By fertility experts from Spain.
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.
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.
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
Dr Bechthold added that it is important to remember that not every woman with endometriosis will have fertility issues.
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:
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.
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.
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.
Regarding GnRH, it depends on the stage of your endometriosis. We know that the implantation of the embryo is decreased in patients with endometriosis. Sometimes, we use the GnRH to down-regulate the ovaries, so we know that with that, we can improve the implantation rates. I think it would be recommendable to use it and you have to use it for 3 months, maybe 4 months, it’s not necessary, but it can improve the cycle or the transfer if you use it for 3 months. There is no such thing as a cure, if you suffer and have a lot of symptoms, it’s possible to do an operation, but if you want to get pregnant, it’s also risky. We could remove too much ovary tissue, so normally, we do not recommend surgery before getting pregnant. The only thing we can do is to give some birth control pills Gynogest or also a Progesterone called Gynogest t like the mini pill and you would take it just without any break, so you would not do the 21/ 7 cycle with the pills, you would just take it straight through. You will not cure the endometriosis, but you can get rid of the symptoms, and it would not get worse, let’s say. You can live with that, and many patients live well with that taking that medication.
If you take it for like 3 months, it should not have long term side effects. What GnRH more or less does is putting you in a menopause status, so it just stops the ovarian function, so of course, if you would take GnRH for a long time, you would be in a pre-menopause that can have effects that we don’t want in young women or women before menopause. If you take it for like 3 months, there shouldn’t be any problem.
No, it’s not the same. Fibroids are called little tumors, it’s not a bad thing, it’s like benign. Endometriosis is derived from the word endometrium. Endometrium, so the inner tissue of the uterus that can be found outside of the womb, so it’s not the same.
Adenomyosis is a bit similar to endometriosis. It’s just inside the uterus, so inside the uterus wall. The treatment would be very similar to endometriosis. We would use birth control pills or for example, if we do an embryo transfer in patients with adenomyosis, we recommend doing the down-regulation for 3 months, before having the transfer. More or less, it’s the same treatment.
Unfortunately, there’s not much we can do to improve egg quality. We know, that patients with endometriosis sometimes suffer from poor egg quality, so it’s important to have endometriosis controlled. As I said, it’s not necessary to do an operation, but try to avoid having regular cycles, so with that, maybe we can improve a bit your egg quality. I think that IVF or ICSI would be the option, so if we’re talking about low ovarian reserve, insemination would not make any sense depending on how low, the AMH would be. The option would be IVF, ICSI, or even if it’s really low, and the ovarian reserve is really low, my suggestions would be to go for an egg donation. Normally, IVF or ICSI would be the option.
Yes, if your tube is blocked and swollen, so if it’s filled with liquid, we recommend doing an operation before because if it’s filled with liquid, this liquid can enter the uterus when the embryo wants to implant, and that can be kind of toxic for the embryo. In this case, the recommendation would be to have surgery and remove one tube that is blocked and swollen.
When it comes to down-regulation, we do not recommend it for all patients with endometriosis, it depends a bit on the stage of the endometriosis. As I’ve said, with adenomyosis, we would recommend doing a down-regulation before the transfer. With light endometriosis, it would not be necessary.
We know that the implantation can be lower if you have endometriosis and adenomyosis. More important is egg quality. We also know that implantation can be affected, but often in medicine, there are many studies, and it’s not 100% clear what those studies see. If you have endometriosis and adenomyosis and if you used donor eggs, there was no significant difference in pregnancy rates. It doesn’t seem to have such a great impact. The egg quality is more important, the pregnancy rates are almost the same if you use donor eggs.
Yes, GnRH treatment is a good idea. There’s a difference if just the tubes are blocked, there would be no surgery necessary, it would be necessary if the tube is filled with liquid. That can be seen in a vaginal ultrasound scan, so you just would need to do surgery if the tubes are full of liquid.