Endometriosis is a condition where tissue similar to the lining of the uterus grows outside of the uterus, causing pain, irregular bleeding, and often problems with fertility. It is estimated that endometriosis affects 6-10% of women of reproductive age. For women with endometriosis, there is an increased risk of infertility. However, the exact rates of infertility among women with endometriosis vary depending on the location and severity of the disease. In mild cases, there may be little impact on fertility, while in moderate to severe cases, infertility rates can be significantly higher. Overall, about 30-50% of women with endometriosis will experience infertility. But with proper diagnosis and treatment, many women with endometriosis can still get pregnant and have children.
What is endometriosis and how does it impact fertility?
Endometriosis occurs when tissue that is similar to the lining of the uterus grows in other areas, most commonly on the ovaries, fallopian tubes, and tissues around the uterus and pelvis. This endometrial-like tissue responds to hormones each month and breaks down and bleeds, just like the lining of the uterus. But unlike normal uterine lining, this tissue has no way to leave the body. It becomes trapped and leads to inflammation, the formation of scar tissue, cysts, and adhesions.
Several factors related to endometriosis can contribute to infertility:
– Scarring and adhesions can distort or block the fallopian tubes, preventing the egg and sperm from uniting.
– Endometrial tissue on the ovaries and other pelvic structures can distort anatomy and disrupt ovulation.
– Inflammation in the pelvis from endometriosis may impact egg quality and sperm function.
– Endometriosis lesions can interfere with implantation of a fertilized egg.
The exact mechanism by which endometriosis causes infertility is not always clear. The location, extent, and depth of endometriosis tissue seems to matter most when it comes to fertility problems.
What are the rates of infertility with minimal, mild, moderate, and severe endometriosis?
The rate of infertility appears to correlate with the severity of endometriosis:
– **Minimal endometriosis:** Approximately 5-10% of women with minimal disease are infertile. The lesions are small and superficial.
– **Mild endometriosis:** Up to 30% of women with mild disease experience infertility. There are some small lesions and adhesions.
– **Moderate endometriosis:** Approximately 30-50% of women with moderate disease have infertility. There are multiple lesions and scarring.
– **Severe endometriosis:** Up to 50-70% of women with severe disease are infertile. There are extensive lesions, deep implants, and severe adhesions.
Rates of infertility based on endometriosis severity:
| Endometriosis Severity | Rate of Infertility |
|---|---|
| Minimal | 5-10% |
| Mild | Up to 30% |
| Moderate | 30-50% |
| Severe | 50-70% |
As shown, the more extensive the endometriosis, the higher the rates of infertility tend to be. However, even in severe cases, some women are still able to get pregnant without treatment. Much depends on exactly where the endometriosis is located and how it impacts reproductive anatomy.
How does endometriosis-related infertility compare to other causes of infertility?
Endometriosis is one of the top three causes of female infertility. The other major causes include:
– Ovulation disorders – problems with ovulation account for about 25% of female factor infertility. The most common is polycystic ovarian syndrome (PCOS).
– Tubal blockages or damage – blocked or damaged fallopian tubes cause about 25% of female infertility.
– Uterine or cervical issues – like fibroids, polyps, or anatomical abnormalities account for 10-15% of female infertility.
– Unexplained infertility – in about 10-20% of cases, no cause is identified. Some of these may be related to endometriosis that was not visualized.
– Other causes – issues like thyroid problems and hyperprolactinemia make up the remainder of female factor infertility.
Among gynecologic conditions leading to infertility in women, endometriosis is by far the most common. It is responsible for 20-50% of female factor infertility cases.
Some key comparisons regarding infertility rates include:
– 30-50% of women with endometriosis are infertile
– 25% of infertility is caused by ovulation disorders like PCOS
– 25% is caused by tubal factor infertility
– 10-15% by uterine or cervical factors
So endometriosis may account for at least as many or more cases of infertility than any other single gynecologic condition. Identifying it as a cause and providing appropriate treatment is important for improving fertility in affected women.
How do fertility rates differ for women with and without endometriosis?
In women without endometriosis, around 85-90% will get pregnant after 1 year of trying. For healthy couples under 35, the monthly probability of conception without endometriosis is around:
– 15-20% in the first month
– 60-70% by 6 months
– 85% within 12 months
Whereas in women with untreated endometriosis, the monthly conception rates are quite a bit lower:
– 5-10% monthly in minimal endometriosis
– 4% monthly in mild endometriosis
– 2% monthly in moderate endometriosis
This means the chance of pregnancy is halved or less each month compared to couples without endometriosis. Over 12 months:
– Approximately 75% will conceive with minimal disease
– 55% with mild disease
– 30% with moderate disease
And less than 10% of those with severe endometriosis will conceive in a year without treatment.
Clearly, fertility rates are far lower for women with endometriosis across all stages of disease. However, fertility is not necessarily hopeless. With the proper diagnosis and treatment tailored to each individual, many women with endometriosis can still successfully conceive and carry a pregnancy.
Can surgery to remove endometriosis improve fertility?
Surgery can be an effective treatment for endometriosis-related infertility. The goals of surgery are to:
– Remove endometrial lesions, scar tissue, and adhesions. This can help restore normal anatomy and function.
– Provide pain relief. Less chronic pain improves libido and frequency of intercourse.
– Confirm the extent of disease. Knowing the location and severity of endometriosis allows for better management.
