Endometriosis has historically been one of the least understood conditions affecting women and their fertility. In the past, it could take many years for a diagnosis and there were few doctors able to treat the condition. Indeed, the average age of diagnosis is 27 and an estimated 70% of women receive an incorrect diagnosis before their condition is correctly recognized.
The scarcity of information on endometriosis and the low level of social awareness leaves affected women feeling isolated and unsupported.
Although there is still no cure, recent efforts in awareness and diagnostics have led to improved therapeutic options. Best of all, specialist facilities are now available and women with endometriosis can go on to have healthy pregnancies and births.
In this RMA blog, we aim to dispel the myths and misinformation about endometriosis as well as cast some light on how you can recognize endometriosis symptoms, how it may have an impact on your fertility and how to access fertility treatment for endometriosis.
What is endometriosis?
The endometrium is the lining of the womb, or uterus, which builds up each month. If conception has not taken place, it is shed through menstrual bleeding as part of the regular monthly cycle.
Endometriosis is a condition in which endometrium-like material lodges and implants itself in parts of the body outside the uterus – for example in the abdomen, bowels, or fallopian tubes. This material responds to hormonal stimulation to grow and eventually shed in the same way as the uterine lining would at the onset of a period.
Since this tissue is not inside the uterus and cannot exit through the vagina, there is no outlet for the tissue; this causes builds, resulting in inflammation and irritation, and often, mild or severe pain.
The different endometriosis stages are classified according to the severity of the disease:
- Stage 1 represents minimal disease levels, with only a few nodules implanted and no visible scar tissue.
- Stage 2 is a minor level in which there are more implants but the total affected area comprises less than two inches of the abdomen. There is an absence of scar tissue.
- Stage 3 is a moderate level of endometriosis in the abdomen, which may create pockets of endometriotic fluid (also known as chocolate cysts or endometriomas) in the ovaries. There can also be scar tissue around the ovaries or fallopian tubes.
- Stage 4 is the most severe form of the condition with a high level of endometriotic implants. It presents the possibility of large cysts in the ovaries and scar tissue near the intestines and around the fallopian tubes or ovaries.
Symptoms of endometriosis
Every patient is different, and not all women who suffer from endometriosis will experience all of the symptoms. In fact, around 15% to 20% have no symptoms at all and some only realize that they have the condition when they have difficulty becoming pregnant.
However, some level of endometriosis pain is a fairly common occurrence. The level of pain and range of symptoms does not necessarily correlate with the severity of the disease.
Some people can have a mild level of endometriosis and yet experience severe symptoms and some may have severe endometriosis but no symptoms. For the majority of patients, the range of endometriosis symptoms can include:
- Painful cramps during periods and sometimes pelvic pain before a period and at the time of ovulation
- Pain during sex
- Frequent or painful urination, particularly around the time of a period, and bowel symptoms such as painful bowel movements, diarrhea, or constipation, also more commonly around the time of a period
- Leg pain or lower back pain around the time of a period
- Some people with endometriosis also experience other immune disorders like asthma, fibromyalgia, and eczema
The causes of endometriosis are unclear. The condition does not appear to be related to any lifestyle-related factors, and is most certainly a physiological condition rather than ‘all in the mind,’ and there should be no question of blame or stigma attached to those who suffer from it.
Some women with endometriosis maintain diets rich in anti-inflammatory foods to try and control the condition; however, this has not been demonstrated as curative for symptoms.
As we can readily understand from the list of symptoms, this is a distressing condition with a major impact on daily life. The sooner it is diagnosed correctly, the sooner it can be treated.
How is endometriosis diagnosed?
While some level of endometriosis testing can be carried out by means of visualization through ultrasound and MRI scans, many adhesions can evade detection by scans and even more invasive tests such as colonoscopy. A definitive diagnosis of endometriosis can only be made through a laparoscopy.
Laparoscopy, also known as “keyhole surgery,” is a surgical diagnostic procedure used for examining the organs inside the abdomen. This is a minimally invasive and low-risk procedure that only requires small incisions, typically less than 1 centimeter.
A laparoscope, a thin tube equipped with a light and high-resolution camera, is inserted through an incision. As it moves along, it shows images of the inside of the abdomen on a video monitor, allowing the surgeon to see inside the body in real-time without the need for major open surgery.
