Endometriosis and Fertility

At the outset, may I say that the average delay in the diagnosis of endometriosis worldwide is eight years. Despite the old literature that is still regurgitated, endometriosis often starts in adolescence. Symptoms may include, but are not limited to:

• Painful, heavy menstrual periods
• Painful intercourse
• Period pain generally
• Pain with ovulation
• Lower-back pain or pain down the legs
• Painful bowel movements or pain with urination at the time of the period
• Infertility

An important aspect I always ask about is whether or not the women, when younger, actually had to take time off school or time off work. The very fact that a woman is having trouble falling pregnant may even point to a diagnosis of endometriosis, if it has not already been found. Although the overall incidence is 10% in the general population, it is up to 40% in the infertile population.

Interestingly, some women who have endometriosis have no symptoms, and the condition is only diagnosed for the first time during a laparoscopy, performed as one of the tools used for fertility investigation. Importantly, an ultrasound scan is generally not helpful. This is a fact that most GPs and the general public often fail to understand.

Unfortunately, the presence of severe endometriosis can result in distortion of the pelvic anatomy. This occurs particularly between the tubes and the ovaries, and the tubes may become blocked or the actual function of the fallopian tubes may become compromised. In some cases, endometriosis impacts on a woman’s chances of falling pregnant due to altered egg quality or even ovulation itself. The blood supply to the endometrium may be disrupted and, specifically, the spiral arteries that supply the endometrium may be narrowed. The effect on the fallopian tubes, and in turn the transportation of the fertilised egg to the uterine cavity from the tube, maybe be compromised as well. Obviously, some women still fall pregnant without intervention and I guess they are the lucky ones.

Endometriosis can be treated in several ways. How we treat it depends on the severity of the condition, and whether the primary goal is to treat pain, maximise fertility or indeed both.

Surgical Treatment: In my opinion, a laparoscopy should be the first line of investigation undertaken if a patient presents with symptoms suggestive of endometriosis. As outlined above, an ultrasound scan is of very little, if any, help. At laparoscopy, modern surgeons no longer burn, zap, or “treat” endometriosis without actually excising (surgically cutting) it. That is to say, an area of normal tissue, including the abnormal tissue, must be removed or excised to fully remove the abnormal areas of endometriosis. Failure to do so on the first laparoscopy will lead to a recurrence of the disease and symptoms.

Medical Treatments: Once endometriosis is excised, medical treatment is then undertaken to suppress the patient’s periods to conserve fertility. I use a group of drugs called GnRH analogues (Zoladex/Synarel), which may be needed for up to 6 months to suppress the endometriosis before starting IVF treatment.

There are also numerous hormonal medications, including Provera, Primolut and the (progesterone-impregnated) Mirena IUD.

Assisted Reproductive Technology: Sometimes surgical treatment may be enough to allow a couple to conceive, but if that does not help, then initially Intra-Uterine Insemination (IUI) may be considered. If that fails, then after a few cycles, IVF should be discussed. Furthermore, if a woman’s fallopian tubes have been damaged beyond repair, or if there is a Hydrosalpinx (the tubes swollen and filled with fluid), then IUI will not help and IVF is the only course of action.

Only in the past 10 years or so has the importance of excluding adenomyosis (the cousin of endometriosis) before IVF is undertaken been realised in the process of fertility investigation and treatment.

With the modern laparoscope and an interested and informed surgeon, the uterus affected by adenomyosis, when seen at laparoscopy, is seen to be soft, “bumpy” and to contain surface markings consistent with inflammation.

Recent articles (see references below) suggest that an MRI scan should be ordered on patients suspected of having adenomyosis to look at the junctional zone (the zone between the endometrium and the muscle, or myometrium, of the uterus). An MRI should be undertaken at the correct time of the cycle. That time is just before ovulation, perhaps on day 10, 11 or 12 of the cycle. At this time, the radiologist will look carefully at the junctional zone (JZ). The JZ should be only 5mm in depth. However, when this zone measures 12mm or more, or if the JZ is more than 40% of the total width of the uterus, the diagnosis, suspected at laparoscopy, is confirmed.

Two important articles (see references below) suggest the use of “downregulation” drugs (meaning switching off estrogen temporarily) until remodelling of the very special blood vessels (spiral arteries). These are the blood vessels that will supply blood to the endometrium and therefore the fetus early on. This remodelling involves a change in the spiral arteries, which have been constricted by adenomyosis, or indeed, severe endometriosis, to very narrow diameters. By starving the adenomyosis or endometriosis of estrogen, these spiral arteries regenerate and become more dilated, and are more receptive to embryo implantation!

Untreated adenomyosis is associated with difficulty conceiving, recurrent miscarriages, serial failed implantation at IVF/embryo transfer, small-birthweight babies and premature labour.

Interestingly, I am seeing more and more teenage patients with this condition.

This highlights the fact that one cannot talk about endometriosis without talking about adenomyosis.

Brosens, Pacenta 34 (2013) 100-105
Tremellen and Russell, ANZJO+G; 2011; 51; 280-283