Fertility and treatment for endometriosis: What you should know

Along with chronic symptoms of bloating, constipation and severe pain, endometriosis can be the cause of poor fertility. In this in-depth guide, highly esteemed consultant gynaecologist and fertility specialist Dr Ahmed Elgheriany details how endometriosis can affect fertility and in turn, how treatments which aim to resolve painful and troublesome symptoms of the condition can also impact on a woman’s ability to conceive naturally. The leading specialist also sheds light on the variety of treatment options which help to alleviate pain and improve fertility in this informative article, the third in his expert series on endometriosis.

How can endometriosis affect fertility?

There are three factors to consider when discussing how endometriosis can affect a woman’s fertility:

• the anatomy being disturbed
• the quality of the eggs and implantation being affected
• treatment for endometriosis

In women with endometriosis, the anatomy of the pelvis can become altered by the growth of chronic scar tissue which forms inside the abdomen or the tummy. As well as changing our natural anatomy and making it more difficult for an egg to follow its natural course, scarring can affect important areas of the reproductive system, such as the fallopian tubes which can become blocked if scarring occurs around them. A sizeable endometrioma, also known as a chocolate cyst, may also cause pressure symptoms inside the ovary and decrease the ovarian reserve.

Secondly, endometriosis can disturb the usual functioning of the reproductive system. Endometriosis is essentially bleeding inside the tummy and once this has occurred, the body sends immune cells to this area, meaning it becomes inflamed and fibrous tissue builds up resulting in something known as toxic pelvic syndrome. Once the egg is released from the ovary, it passes through this poor and toxic environment which can alter the quality of the egg.

Additionally, due to the alternation of auto-immune responses inside the body, the lining of the womb can also be affected, making it difficult for an embryo to be implanted. These issues which affect implantation can unfortunately lead to miscarriages or prevent pregnancy from occurring all together.

Thirdly, treatment for the condition itself can also be a factor which affects fertility. For patients with an endometrioma inside the ovary, even the most precise treatment by a skilled specialist can affect fertility, as tissue is removed from the ovary when the cyst is extracted. For most women, removing an endometrioma will result in a decrease in the ovarian reserve, especially if the cyst is large in size or has been present for a long time.

An endometrioma which has been in the ovary for two or three years will have a lot of scar tissue around it and so once it has been removed, there will be some fresh tissues from the ovary which contain some eggs.

Contraceptive hormone treatment may also be used to supress hormones and control pain symptoms of endometriosis which, of course, also prevents pregnancy. However, long term use of hormonal contraception is highly debated at the moment due to recent studies from the United States which report women having a low ovarian reserve following their use of pills or injections of this type over long periods of time, with some women’s reserve decreasing by between five and fifty-five per cent according to the duration of their treatment.

How is endometriosis currently treated?

For each patient with endometriosis, their treatment will depend on many factors, including their age, the severity of their symptoms and whether or not they wish to become pregnant. All treatment options, however, aim to help to ease the symptoms of endometriosis, rather than curing the condition.

If your symptoms appear to be improving on their own, it’s possible your doctor may recommend not starting treatment immediately. Whatever form of treatment you do opt for is temporary and if you are experiencing issues with subfertility, it’s important that you see a fertility specialist for advice about the best option for treatment in this regard.

There are a number of treatment options for endometriosis which include:

• painkillers
• hormone medicines and contraceptives, including the combined pill, the contraceptive patch, an intrauterine system (IUS), and medicines called gonadotrophin-releasing hormone (GnRH) analogues
• surgery to cut away the endometriosis tissues

In some cases, removal of the uterus and the ovaries may also be suitable, especially in cases of adenomyosis, where the endometriosis affects the muscle of the womb. It’s important to be aware that all types of hormone treatment will affect fertility, as will surgery to remove an endometrioma.

The idea behind these treatment options is to decrease levels of the oestrogen hormone which leads to endometriosis growth. It is true this can mask your symptoms during the treatment period. Even after having surgery, you may experience a temporary period where you are free of symptoms and pregnancy could occur for up to eighteen months following the procedure.

Another aspect of endometriosis management is pain management. Acupuncture, care from a pain therapist as well as cognitive behavioural therapy (CBT) can be very beneficial in relieving pain. CBT, for instance, can help to ease the symptoms of chronic pelvic pain caused by muscle spasm, which can still continue in the memory even after receiving surgery.

In addition, patients with IBS can benefit from trying a Low-FODMAP diet under the supervision of a dietitian. Recently, there has been a lot of talk about the role of diet and microbiomes in treating endometriosis without affecting fertility. More specifically, this relates to following an anti-inflammatory diet which, theoretically, can enhance your reproductive system function and improve your chances of a natural pregnancy.

My recommendation for young patients with endometriosis is to seek fertility specialist advice as soon as possible. There are many options for fertility preservation, such as egg freezing or embryo freezing if you are not currently ready to start a family. These options will be of great benefit later on if you develop severe endometriosis that requires surgical removal.

You can read more about the causes and symptoms of endometriosis and how the condition is diagnosed in his other expert articles in this informative series on endometriosis. 

If you are seeking treatment for endometriosis and wish to discuss your individual case with Dr Elgheriany, you can schedule a consultation with him by visiting his Top Doctors profile.