It is also possible to take samples for biopsy during laparoscopy.
Endometriosis and infertility
While endometriosis can impact fertility, an estimated 70% of women with mild or moderate endometriosis conceive over a period of three years without any fertility treatment.
It is true, however, that severe cases are more likely to be associated with infertility. The reasons for this are not fully understood.
It is not simply a matter of scar tissue causing a blockage in the fallopian tubes, although this can be a contributing factor. Scar tissue can also cause adhesions in the pelvis, distorting anatomical structures.
Infertility can also be caused by an inflammatory response that negatively affects ovulation, fertilization, or implantation of the embryo.
Over the past decade, thousands of women have sought treatment at our RMA offices due to fertility problems associated with endometriosis. If you are experiencing this condition, you can rest assured that you are certainly not alone.
Recent IVIRMA research has found that Early fertility preservation in patients with endometriosis helps increase their chances of pregnancy. You can read the full endometriosis study here.
Fertility treatment for endometriosis
Some types of treatment for endometriosis are aimed at alleviating pain or suppressing symptoms, so not all treatments are appropriate if the patient is intending to become pregnant.
For example, over-the-counter pain relief from NSAID medications can be very effective in reducing endometriosis pain but would not be recommended while trying to have a baby, as it could negatively impact a developing fetus.
Similarly, hormonal-based contraceptive pills containing synthetic estrogen and/or progestin may be prescribed but obviously would not be appropriate in the case of a woman who is trying to become pregnant.
In addition to these above medical options, there are a number of alternative options for fertility treatment for endometriosis. The optimal treatment modality for any given case largely depends on the individual circumstances of the patient, as well as the severity of the disease.
Surgical fertility treatment for endometriosis
There is evidence that pregnancy rates are improved when stage 1 – 2 endometriosis is subject to surgical removal.
For women under 35, this could be the first line of fertility treatment. In the case of stage 3 – 4 endometriosis, pregnancy rates improve when scar tissue or large cysts are removed surgically. If a pregnancy is not conceived within six months after surgery, other fertility treatments such as In Vitro Fertilization (IVF) may be indicated.
In the case of women over 35 years old, other fertility treatments would usually be recommended in place of surgery.
Artificial Insemination (IUI) fertility treatment
Artificial insemination, also known as intrauterine insemination (IUI), is a fertility treatment that combines orally delivered hormonal medication and laboratory intervention.
For stage 1 – 2 endometriosis, an oral fertility hormone medication is given for five days after the start of the menstrual period.
When ovulation occurs, a sperm sample that has been optimized in the laboratory is injected into the woman’s uterus, thus placing sperm and egg as close to one another as possible to maximize the chances of conception.
If this treatment is not successful within approximately three rounds, the next step may be to use injected hormonal medication in combination with IUI or to progress to IVF.
IVF fertility treatment for endometriosis
As we have seen, IVF is likely to be the recommended treatment for cases of severe endometriosis or for affected patients over the age of 35. This well-known and established technique has a number of distinct stages:
- Hormonal medication is administered to stimulate the development of multiple eggs in the ovaries, rather than just one that is typically produced as part of a normal monthly cycle.
- When an adequate number of eggs reach the optimal size, a dose of the hormone hCG and/or leuprolide is delivered in order to induce the maturation of the oocytes. These medications are called “trigger shots.” Around thirty-six hours later, an egg retrieval, which takes place in the fertility clinic, is scheduled.
- The eggs are collected in a minor procedure carried out in an operating room with light sedation to avoid any discomfort.
- The next step is the fertilization of the eggs with sperm that has been prepared in the laboratory. Historically, the two were mixed in a glass dish in a process called conventional insemination, but today the Intracytoplasmic Sperm Injection (ICSI) method is more common. With ICSI, a single selected sperm is microinjected directly into each of the eggs to facilitate fertilization.
- The resulting embryos are cultured in the laboratory for five to seven days, during which time the embryos are monitored and selected. Patients may elect to do genetic testing to determine the chromosomal number to select the healthiest embryos. After this testing, an embryo is deposited into the maternal uterus with the goal of implantation and pregnancy.
Fertility preservation for patients with endometriosis
Fertility preservation is a treatment virtually identical to IVF but the process is ‘interrupted’ after the collection of oocytes.
