Endometriosis & infertility commonly coexist. Endometriosis can have profound effects on woman’s fertility and the ability to conceive in the future, either by virtue of the disease itself or its treatment. Endometriosis means that the tissue that lines the uterus is found in other areas, most notably the ovaries and the lining of the pelvis, frequently causing pelvic pain and infertility. In early stages of endometriosis, the implants in the pelvis may chemically affect various stages of reproduction including fertilization and implantation. In later stages, endometriosis incites scarring that can block the fallopian tubes and can produce cysts in the ovaries called endomertiomas. Experienced reproductive endocrinologist can diagnose endometriomas with high degree of accuracy using ultrasound. In other areas the diagnosis of endometriosis may requires laparoscopy.
Treatment of Endometriosis
Women seek treatment for endometriosis because of pain or infertility. Treatment for endometriosis is either medical or surgical.
Medical treatment For Endometriosis
It entails suppression of ovulation and estrogen production. Estrogen stimulates the growth of endometriosis. Medical treatment has side effects and is not suitable for women seeking pregnancy now. It, however, does not have a long lasting effects on fertility. Medications used include oral contraceptive pills, androgenic medications or gonadotropin releasing hormone agonists as depot leuprolide. Women on these medications does not need to consider fertility preservation strategies because of treatment.
Surgical Treatment For Endometriosis
Surgery aims at removal of endometriosis spots in the pelvis or excising endometrioma cysts from the ovary. Cutting the ovary and stripping the wall of the endometriomas is associated with loss of eggs during the procedure. The ovary, where the procedure is done commonly have less reserve and may show lower response to fertility medication. The risk for decreased fertility is higher if the procedure is done on both ovaries. It is also higher after extensive surgery, commonly associated severe disease in the pelvis. Sometimes the ovary need to be completely removed . Removal of endometriosis deposits in the pelvis-usually burning them using cautery-can also incite scarring that can block the fallopian tubes. Women undergoing surgery for endometriosis should consider fertility preservation. Aspiration of endometriomas is generally not a recommended treatment as they tend to recur and can cause infection.
Fertility Treatment in Women with Endometriosis
Severe Endometriosis mechanically blocks the fallopian tubs due to scarring. IVF appears to be the best treatment option. Although endometriosis reduces the response to ovarian stimulation, it does not appear to reduce the pregnancy rates
Mild endometriosis does not distort the fallopian tubes. Two treatment options are available: laparoscopy with excision or burning of endometriosis or ovarian stimulation + IUI. Both can increase the chance for pregnancy but IUI is less invasive.
Fertility Preservation strategies in women with endometriosis
Reproductive age women diagnosed with endometriosis and advised to undergo surgery by their physicians should inquire about the possible effects of surgery on future fertility and consider fertility preservation strategies. Strategies include embryo cryopreservation, egg freezing or ovarian tissue freezing.
Its the standard method for preservation of fertility. It requires stimulation of the ovaries using fertility medication for approximately 10 to 12 days, followed by egg retrieval. Eggs are fertilized using partner or husband sperm. The resulting embryos can be frozen indefinitely. One risk is that endometrioma cysts can get infected at the time of egg retrieval.
It can be used in women not in stable relationship and declining the used of donor sperm. It require ovarian stimulation. This is followed by retrieval and freezing. Eggs are frozen using vitrification. Vitrification is associated with better survival after thawing than slow freezing. When desired, the eggs are thawed and fertilized using intracytoplasmic sperm injection-ICSI and the resulting embryos are transferred to the uterus.
Endometriosis and Ovarian Cancer
It was noticed that women diagnosed with endometriosis has a small increase in the risk for certain rare types of ovarian cancer. Its essential that endometriomas in the ovary be thoroughly investigated using ultrasound and other imaging modalities and sometimes blood tests. Surgery may be needed to remove the cyst and submit it for pathological examination to exclude cancer.Endometriosis & Infertility by Dr. Amr Azim