Not all women with endometriosis require surgery. But those with moderate to severe disease that has impacted their fertility should consider it.
Types of surgery for endometriosis-related infertility include:
– Laparoscopy – minimally invasive surgery done through small incisions using a camera. Most common technique.
– Laparotomy – open abdominal surgery with larger incision. Rarely used just for endometriosis.
– Hysteroscopy – used to remove endometrial polyps and lesions inside the uterus.
Success rates for pregnancy after laparoscopic surgery for endometriosis are:
– Approximately 60-70% after 1 year without assisted reproduction
– Over 70% after 1 year with assisted reproduction like IVF
However, there are risks of recurrence. Many experts recommend trying to conceive within 6-12 months after surgery before the endometriosis returns. Laparoscopy can greatly improve the chances of pregnancy but outcomes still depend on the extent of disease and whether other fertility issues exist.
What medical treatments improve fertility with endometriosis?
Several medication options may be used alongside or after surgery to improve the chances of conception for women with endometriosis:
– **Oral contraceptives -** Help temporarily suppress endometriosis lesions and control painful symptoms. Often used before surgery or to delay recurrence after surgery. Do not take while trying to conceive.
– **Gonadotropin-releasing hormone (GnRH) agonists -** Hormone therapy that induces a temporary menopausal state, suppressing ovarian function. Helps improve symptom control prior to surgery. Causes thin uterine lining so cannot use while attempting conception.
– **Aromatase inhibitors -** Helps lower estrogen levels to suppress any remaining endometriosis lesions after surgery. May improve pregnancy rates.
– **NSAIDs -** Help reduce inflammation and provide pain relief during attempts to conceive.
– **Adjuvant treatments -** Some research shows melatonin, pentoxifylline, and Chinese herbs may improve fertility with endo. More studies needed.
– **Fertility medications -** Ovulation induction agents like clomiphene or gonadotropins can improve fertility if endometriosis has caused ovulatory problems.
Medical management combined with the surgical removal of endometriosis provides the best chance of conception for patients with endometriosis-related infertility. Treatment should be individualized based on each patient’s symptoms, exam findings, and infertility workup.
How effective is IVF for treating infertility caused by endometriosis?
In vitro fertilization (IVF) is often an effective last resort for achieving pregnancy when endometriosis has caused severely reduced fertility not amenable to surgery or other treatments. Success rates with IVF for endometriosis patients are:
– Approximately 28-30% per IVF cycle when using the patient’s own eggs
– Around 45% cumulative live birth rate after 2 cycles
– Up to 60% success rate with 3 complete IVF cycles
Success is again very dependent on the severity of disease and age/egg quality for each patient. Using donor eggs from a younger woman with IVF significantly improves live birth rates in cases of advanced endometriosis. Some key advantages of IVF include:
– The ability to fertilize and develop embryos in a protected laboratory environment.
– Circumventing distorted pelvic anatomy and allowing direct embryo transfer into the uterus.
– Screening embryos for genetic issues before transfer.
– Option to use frozen embryos to attempt multiple transfers from a single egg retrieval.
– Can be used in conjunction with laparoscopic surgery to maximize results.
Despite moderate per cycle success rates, IVF provides an important pathway to parenthood for many endometriosis patients battling infertility. Patients should undergo an infertility workup first before pursuing IVF. Multiple treatment options, including surgery to remove endometriosis, should be tried before IVF when possible.
What are the best fertility treatment options for endometriosis patients?
There is no single best treatment for every patient with endometriosis-associated infertility. Treatment must be individualized and may incorporate a combination of approaches over time. General fertility treatment recommendations based on endometriosis severity include:
**Minimal to mild endometriosis**
– 6 months of attempting natural conception
– Laparoscopic surgery to remove endometriosis and restore anatomy
– Post-surgical medical therapy for symptom relief
– Ovulation inducing medications if needed
– 2-3 cycles of monitored medicated IUI treatment
– IVF if no success with above treatments
**Moderate endometriosis**
– 3-6 months attempting natural conception with timed intercourse
– Laparoscopic surgery with excision of all visible endometriosis
– Trying naturally for 6 months after surgery
– Use of ovulation stimulation medications combined with IUI for 3-4 cycles
– IVF after the above steps have failed
**Severe endometriosis**
– Laparoscopic surgery with extensive excision of disease
– Potential need for fertility specialist immediately after surgery
– Use of suppression therapy temporarily to prevent lesion recurrence
– Proceeding rapidly to IVF if pregnancy not quickly achieved after surgery
– Donor eggs a strong option for patients >35 years old
Treatment must be a shared discussion between doctor and patient based on symptoms, exam findings, test results, and desires for intervention or time spent trying to conceive. Endometriosis patients should see a fertility specialist and have a full infertility workup done early in the process. Prompt and thorough treatment provides the best odds of conception.
Conclusion
Endometriosis significantly impacts fertility and conception rates. Approximately 30-50% of women with endometriosis will experience infertility. Rates of infertility correlate with severity of disease. However, even women with severe endometriosis can get pregnant in some cases, and should not lose complete hope. A combination approach of surgical removal of endometriosis followed by fertility medications, ovulation induction, artificial insemination, and/or IVF provides the best outcomes for patients. Treatment must be tailored to each unique patient scenario. While endometriosis can make getting pregnant more difficult, there are many proactive fertility treatment options women should explore with their trusted healthcare providers. With proper diagnosis and management, parenthood can still be successfully achieved for many women living with endometriosis.