The eggs are cryopreserved by immersion in liquid nitrogen at a temperature of – 196º to keep them intact as long as necessary before their use in future treatment.
When a patient chooses, the eggs are thawed and the IVF process continues. This includes fertilization of the eggs in the laboratory, observation of the developing embryo, and insertion of the selected embryo into the maternal uterus.
The cryopreservation method of fertility preservation is used by women who wish to delay motherhood for health, social, or financial reasons.
It is also important for women who are about to undergo treatment for cancer, such as chemotherapy or radiotherapy, which could damage their future fertility. In this context, it also has a significant role to play in the treatment of endometriosis.
Because endometriosis is a chronic condition and is likely to worsen over time, it is important that patients receive the correct diagnosis and are advised not to delay attempts at parenthood or fertility preservation.
However, many women avoid surgery as a treatment due to concern for damaged fertility, and they stick with pain relief, which in itself does nothing to help their fertility.
Egg freezing can take away this time pressure and allows women to undergo the most appropriate treatment, including surgery if needed, with confidence.
Endometriosis and pregnancy
The good news is that the best time to conceive is in the few months following surgery to correct mild to moderate cases of endometriosis.
Furthermore, once the longed-for pregnancy has occurred, the very state of being pregnant tends to alleviate symptoms, and following the birth, breastfeeding also usually has the effect of suppressing symptoms.
Dietary Recommendations for Women with Endometriosis
Though very few studies exist on the topic, there does seem to be some scientific evidence that diet, particularly one high in prostaglandin-producing foods, impacts endometriosis. Prostaglandins are chemicals that cause muscles to contract and can also increase inflammation. Consuming a well-balanced, vitamin-rich diet may improve your symptoms and certainly can’t hurt your overall health.
A review of the literature on a woman’s diet and the incidence of endometriosis was published in the journal Reproductive BioMedcine Online in January 2013. The researchers discussed scientific findings over the years that point to a link between diet and the onset of endometriosis.
Increase your intake of omega-3 fatty acids
Omega-3s reduce inflammation in the body which is one of the primary complications of endometriosis. Inflammation is responsible for pain and difficulty trying to conceive. Omega-3 is contained in oily fish like salmon and herring.
Take a Magnesium supplement
Magnesium is found in seeds, whole grains, and vegetables, but we just don’t seem to get enough of it from diet alone. Taking a supplement of 300mg will help relax your muscles and minimize cramping.
Limit red meat and dairy. Increase fruit and vegetable consumption
This is presumed to be because animal fats contain the “bad” kind of fatty acids which increase inflammation.
Limit refined sugars and flours
These can contribute to inflammation. Instead, try raw or organic sugar and whole grains.
Increase fiber intake
Endometriosis is a tricky disease in that scar tissue can attach to other organs outside of the uterus, including your bowels. Women with endometriosis report intense pain and elevated hormone levels can make going to the bathroom an unpleasant experience. Increasing your fiber intake, it will make things a little easier in that department.
Limit caffeine and alcohol intake
For any fertility patient, it is recommended that caffeine and alcohol are consumed in moderation.
Drink more water
Water is good for your health but has some added benefits for managing endometriosis. Increased water consumption can help flush out toxins and can help with cramps and bloating.
Studies have shown that women who engage in frequent exercise have a 75% lower risk of endometriosis
Moderate exercise is probably sufficient and definitely better than sitting on the couch; however, you should always consult your doctor first.
One of the enduring endometriosis myths is that hormonal treatment, such as the contraceptive pill, “cures” the condition. It does not: all such treatments can do is to mitigate the symptoms.
The problem with this is that in patients desiring pregnancy, this kind of temporary amelioration of the problem simply narrows the window of opportunity to seek help with fertility.
If you are suffering from endometriosis, your first step should be to find an endometriosis specialist near you. Make sure any medical practitioner that you consult is fully aware of your objective to become a parent, rather than to merely alleviate your symptoms.
When trying to conceive with endometriosis, the best way forward is to consult a fertility clinic with expertise in endometriosis.
At RMA, we have this expertise and are experienced in treating women with endometriosis and helping them get pregnant and deliver healthy babies.
The most important thing for women with endometriosis is to understand that you are not alone, that there is help, and that you can be a mother.