Endometriosis and Infertility:
Endometriosis is commonly associated with infertility. It is associated in 30% of women who have infertility. 14% of couples present to their GP and then to their specialist with infertility. These couples should have appropriate investigations which would include an assessment of ovulation, confirmation of immunity to rubella and chicken pox, a semen analysis on the male partner and an ultrasound to see if there is any endometrioma within the pelvis. This is then followed by a laparoscopy to assess the state of the pelvis and the tubes.
Treatment of the endometriosis can often occur at this primary laparoscopic procedure. The principle treatment of endometriosis is surgical. Occasionally patients will require a 2 step procedure depending on the severity of the disease.
Endometriosis causes infertility in different ways. If the endometriosis damages the tubes and the ovaries then this will significantly reduce the woman’s ability to conceive. This will significantly alter the movement of the egg and sperm.
Even if the tubes and ovaries are not damaged then the endometriosis can affect the movement of sperm, egg pick up by the tube, egg fertilisation, embryo growth and implantation.
Suppression of ovarian function with drugs does not improve infertility in minimal to mild endometriosis. It should not be offered for this indication with women with endometriosis. It may have a place in pre-treatment of patients who are about to undergo IVF. Treatment with ovarian suppression using gnrh analogues maybe of value for 2-3 months prior to starting an IVF cycle.
Surgical treatment of endometriosis is the most effective method of treatment with an infertile woman with minimal to mild endometriosis. Surgical excision of more significant moderate to severe endometriosis also appears to improve infertility. Certainly patients who have ovarian endometriomas removed that are above 4cm do have a significant improvement of their fertility. Our recommendation for patients who have had their endometriosis removed and their anatomy corrected is to try and conceive spontaneously for the next 6 months. If they have not conceived after that time then IVF is the appropriate course of action.
One of the main reasons that ECCA is dedicated to diagnosing and treating endometriosis is prevention of infertility. Many women have symptoms for many years before diagnosis of endometriosis is made. Often the endometriosis is progressive and destructive to the pelvic tissues. It is important that a young woman who suspects that she has endometriosis seek help. These women should have a laparoscopy and treatment of their endometriosis as this is the best way to preserve their long term fertility. This is one of the most important take home messages of this chapter on endometriosis and infertility.
Women who have endometriosis from moderate to severe degree in the ovaries and who are in danger of losing one or both ovaries may wish to store a small piece of the ovary to use as a possible source of eggs in the future. Eggs can be obtained in these patients either by the patient undergoing an IVF cycle and storing eggs or ovarian tissue may be removed and immature eggs identified, removed and frozen. There have been many advances in the area of cryo preservation (freezing) of eggs and subsequent maturing and fertilisation of these eggs.
Patients with severe endometriosis in the ovary may lose both ovaries and retain the uterus. Subsequently a donor egg may be used to obtain a pregnancy.