The relationship between endometriosis and infertility explored

In this article below, highly regarded consultant gynaecologist, Mr Hemant Vakharia, shares his expert insights with regards to the relationship between endometriosis and fertility. 

How does endometriosis affect fertility?

Endometriosis is a condition where tissue similar to the lining inside the uterus (endometrium) grows outside the uterus, leading to various symptoms, including painful periods, pain with intercourse, heavy periods, and in some people, difficulty conceiving. 

The prevalence of endometriosis in women of reproductive age in the UK is approximately 10%; in women with subfertility it increases to 25–50%. When it comes to fertility, endometriosis can affect it in several ways:

1. Inflammation and scarring: The endometriotic tissue outside the uterus can cause inflammation (the body's response to injury or infection) and scarring (fibrous tissue that replaces normal tissue after an injury). This can affect the ovaries, fallopian tubes, and the lining of the pelvic cavity, potentially hindering the movement of the egg and sperm and also causing adhesions (structures sticking together). 

2. Impaired egg quality: Endometriosis when affecting the ovaries directly can lead to the formation of cysts known as endometriomata. These cysts can negatively impact ovarian tissue, potentially affecting the quality and quantity of eggs.

3. Blocked fallopian tubes: The scarring caused by endometriosis as described above can lead to the fallopian tubes becoming blocked, preventing the egg and sperm from meeting, which is essential for fertilisation. Up to 30% of women with endometriosis have tubal pathology (obstruction, adhesions or hydrosalpinx - (swollen fallopian tube)).

4. Altered pelvic environment: Endometriosis can lead to changes in the hormonal environment necessary for ovulation (the release of an egg from the ovary), fertilisation, and implantation of the embryo in the uterus.

Crucially, not all individuals with endometriosis will experience difficulty conceiving as the impact of endometriosis on fertility can vary greatly from person to person.

What are the options for getting pregnant with endometriosis?

The chances and challenges of achieving pregnancy with endometriosis largely stem from how the condition affects the reproductive organs in an individual. As mentioned above, inflammation and scar tissue can distort the anatomy of the pelvis, making it harder for the sperm to reach the egg or for the fertilised egg to implant in the uterus.

The quality of the eggs can also be compromised, and the environment within the uterus may become less conducive to implantation, further complicating the process of getting pregnant. These are all unique variable to an individual and therefore the chances of conceiving depend on individual circumstances. 

Despite these challenges, there are several options for those looking to conceive with endometriosis:

1. Medical treatment: Hormonal treatments can sometimes be used to manage the symptoms of endometriosis and reduce inflammation until the patient is ready to conceive.  Medical therapies do not eradicate the endometriosis however and studies have shown no benefit in endometriosis-related infertility.
2. Surgery: Surgery to remove endometriosis tissue can alleviate pain and may improve fertility, particularly for those with mild to moderate endometriosis. This is typically done laparoscopically, a minimally invasive procedure that removes endometrial implants and scar tissue. The evidence for the benefit for surgery in severe disease is less clear and depends on individual circumstances 
3. Assisted reproductive technologies (ART): Techniques such as in vitro fertilisation (IVF) can be helpful for those with endometriosis especially in those with blocked fallopian tubes. IVF involves fertilising an egg outside the body and then implanting the embryo into the uterus, bypassing many of the challenges endometriosis may pose to natural conception. 
4. Lifestyle changes: Whilst not a direct treatment for difficulty conceiving, adopting certain lifestyle changes can support overall reproductive health. This includes maintaining a healthy weight, reducing stress, and stopping smoking.

Does everyone with endometriosis require infertility treatment? What does that entail? 

The short answer is no. Not everyone with endometriosis will require fertility treatment and some patients may not realise they have endometriosis until it is picked up on imaging or during a surgical procedure.

Can you get pregnant naturally with endometriosis?

Absolutely!  I have seen patients with severe endometriosis conceive naturally but again this depends on their individual circumstances.

Does endometriosis affect pregnancy? How?

Endometriosis can affect pregnancy in a number of ways. Studies have shown that endometriosis in pregnancy is associated with an increased risk of spontaneous miscarriage, pre-eclampsia, postpartum haemorrhage (bleeding after birth), caesarean section, placenta praevia, fetal growth restriction, prematurity and adverse neonatal outcomes.

Those with mild disease are considered less at risk and in general can expect a normal pregnancy and labour. Those with serve disease are considered high-risk and require additional antenatal and intrapartum care.

How can I prepare my body for pregnancy with endometriosis?

There is no specific advice in this context but it is important to discuss your pregnancy with your midwife and be booked under consultant led care, especially in those with severe disease. Of course, general lifestyle measures such as maintaining a healthy weight, reducing stress, and stopping smoking apply as they do to all patients.  

Can endometriosis cause ectopic pregnancy? Is there anything that can be done to help avoid this?

In patient with tubal disease (blocked fallopian tubes/swollen tubes) there is an increased risk of a tubal ectopic pregnancy. In some cases, to improve fertility outcomes, patients may be advised to have the affected tube clipped or removed to reduce this risk. If not, then there is nothing specific that can be done to avoid this, but patients are advised to have an early scan in pregnancy.