Watch the webinar with Dr Jana Bechthold, gynaecologist, fertility specialist at Clinica Tambre, Spain, in which she talked about endometriosis and how it affects fertility. Dr Bechthold also discussed patients’ options for IVF treatment.
Endometriosis — definition
Dr Jana Bechthold explained that we all know the endometrium is the inner lining of the uterus.
Endometriosis is an endometrial tissue that is growing outside the uterus on the outer wall,
it can grow on the ovaries, and for example, also result in the form of cysts. It can also
appear on the bladder bowel.
The endometrium grows every month during our menstruation cycle and results in menstruation.
Endometriosis that is outside the uterus also grows, and there it can cause, for example, pain or other things.
More or less 10 to 15% of women of fertile age suffer from endometriosis, so it’s quite common.
The cause of endometriosis is still not scientifically 100% proven. There are some theories on how endometriosis starts to develop, but they are not yet proven. These are connected with some
genetic issues, immunological and endocrine components. The
hormones of the menstrual cycle also have an impact on endometriosis.
Endometriosis — symptoms
- strong pain during menstruations
- strong & irregular menstrual bleeding
- pain during sex
- changes in colon rhythm
Up to 50% of the women who suffer from endometriosis do not experience any symptoms. On the other hand, not every woman who, for example, has strong pain during menstruations suffers from endometriosis. Therefore,
it can be quite difficult to diagnose endometriosis. If we suspect endometriosis, we can do an ultrasound and sometimes, if there are bigger cysts, it can be seen on ultrasound, but if there are no cysts, it’s really hard to see it. Normally, we maybe would not even see it on the ultrasound.
The diagnosis is done through laparoscopy. If a woman suffers from a lot of pain, and we suspect endometriosis, we should do a laparoscopy. That way, we will be able to see the endometriosis, and we can take a biopsy and verify if it is indeed the endometriosis that we are seeing.
Many women who suffer from endometriosis are diagnosed many years later, so it can sometimes take even 5 or 7 years before it’s diagnosed
Endometriosis — fertility
- up to 50% of the women with endometriosis have fertility issues
- blockage of the fallopian tubes (inflammation)
- decreases the ovarian reserve and the quality of the oocytes
- changes in the menstrual cycle
- deterioration on the immune environment & implantation
Dr Bechthold added that it is important to remember that
not every woman with endometriosis will have fertility issues.
Endometriosis — treatment
There are surgical and conservative options as well as fertility treatments. When it comes to endometriosis, it’s not easy to decide on surgical or conservative therapy. Surgical removal can improve fertility. If we perform a
laparoscopy and get rid of the endometriosis we see in the pelvic, it can improve our fertility, normally it does. The problem is that
endometriosis also often affects the ovaries. If we operate on the ovaries, we will always take some healthy ovarian tissue, which will decrease the ovarian reserve. Therefore, the decision of whether the surgery should be performed is not an easy one. This depends on the severity of each case. How endometriosis is treated, and if the patient has a lot of symptoms or is asymptomatic.
The conservative treatment would be, for example, taking painkillers that we can use and suppression of the ovarian function by hormones. In a lot of cases, we use a specific anti-baby pill without any pause, with that, we can down-regulate the ovaries, there would not be a menstruation cycle.
It’s not possible to heal endometriosis completely, but we can improve it, or just suppress it. Normally, the patients wouldn’t have many symptoms, and then endometriosis would not get worse.
When it comes to fertility options, we can perform:
- insemination: (younger women with light endometriosis)
- IVF/ICSI: more pronounced endometriosis & other factors that affect fertility
- egg donation: women with greatly reduced ovarian reserve
We need to remember that
not only ovarian reserve can be impacted by endometriosis, but also embryo implantation. This can happen due to chronic inflammation, or there are changes in the endometrial lining microbiome. It is also possible that some patients with endometriosis can have a relative progesterone resistance. It would affect the embryo implantation rate as well.
Endometrial receptivity improvement — options
Dr Bechthold later explained that there are some possibilities to improve the endometrial receptivity.
More or less 30% of all patients with or without endometriosis show alterations in the implantation window. That means that
at the moment the embryo is implanting in the endometrium, it is not prepared and ready, it can be
pre-or post-receptive. There are currently 3 tests available that help to determine the endometrium status.
ERA test can help to find the
optimal time for implantation.
ALICE, which lets us know if there’s
any infection in the endometrium. The 3rd test is the
EMMA test, and this tells us about the
microbiome in the endometrium. Those tests can be performed all at once, a small sample of the endometrium is taken. That way, we can eliminate problems with the endometrial lining and improve the endometrium receptivity. We also recommend
checking the progesterone level before the embryo transfer. If it’s decreased, we can add some progesterone before the transfer.
Endometriosis — pregnancy
There’s
no higher risk during pregnancy in patients with endometriosis. Once you get pregnant, there should not be any problems during pregnancy. If you suffer from pain before getting pregnant, usually during pregnancy and breastfeeding, typical symptoms disappear. Unfortunately, endometriosis recurrence is possible. Even if you have an operation and get rid of the endometriosis, it may come back.
About five years later, in around 15% of the patients’ endometriosis comes back.
Conclusions
- endometriosis is a common cause of infertility (10-20% of women at fertile age suffer from it; more or less 50% of these women have fertility issues)
- surgical therapy depends on the severity and the symptoms
- it can lead to fallopian tube conglutination, low ovarian reserves and poor endometrial receptivity
- IVF/ICSI is the best treatment option for women suffering from severe endometriosis
- egg donation would be an option in women that have a very low ovarian reserve (the same pregnancy rates as in patients without endometriosis)
