Questions? Email Us

Endometriosis and Infertility

Endometriosis and fertility
Treatment of endometriosis-related infertility
Developing a treatment plan

Does Endometriosis Affect Fertility?

In cases where there is obvious distortion of the normal anatomy (i.e. blocking the fallopian tubes), endometriosis is a known cause of fertility. In fact 30-40% of patients with endometriosis are infertile. This is two to three times the rate of infertility in the general population.

In patients with endometriosis, the chance of conception decreases by 20 – 30%. However, the long term pregnancy rates are the same in patients with minimal endometriosis and normal anatomy (i.e., open tubes) Studies provide contradicting information, but the bulk of research at this time indicates that pregnancy rates are not improved by treating minimal endometriosis.

We know that during in vitro fertilization, endometriosis patients have normal hormonal profiles. There is a tendency towards obtaining fewer eggs and it appears that eggs derived from ovaries with endometriomas may have a lower fertilization rate and implantation rate.

Immune System: The immune system is affected by endometriosis and this may affect fertility. Patients with endometriosis may show decreased nature killer cell function. In addition, complement, an immune component that breaks apart abnormal cells, is higher in patients with endometriosis.

Treatment of Endometriosis-Related Infertility

Danazol, birth control pills, Lupron, Synarel, Zoladex, Depo-Provera and Norplant have not been proven effective as either primary or adjunctive therapy (combined with surgery) for endometriosis-related infertility. While the use of medical treatment may decrease inflammatory reactions making surgical correction easier and reduce endometriosis-related pain, use of these medications in patients with minimal disease is of no proven benefit in treating infertility.

Multiple studies have reported a 4-5 times improvement in fecundity (monthly chance of conception) with empirical treatment, superovulation combined with intrauterine insemination. (The medicines commonly used are Follistim®, Repronex®, Gonal F® and Bravelle®.)

While complete removal of all disease and restoration of normal anatomy should be the goal of any surgical treatment, aggressive surgery may result in post-operative adhesion (scar tissue) formation. The endoscopic surgeon may need to strike a balance between excising all visible disease and limiting the risk of adhesion formation. If surgical excision is incomplete or attempts at pregnancy are to be delayed, it is advisable to plan continuous hormonal suppression following surgery. (i.e. use Lupron)
In women with distorted tubal-ovarian anatomy due to endometriosis, the first surgery is the most effective. Repeat surgical interventions are less effective at restoring fertility than the initial attempt, which is best performed by a skilled endoscopist. Endometriosis is generally considered a progressive disorder and aggressive management at the time of its discovery is appropriate.

Surgical treatment of endometriosis consists of cautery, coagulation, excision or vaporization. As most cul-de-sac endometriosis is generally deeper than it may at first appear, excision should be the treatment of choice. Vaporization of adhesions on the ovarian surface, bladder flap, and uterine peritoneum may be beneficial.

Treatment of ovarian endometriomas has included removal of the ovary, simple drainage, destruction of the cyst-lining with laser, bipolar electrosurgery, monopolar electrosurgery, and excision of the ovarian cyst. Although in many cases the cyst-lining can be stripped from inside the ovary during laparoscopy, in approximately 30% of the cases, this cannot be performed. In these cases, unless destruction of the lining is carried out, the endometrioma will likely reoccur.

Pregnancy rates following surgery generally range between 35-40% for severe endometriosis to 55-65% with milder disease. Surgical studies show that monthly pregnancy rates are as low as 3-6% per month following surgical treatment of this disease. Usually normal fertility can be achieved with ovulation induction and intrauterine insemination.

In patients with normal anatomy, it is reasonable to try 3 – 4 cycles of. If normal anatomy cannot be restored or the patient has not been successful with ovulation and intrauterine insemination, in vitro fertilization should be considered. In women with large endometriomas, removal of the ovarian cyst may be necessary prior to proceeding with in vitro fertilization.

Developing a Treatment Plan

When determining appropriate course of treatment for this disease, it is necessary to determine what is the most important to each patient: Improving pain or improving fertility. Sometimes both cannot be accomplished using the same treatment. Surgical treatment is best performed by skilled laparoscopic surgeon who can balance your desired fertility with the need to aggressively excise abnormal endometrial tissue, restore normal anatomy, and treat pain and other symptoms. As this is a progressive, ongoing, long term disorder, patients will do best to establish an ongoing relationship with a physician who can provide appropriate care.