What is endometriosis?
Endometriosis is a condition where tissue similar to the inner lining of the womb (endometrium) is found elsewhere, usually in the pelvis around the womb, ovaries and fallopian tubes. It is a very common condition, affecting around 1 in 10 women. You are more likely to develop endometriosis if your mother or sister has had it. Endometriosis usually affects women during their reproductive years. It can be a long-term condition that can have a significant impact on your general physical health, emotional wellbeing and daily routine.
What are the symptoms of Endometriosis?
Common symptoms include pelvic pain and painful, sometimes irregular or heavy periods. It can cause pain during or after sex and can lead to fertility problems. You may also have pain related to your bowels, bladder, lower back or the tops of your legs, and experience long-term fatigue. Some women with endometriosis do not have any symptoms. Endometriosis can cause pain that occurs in a regular pattern, becoming worse before and during your period. Some women experience pain all the time but for others, it may come and go. The pain may get better during pregnancy and sometimes it may disappear without any treatment
What causes endometriosis?
The exact cause of endometriosis is not known but it is hormone-dependent. This means that, just like the endometrium which response to hormonal changes resulting in a period, the endometrial-like tissue located outside the womb also bleeds. This bleeding can cause pain, inflammation and scarring, and can damage your pelvic organs.
Endometriosis may be found:
• on the ovaries, where it can form cysts (often referred to as endometriomas or ‘chocolate cysts’)
• in the peritoneum (the lining of the pelvis and abdomen)
• in or on the fallopian tubes
• on, behind or around the womb
• in the area between the vagina and the rectum. Endometriosis can also occur within the muscle wall of the womb (adenomyosis) and occasionally on the bowel and/or bladder. It may sometimes be found in other parts of the body, but this is rare.
How is Endometriosis diagnosed?
Endometriosis can be a difficult condition to diagnose. This is because:
• the symptoms of endometriosis vary so much
• the symptoms are common and can be similar to the pain caused by other conditions such as irritable bowel syndrome (IBS) or pelvic inflammatory disease (PID);
• different women have different symptoms
• some women have no symptoms.
What are the tests for endometriosis?
Tests usually include a pelvic ultrasound scan. This may be a transvaginal scan to check the uterus and ovaries. It may show whether there is an endometriotic (also known as a ‘chocolate’) cyst in the ovaries or may suggest endometriosis between the vagina and rectum. You may be offered a laparoscopy, which is the only way to get a definite diagnosis. This is carried out under a general anaesthetic. Small cuts are made in your abdomen and a telescope is inserted to look at your pelvis. You may have a biopsy to confirm the diagnosis and images may be taken for your medical records. Your doctor may suggest treating the endometriosis at the time of your first laparoscopy, either by removing cysts on the ovaries or treating any areas on the lining of your pelvis. This may avoid a second operation. Sometimes, however, the extent of endometriosis found means that you may need further tests or treatment. The procedure, including any risks and the benefits, will be discussed with you. After your operation you be will be told the results. You can often go home the same day after a laparoscopy.
What are the options for the treatment of endometriosis?
Pain-relieving medication: There are several different medications to help relieve your pain.
Hormone treatments: These treatments reduce or stop ovulation (the release of an egg from the ovary) and therefore allow the endometriosis to shrink by decreasing hormonal stimulation. Various options include combined oral contraceptive (COC) pill or patch, an intrauterine system (IUS/Mirena®), progestogens injections, tablets or implants and GnRH Agonist (Prostap).
Surgery: Surgery can treat or remove areas of endometriosis. The surgery recommended will depend on where the endometriosis is and how extensive it is. This may be done when the diagnosis is made or may be offered later. Success rates vary and you may need further surgery. Possible operations include:
• laparoscopic surgery (keyhole surgery) – when patches of endometriosis are destroyed or removed
• laparotomy (Open operation) – for more severe cases
How could endometriosis affect your ability to get pregnant naturally?
Getting pregnant can be a problem for some women with endometriosis. Hormonal treatment is not advisable when you are trying to conceive, and surgical treatment may be more appropriate.
There is an association between infertility and endometriosis. Endometriosis may cause a toxic effect on eggs, sperms and embryos, and impairment of tubal motility: endometriotic implants secrete pro-inflammatory chemicals called cytokines. It may lead to an abnormal follicular environment, high in cytokines. In cases of moderate and severe endometriosis chances of natural conception are reduced. This is because more adhesions can trap the egg and stop it from moving down the Fallopian tube. The inflammation and irritation caused by the endometriosis can affect fertility. Inflammation of the fimbria, which picks up the egg and transports it into the fallopian tube, causes swelling and scarring so the egg may not reach its destination. As well, the inflammation damages the sperm and eggs when they are exposed to the inhospitable environment caused by the endometriosis. In more advanced cases, the endometriosis starts to cause adhesions, and the pelvic organs become stuck to each other, resulting in decreased function. Endometriosis can also block the fallopian tubes.
What fertility treatment options are available for women with endometriosis?
There are several fertility treatments options available for women with endometriosis. The suitability of the treatments depends on the severity of the endometriosis, the woman’s age, how long they have been trying to conceive and whether there are other fertility factors. We tailor fertility treatment and suppression of endometriosis with P4 fertility protocols.
For infertility caused by endometriosis, rates of pregnancy are much improved with IVF treatment. Exactly which treatment is right for you depends on a variety of individual factors such as egg reserve, so we offer tailor-made treatment protocols depending on each patient’s needs.
Shall I treatment endometriosis first before IVF treatment?
If fertility and having a baby is your primary goal, then you should see a fertility doctor then an endometriosis specialist. If you are getting symptoms of pain with endometriosis and that is your primary concern than having a baby, you should see an endometriosis expert first.
This is because every expert thinks primarily on what the best option of the patient in their area of expertise is. If you are keen to have baby, although you have been diagnosed with endometriosis or there is a suspicion of endometriosis, the best option is to consult fertility consultant. At P4 fertility, we discuss the endometriosis in detail with the latest evidence-based treatment options to balance your individual need.
In few women, it is wise to have minimal invasive and minimum damaging treatment for endometriosis before IVF, on the other hand, it would the best decision to start IVF immediately with suppression endometriosis with fertility drugs for another group of women.
Endometriosis has various grades of severity and organ involvement.
If the ovarian reserve is already on the lower side of the normal range, any further surgery in the pelvis on or around ovaries could damage the eggs in ovaries. This could further result in poor ovarian reserve.
It requires discussion on an individual level if the endometriosis is resulting in large chocolate cyst / endometriotic cyst. The complexity is, if such cyst is excised completely, there is a chance that it will reduce ovarian reserve (total number of eggs ovaries have). If it is not operated, it can cause difficulty in getting all follicles during IVF egg collection. Therefore, at P4 fertility we trust on personalised plans as not one size (one approach) fits all.
Does endometriosis increased risk of infections in IVF?
Yes. An endometriotic cyst is a good medium for bugs to grow. During egg collection, there is a risk of introducing an infection inside. It can result in severe infection. We advise antibiotics for such women at the time of egg collection.