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Treatment of Endometriosis-Associated Infertility

Can Endometriosis Cause Infertility?

Endometriosis, as discussed in a prior blog, is a condition found in women of reproductive age which commonly causes symptoms of pelvic pain and difficulty conceiving. According to the American Society of Reproductive Medicine (ASRM), up to 50% of women with endometriosis may have subfertility, reducing the probability of having a baby from 20% per month in couples without infertility, to as low as 2-10% in women with endometriosis. Fortunately, not all women with endometriosis will have problems conceiving, but for those that do, there are multiple different treatments that may be available.


What treatments are available if endometriosis is causing your infertility?

If you’ve previously been diagnosed with endometriosis or are concerned you may have it and are having trouble getting pregnant, the first step should be to schedule an appointment with a fertility specialist. If you’ve previously undergone surgery(s), obtaining the operative report for your fertility consultation will help the specialist develop the best treatment plan for you. Regarding treatment options, its easiest to discuss them using the following categories: expectant management (no intervention), medical management, surgical management, and assisted reproductive technology (ART).


Expectant Management

When considering expectant management, there are a couple of factors to consider. Although pregnancy rates are significantly lower compared to couples without endometriosis, for women who have minimal-mild endometriosis (this can only be assessed in surgery), continuing to try and conceive naturally is still possible. This option is not ideal for women that have moderate-severe disease (such as distortion of normal pelvic anatomy/fallopian tubes, presence of endometriomas, or deep pelvic endometriosis lesions), those who have been trying naturally for over a year, women older than 35 years old, or couples with any other additional cause of infertility.


Medical Management

Although medical therapy is effective in relieving pain associated with endometriosis, there is no evidence that medication can improve pregnancy rates when trying to conceive without ART.  In fact, most medications used to treat endometriosis act by shutting down or suppressing ovarian function, which in turn prevent ovulation and delay the time to a potential pregnancy. Similarly, medical hormonal suppression has not shown any benefit when used either before or after surgical management for women who plan to try and conceive naturally.


The one exception for medical management is in women who plan to use In-Vitro Fertilization (IVF) for a treatment option. Studies have shown that using birth control pills for 6-8 weeks or a medication called a GnRH agonist for 3-6 months to shut down your ovaries before IVF, can significantly improve your IVF outcome, especially in patients with more advanced stages of disease.


Surgical Management

Surgical treatment of endometriosis-associated infertility can be useful regardless of how severe the disease, however it is often difficult to decide if its right for you. An article published this month in Fertility and Sterility (S. Singh, 2017) tried to outline proposed indications for surgery. Based on current evidence, the article recommends surgery be used for women with mild-moderate disease, or in patients with any severity of disease who decline or are unable to access interventions such as ART. We believe that the ultimate decision should be individualized to each patient after a full discussion with their fertility doctor.

The surgery is usually done through small abdominal incisions using a camera and instruments (called laparoscopic surgery), which rarely requires an overnight hospital stay. The goal of the surgery it to help restore normal pelvic anatomy by removing scar tissue and endometriosis lesions which can cause inflammation. In patients who have very severe disease or multiple prior surgeries, sometimes surgery won’t be able to restore normal anatomy and the surgical risks may outweigh the benefits. Similarly, removing endometriomas can help improve natural pregnancy rates, but for women that have them bilaterally, or have had them removed previously, there is an increased risk of removing normal ovarian tissue which would decrease the number of eggs available in the ovaries. For these reasons, a discussion should be had with your infertility doctor to weigh the options of surgical treatment versus proceeding directly to IVF.

For women who plan on using IVF, surgery is not routinely performed. Indications for surgery prior to IVF would be for constant pelvic pain or removal of a hydrosalpinx (fluid in the fallopian tube which can impact embryo implantation). Current standard of care also does not support removing endometriomas prior to IVF, especially if greater than 3cm, unless they are causing pain or impeding access to the ovarian follicles which would be aspirated during IVF.


Assisted Reproductive Technologies

Assisted reproductive technology (ART) is the most successful option for patients with endometriosis-associated infertility who are trying to conceive. For patients with normal pelvic anatomy and patent fallopian tubes (usually minimal-moderate endometriosis), treatment with oral/injectable medications combined with an intrauterine insemination (IUI) has been shown to improve pregnancy rates. Although pregnancy rates with this approach can reach 10-15% per month, they are often much lower (~ 5%) and significantly depend on the severity of disease (Macer ML, 2012).


To get the highest pregnancy rates and optimize your chances of conceiving, In-Vitro Fertilization is the best treatment available, regardless of disease severity. Multiple studies have been performed to evaluate IVF outcomes of patients with endometriosis compared to patients with other causes of infertility. Although the data was initially mixed, the majority now appear to show that when matched for age, outcomes are very similar. This means that in general, your chance of conceiving with IVF is at least as good as any other women your same age with infertility. All clinics differ in success rates using IVF, but in general they range from about 40-70% when transferring a genetically normal embryo. Although this is the best option for all stages of endometriosis, it should be even more strongly considered for women who have severe disease, are older than 35 years old, or have additional factors which may be causing infertility (such as problems with ovulation or with sperm).


In summary, although there are currently multiple options to help women conceive, both naturally, as well as with assistance, there is still a lot to learn about endometriosis and how it impacts fertility. The most important thing is to find a fertility specialist you trust to discuss both your medical history as well as family planning goals, so that personal treatment options can be designed specifically for you.

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