It’s Endometriosis Awareness Month! Here at Binto, we know how difficult it can be to navigate your health and fertility when managing an endometriosis diagnosis. Today we’re going to explain how endometriosis affects your fertility, and what treatment options are available if you are trying to get pregnant. Let’s dive in.
First, a quick refresher: What is endometriosis?
Endometriosis is a disorder involving abnormal endometrial tissue growth. This tissue normally lines your uterus in the weeks leading up to your period, but in women with endometriosis, it grows in places it shouldn’t. This can include your ovaries, fallopian tubes, bladder, rectum, and even outside of your uterus.
Endometriosis affects over 11% of women in their childbearing years and can be a painful disorder to live with. The most common symptoms are painful periods, pain during sex, or pain when using the bathroom. For more information on pain and endometriosis, click here.
Since endometriosis is a progressive disorder, meaning these growths of tissue may get larger or worse over time, it can take a while to get a clear diagnosis. Endometrial growths can develop as soon as a woman begins menstruating, but often a diagnosis doesn’t come until much later down the line. Some research estimates that this delay in diagnosis can take between 8 and 12 years.
Consequences of A Delayed Diagnosis
Let’s imagine a woman gets her period at 14 and experiences an irregular cycle and intense & debilitating cramps while menstruating. Her doctor may associate these symptoms with the irregularity that is typical when girls first get their period, and encourage her to wait it out to see if her cycle self-regulates.
Fast forward two more years, now she is 16 and still suffering from painful period symptoms which don’t respond to over-the-counter pain medication. Her doctor may prescribe a low grade hormonal birth control pill to help regulate her period and reduce these symptoms. Luckily for her, it works! Her period becomes regular and her symptoms subside.
Moving ahead 14 years into the future, this woman is now 30 and ready to start a family. She decides to stop taking her hormonal birth control pill and starts trying to get pregnant. Unfortunately, after months of trying, she and her partner are unsuccessful. They decide to visit a fertility specialist, and after lots of testing and a laparoscopy, she learns that she has endometriosis.
If her doctor had performed a laparoscopy when she was 16, they might have found the evidence of endometrial growths necessary to diagnose her condition. With hormonal birth control managing her symptoms for so long, her condition went unnoticed until it became apparent that something was affecting her fertility. This sort of situation is not uncommon.
Endometriosis & Infertility
All this to say, many women do not know they suffer from endometriosis until they start trying to get pregnant, especially if they do not experience the typical pain symptoms associated with the condition. Did you know that endometriosis is not always painful? According to NIH, 20-25% of patients are asymptomatic.
While endometriosis can impact your fertility and make it harder to get pregnant, a diagnosis does not necessarily mean the end of the road for your dreams of having a baby. If you are having issues getting pregnant and you have a history of painful periods, it’s a good idea to check in with your healthcare provider and see if they recommend evaluating you for endometriosis.
How Exactly Does Endometriosis Cause Infertility?
Despite extensive research, the academic community has yet to come to an agreement about which mechanisms explain the link between endometriosis and infertility. That being said, there are a few areas of research that point to some potential contributing factors:
“The Pelvic Factor”
One possible cause could be what researchers call the “pelvic factor”. This refers to the growths of endometrial tissue that distort your pelvis. These tissue growths might block eggs from dropping to your uterus the way they should, or block them from being released from the ovary in the first place, getting in the way of conception and implantation. Research indicates that this could be a major factor in women with more severe endometriosis, and thus more tissue physically blocking the path of the egg.
Some research also indicates that endometriosis has a negative effect on your endocrine system, which can impact healthy ovulation. Studies have identified premature luteinizing hormone (LH) surges in women with endometriosis. This hormone tells your body to release an egg from the ovary, so if these surges are not times correctly with your menstrual cycle it could be throwing off your ovulation window. For more information on hormonal imbalances, click here.
Additional research indicates that endometriosis can alter the composition of the peritoneal fluid, a fluid mostly exuded by the ovaries. This fluid functions as a sort of microenvironment around the ovaries, and changes to its composition could impact your ability to grow good quality oocytes.
