By Jessica R. Brown, MD
Published in Resolve for the future and beyond, Winter 2012
Endometriosis is a disease that affects women of reproductive age and that may be associated with both pelvic pain and infertility. Scientific advances have improved our understanding of this benign (non-cancerous) but sometimes debilitating condition. And modern medicine now offers women with endometriosis many treatment options for relief of both pain and infertility.
But much remains unknown. Women who have been diagnosed with endometriosis may wonder what this means for their future fertility. Similarly, women experiencing infertility may wonder whether they have endometriosis and how that may affect their prognosis. To quote a recent committee opinion from the American Society for Reproductive Medicine (ASRM): “Treatment of endometriosis in the setting of infertility raises a number of complex clinical questions that do not have simple answers.”
Here we aim to address the concerns of women facing endometriosis and/or infertility and answer their most pressing questions. Armed with this fundamental knowledge, women can take action to optimize both their own health and fertility.
Endometriosis is a disease involving growth of tissue resembling the endometrium (uterine lining) in places outside the uterus. In the ovaries, cysts known as endometriomas or “chocolate cysts” may form. Implants of endometriosis may grow on the peritoneum (the lining of the abdomen and pelvis), sometimes causing scarring that may involve the ovaries and block the tubes. In some women, endometriosis grows deep beneath the peritoneal lining, such as in the area between the vagina and the rectum. These cases are often associated with more severe pain, but not necessarily more severe infertility. Although you or your physician may suspect endometriosis based on signs, symptoms and findings on physical exam, the only way to definitively diagnose endometriosis is with a surgical procedure called a laparoscopy.
The cause of endometriosis is not known, although it often runs in families. Numerous biochemical and immunological changes have been identified in association with endometriosis, but it is unclear which may contribute to endometriosis and which simply result from it.
Birth control pills help relieve pelvic pain in many women, including those with endometriosis.
Women whose symptoms continue despite the pill should discuss laparoscopy to see if they have endometriosis, which can often be treated surgically at the time of the laparoscopy. Surgical treatment for endometriosis has been shown to improve fertility, but women not ready to become pregnant are encouraged to resume the pill to prevent endometriosis from recurring. Stronger medications, such as leuprolide acetate, are effective to treat pain, but not infertility, related to endometriosis.
The birth control pill is commonly prescribed to reduce menstrual cramping and help prevent endometriosis recurrence. Preventing endometriosis can help preserve fertility, so the pill is an excellent treatment option following endometriosis surgery if you are not yet ready to become pregnant. Women with endometriosis should also strongly consider consulting with a fertility specialist, (a specialist in Reproductive Endocrinology/Infertility), even if they are not yet ready to try to conceive. This is particularly important if you are over 30 or if you have “decreased ovarian reserve.” Fertility in women decreases with age. In addition to age, “ovarian reserve” also helps predict your ability to conceive. Ovarian reserve is most easily measured with a simple blood test called AMH (anti mullerian hormone). Surgery to remove or destroy endometriosis involving the ovaries may also reduce ovarian reserve and thus lower a woman’s chances for pregnancy even with fertility treatment such as IVF. Women with moderate to severe endometriosis may have scarring that can prevent the egg from entering the fallopian tube. Mild and minimal endometriosis are also associated with infertility, so all women with endometriosis need to consider the impact endometriosis may have on their fertility. A newer option is for women to freeze eggs for possible future use in the event they experience infertility. Unfortunately, egg freezing is costly and is usually not covered by insurance.
No. In the 20th Century, it was standard for all women with infertility to undergo laparoscopy to see if they had endometriosis. Today, women with regular ovulatory cycles, patent fallopian tubes, normal ovarian reserve and a partner with a normal semen analysis are said to have unexplained infertility, though some of these women undoubtedly have endometriosis. Infertility treatments and success rates are generally similar for women with endometriosis-related infertility and women with unexplained infertility. Very few infertile women who undergo laparoscopic treatment of endometriosis become pregnant as a result. But laparoscopy may be a good option for women suffering from pelvic pain along with infertility, as well as for women who do not consider IVF to be an option.
It is helpful to bring the records from your surgery to your fertility specialist. Knowing the severity of your endometriosis, whether it appears to have caused extensive scarring, and whether it has affected your ovarian reserve will help you and your doctor plan the most appropriate course of treatment. Although pregnancies do occur naturally in women with endometriosis, pregnancy rates are superior with IVF. Women with low ovarian reserve who do not conceive with IVF using their own eggs generally have an excellent prognosis with donor egg IVF.
Surgery to diagnose and destroy endometriosis can improve fertility, but repeat surgery is generally not beneficial, and may cause harm by reducing ovarian reserve. Large endometriomas may need to be removed surgically prior to IVF, but smaller ones are generally best left in place. Consider consultation with a fertility specialist before undergoing another operation.
Jessica R. Brown, MD is a Clinical Assistant Professor of Obstetrics and Gynecology at NYU School of Medicine and is board certified in both Reproductive Endocrinology/Infertility and Obstetrics and Gynecology. She practices Reproductive Endocrinology/Infertility and Gynecology at Madison Women’s Health & Fertility on Manhattan’s Upper East Side, offering medical and surgical care for all reproductive endocrine and gynecologic disorders along with full service infertility care including IUI, IVF and egg freezing. She also directs the Reproductive Endocrinology/Infertility clinic at Woodhull Hospital in Brooklyn, an NYU affiliate. Dr. Brown has served as President of the New York Gynecological Society, has been a regular speaker at educational conferences sponsored by patient advocacy organizations including The Endometriosis Foundation of America and RESOLVE, and has been featured on ABC’s 20/20.