During this session, Dr Elias Tsakos, FRCOG, Medical Director of Embryoclinic – Assisted Reproduction Clinic in Thessaloniki discussed the impact of endometriosis on IVF results, ways to treat it and outcomes.
Endometriosis – what is it?
Endometriosis is a condition in which tissue from the lining of the uterus, known as endometrial tissue, grows in ectopic locations. These locations can include the tubes, ovaries, uterus, peritoneum, intestines, bladder, and even remote areas like the diaphragm, chest, surgical scars, and eyelids. The presence of endometrial cells in these ectopic sites can lead to small bleeding areas and inflammation, causing various symptoms such as pain and infertility.
How common is endometriosis?
Endometriosis affects approximately 10% of women, making it quite common. It has been estimated that around 200 million women worldwide suffer from endometriosis. While it mainly affects women of reproductive age, it can also be found in women older than 50 or 60 years old. The most common age range affected by endometriosis is between 30 and 40, and the diagnosis is often delayed by about 7 years or more.
Endometriosis and fibroids are more common in African and Asian populations, but they can be found worldwide, including in the Americas and Europe. The age distribution of endometriosis shows that the highest prevalence is between 30 and 40. However, considering the potential delay in diagnosis, the disease may have started much earlier but remained undetected until that age range.
Clinical symptoms of endometriosis
Common symptoms of endometriosis include tiredness, low energy, abdominal pain, painful periods (dysmenorrhea), pelvic pain, back pain, and abdominal bloating. Additional symptoms may include painful intercourse, painful passage of stools, and painful urination. These symptoms arise due to chronic inflammation, chronic pain, and irritation affecting various organs.
Endometriosis & Infertility
Endometriosis is associated with infertility in about 30% to 50% of women. The presence of endometriosis increases the chance of coexisting infertility, and the effect on fertility can be five times higher than in the general population. Endometriosis can affect fertility through various mechanisms, including damage to the fallopian tubes, impaired ovarian function, effects on the uterus and implantation, and potential effects on sperm.
Endometriosis – outcomes and challenges
Endometriosis can affect pregnancy outcomes, with higher rates of placenta previa and increased bleeding risks. However, there are no significant differences in live birth rates, low birth weight rates, or neonatal complications. The challenges in treating endometriosis lie in the chronic nature of the disease, delayed diagnosis, extensive organ damage, and the complexity of managing both fertility and symptoms. The responsibility of managing endometriosis in fertility patients requires careful consideration, individualized treatment plans, and comprehensive support from a multidisciplinary team.
When undergoing assisted reproductive techniques like in vitro fertilization (IVF), women with endometriosis have lower implantation rates and fewer eggs retrieved. This can be attributed to the effects of endometriosis on the ovaries. Furthermore, the chance of multiple pregnancies and ectopic pregnancies is higher in women with endometriosis, making it more challenging to achieve successful outcomes in IVF.
During pregnancy, women with endometriosis have a higher risk of placenta previa (abnormal location of the placenta) and increased bleeding rates. However, there are no significant differences in live birth rates, low birth weight rates, or neonatal complications. Proper management can help mitigate these risks and ensure the well-being of both the mother and the baby.
Endometriosis – treatment options
Treatment for endometriosis and fertility aims to balance preservation and enhancement of fertility while alleviating symptoms. It often requires a multidisciplinary team, including gynaecologists, fertility specialists, minimal access gynaecologists, pain management specialists, and more. Treatment options can include surgery, medical management, hormonal manipulation, and fertility treatments such as in vitro fertilization (IVF) or oocyte cryopreservation (egg freezing). The choice of treatment depends on factors such as the patient’s age, physical condition, extent and severity of the disease, additional infertility factors, and severity of pain.
Treating endometriosis in the context of fertility is a challenging task, and its treatment becomes even more challenging for fertility patients. The primary goals in such cases are to strike a balance between preserving and enhancing fertility while also alleviating symptoms. Radical surgery is not desired, but effective surgery, such as plasma minus effective medical management, can be considered.
It is crucial to consider various factors when making decisions about endometriosis and fertility treatment.
The age and physical condition of the patient are significant determinants. For young patients not planning to have a family yet, fertility preservation options like oocyte or embryo cryopreservation may be considered. For symptomatic patients, a combination of surgery and medical management can be used. It’s important to note that managing endometriosis requires a multidisciplinary team, as no gynaecologist alone should be solely responsible for the treatment. The team should include a fertility gynaecologist, minimal access gynaecologist, robotic surgeon, imaging specialist, pain management specialist, psychologists, colorectal surgeons, and nurses.
The extent and severity of the disease also play a crucial role. Balancing symptom alleviation and fertility enhancement becomes challenging. Surgical excision, especially through laparoscopy or robotic surgery, has shown improvement in pregnancy rates, even in cases classified as unexplained infertility. Therefore, considering laparoscopy for younger women with suspected endometriosis and unexplained infertility may be beneficial.
Infertility factors beyond endometriosis are also important to consider. Complex cases involving deep endometriosis, ovarian endometriosis, and additional male factor problems require careful evaluation and discussion with the patient to determine the best course of action. Depending on the circumstances, options like oocyte donation, surrogacy, or advanced fertility treatments like IVF or ICSI may be considered.
Medical treatments for endometriosis include various hormonal manipulation, suppression, contraceptives, and anti-inflammatory or antioxidant agents. Surgical options have advanced with minimally invasive solutions, such as laparoscopy and robotic surgery. Robotic surgery provides improved control, precise movements, safer excision, and minimal complications, allowing for careful sparing and protection of healthy tissues, including reproductive organs, vessels, and nerves.
In addition to traditional treatments, emerging options like molecular targeting in gene expression, prostaglandin inhibitors, and stem cells are being explored, although they are still considered experimental.
The key take-home messages are:
- Endometriosis is a common condition with a significant impact on quality of life and fertility.
- It negatively affects IVF outcomes, making its treatment within the context of fertility challenging.
- Specialized centres with multidisciplinary teams are required for optimal management.
- A combination of surgical and fertility treatments is often necessary.
- Robotic surgery is a safe and effective solution for endometriosis.