The inflammation caused by endometriosis can have an effect on embryo implantation as well. Inflammation causes a higher concentration of immune cells in your body which can impact the function of oocytes, embryo, sperm, and your fallopian tubes. In addition, women with endometriosis often have higher levels of certain antibodies in their endometrial tissue, which might affect the ability of an embryo to properly implant.
Eutopic Endometrium Issues
Eutopic endometrium refers to endometrial tissue that is in the right place, aka lining your uterus. Research indicates that endometriosis may cause progesterone resistance in even the tissue that does grow where it’s supposed to be. Since progesterone is so important for supporting the early stages of pregnancy, this can impact implantation rates as well.
Fertility Treatment & Endometriosis
Many of the most common treatments for managing endometriosis involve a symptom management plan. Providers often turn to medications like hormonal birth control to regulate your cycle. These can be considered more of a Band Aid solution, since once you stop taking the hormones the symptoms will return. Also, more obviously, if you’re trying to get pregnant hormonal birth control is not going to be a good treatment option for you.
When we’re talking about fertility and endometriosis, it’s important to get a personalized plan from a fertility specialist. NIH recommends that couples undergo a full medical workup before discussing treatment options with their provider. Be sure to discuss any previous treatment for endometriosis you have received.
Whether you receive an endometriosis diagnosis as part of your fertility diagnosis or you knew you had the condition going into your journey to get pregnant, your provider will be the best point of contact for determining the treatment plan that’s right for you.
What Are My Treatment Options?
Your treatment plan will likely depend on the severity of your individual case of endometriosis. As with any infertility journey, everyone’s body is different and the right approach for you is not a one size fits all decision.
When determining your treatment plan, your provider will consider the following two questions:
- Could surgery help improve my fertility?
- Is natural conception possible?
Considered alongside your age, ovarian reserve, history of surgery, partner’s sperm quality and severity of your case, the answers to these questions will likely guide your next steps.
Since your diagnosis will likely come after a laparoscopy, your doctor will be able to evaluate your ovarian reserve and fallopian tubes and determine whether or not natural conception is possible for you. If they deem it is, or your ovarian function is compromised, they may recommend pursuing IVF right away.
The current medical guidelines recommend abstaining from surgery before pursuing an assisted reproductive technology like IVF, but research does indicate medical treatment plans that can improve your outcomes. A meta-analysis of studies on the topic revealed that a 3-6 month regime of taking gonadotropin-releasing hormone analogues can significantly improve the outcome of assisted reproductive technology, like IVF, for women with endometriosis.
If your doctor believes you will not be able to conceive naturally, or that your endometrial growths are too large to make IVF effective, they may recommend surgery. This is a laparoscopic procedure and allows your doctor to remove the tissue that is getting in the way of conception.
For women with more severe cases of endometriosis, this might be the recommended first step. Removing the tissue blockages can improve your odds of getting pregnant naturally. After surgery, your doctor may ask you to wait for 6-18 months to see if you can conceive naturally before moving forward with further treatment.
Some research recommends that all patients consider surgery as a first step, given how effective it can be at enabling natural conception without the need for IVF. This is slightly counterintuitive, since normally surgery is considered as a last resort if other treatments continue to fail. Since endometriosis is a progressive condition, it’s a good idea to talk with your doctor about whether surgery is right for you. Ultimately everyone’s body is different and the final decision will come on a case by case basis.
Your treatment plan might change depending on how different procedures go. Some women undergo surgery and are able to conceive naturally afterwards. Some women undergo surgery and then also need to undergo IVF. It will all depend on your personal situation and medical history.
One piece of advice: never be afraid to get a second opinion, particularly if you are hesitant about undergoing any of these procedures. Any good provider will understand your desire to make sure you’re moving forward with the best possible plan for your body.
We know endometriosis can be challenging to manage, especially if you are trying to get pregnant. Know that we are here to help and answer any questions you may have. You can reach us anytime using the chat portal or by scheduling a telehealth appointment here.