if Endometriosis is suspected clinically and no endometriosis could be detected during ultrasound or MRI. This is carried out under general anaesthesia. Telescope is inserted through small cuts in your abdomen and allows you to have a detailed look at the structures affected by Endometriosis. You may have a biopsy of the endometriosis tissue removed to confirm the diagnosis. In case of severe Endometriosis, a second operation at an endometriosis specialist centre may be required.
What are the treatment options?
Treatment options are designed depending on individual needs, whether for symptom relief or fertility issues. Some of the treatment options are:
- Pain killers
- Hormonal medications in the form of pills or injections
- Keyhole surgery to remove or burn the lesions of Endometriosis (cysts on ovaries, lesions around the uterus or in the lining of the pelvis) and to release the scar tissue. This may be combined with hormonal treatment. Surgery for an endometriosis cyst in the ovaries can damage the ovary and may affect your ovarian reserve.
- Removal of the womb if symptoms do not respond to the above treatment options and if you no longer wish to conceive.
Measures like dietary changes (cutting out dairy or wheat products from the diet) and regular physical activity may be helpful as well.
Endometriosis and fertility
Not all women with the diagnosis of Endometriosis have difficulty conceiving. It is estimated that 30 to 50% of women who have difficulty conceiving after one year of regular sexual intercourse have Endometriosis.
At Care, we tailor the management plan in an individualized and patient-centric manner for your fertility journey if Endometriosis is diagnosed. The options include surgery or medically assisted reproduction.
In mild to moderate Endometriosis cases, surgery for Endometriosis may improve your chance of getting pregnant spontaneously. Endometriosis Fertility Index (EFI) is a validated tool for predicting chances of conceiving spontaneously after endometriosis surgery and is based on surgical findings, age, years of fertility issues and any prior pregnancy.
Fertility treatment, which can include intrauterine insemination (IUI) and in vitro fertilization (IVF), is recommended in the following cases:
- Moderate to severe Endometriosis
- Endometriosis fertility index suggests low chances of natural conception
- Advanced reproductive age
- Patients with additional factors including blocked fallopian tube, low ovarian reserve, and abnormal semen analysis)
Ovarian stimulation at the time of IVF does not worsen Endometriosis and is safe. Having surgery before starting IVF does not increase the chance of pregnancy. It is only recommended if one has significant pain or cannot reach the ovaries during IVF in case of a large endometriosis cyst of the ovary. We can reassure you that patients with Endometriosis have had babies successfully.
If you think you may be suffering from Endometriosis, or if you are worried about your fertility, please don’t hesitate to contact your nearest Care clinic to discuss your fertility options. Or you can call our new patient enquiry team on 0800 564 2270. Our expert team will be happy to help you.