What is endometriosis?
Endometriosis is normal tissue in an abnormal location. The endometrial lining that normally sheds every month also can flow back through the fallopian tubes and into the abdomen. For most women, this tissue will naturally be absorbed by the body but in a small percentage that endometrial tissue will implant and lead to endometriosis. Women with endometriosis can experience pelvic pain and infertility.
How does endometriosis cause infertility?
The most obvious way endometriosis can lead to infertility is through distorted pelvic anatomy. You can imagine as the endometrial tissue comes of the fallopian tube, it can implant on the ovary (and lead to an endometriosis cyst called an endometrioma) or implant right next to the tube and cause scar tissue that can lead to occluded fallopian tubes. The other more subtle effects from endometriosis may be secondary to an altered intra-abdominal inflammatory environment or effects on egg quality.
What fertility treatment is recommended?
Surgery is not recommended to improve fertility for minimal or mild endometriosis, or in women with otherwise unexplained infertility just to evaluate for the presence of endometriosis. In these women, it is reasonable to consider simple treatment options such as ovarian stimulation with intrauterine insemination (IUI). A randomized control trial evaluated this in women with minimal or mild endometriosis. The live birth rate in this study was 11% with IUI versus 2% without treatment. During an IUI the ovulated egg is still, however, exposed to the intra-abdominal environment that is associated with subfertility in endometriosis. Therefore, the highest success rates are seen with in vitro fertilization (IVF) which avoids this inflammatory environment either as a second step if simpler treatments are unsuccessful or as first line therapy. Certainly, patients also with advanced maternal age, diminished ovarian reserve, male factor, or a combination of these should consider immediate IVF. In patients with an endometrioma planning IVF, surgery prior does not improve outcomes and may hinder outcomes by reducing ovarian reserve. The exceptions to this would very large endometriomas that may inhibit our ability to perform an egg retrieval or in patients with severe pain.
March is Endometriosis Awareness Month and a great opportunity to start a conversation. If you have endometriosis and are struggling with infertility, call 843-883-5800 to make an appointment!