Endometriosis,FertilityandPregnancy

Endometriosis UK is a registered charity No. 1035810. Company Limited by Guarantee No: 2912853 1

IntroductionThisleafletcoversendometriosisandfertility.Itprovidesinformationforwomenwhohavebeendiagnosedwithendometriosiswhowouldliketoknowifandhowthiscanaffecttheirfertility,andforwomenwhohavebeentryingtoconceiveandhavebeendiagnosedwithendometriosisduringtheirinvestigations.Thesectionscoversurgical,medicalandfertilitytreatmentincludinginvitrofertilisation(IVFortesttubebaby).Thereisadetailedreferencelistandsuggestionsforfurtherreadingattheendoftheleaflet.Medicaltermshavebeenhighlightedinitalics.EndometriosisandfertilityEndometriosisisacommongynaecologicalproblem.Itdoesnotnecessarilycauseinfertilityorpain.Minimaltomildendometriosisiscommonanditisfarmorelikelythatyouwillhavenodifficultyconceivingnaturally.Withincreasingseverityofendometriosis,scartissue(adhesions)becomesmorecommonandthechanceofnaturalconceptiondecreases.Thereisanassociationbetweeninfertilityandendometriosis,butcausehasnotbeenfullyestablished.Evenwithsevereendometriosis,naturalconceptionisstillpossible.Themainfactorthatinfluencesfertilityisawomansage.Fertilitystartstorapidlydeclineaftertheageof38whentherateatwhicheggsacs(follicles)disappearfromtheovariesaccelerates.Inaddition,theratesofmiscarriageandchromosomalabnormalities,suchasDownssyndrome,increaseaswomenage.Thereasonforthisisthatawomanisbornwithherlifetimesupplyofeggs(oocytes)withinherovaries.Theyundergomaturationandovulation,butnoneweggsareproduced.Amanproducesnewspermeverythreemonthsandcanfatherachildintooldagealthoughthereisevidenceemergingthatthechanceofmiscarriagealsorelatestothemansage.WillIbeabletoconceivenaturallyifIhaveendometriosis?Anatomicaldistortionandadhesionscausedbyendometriosis,particularlyinmoderateandseveredisease,reducesthechanceofnaturalconception.Thechanceofconceivingwithminimaltomildendometriosisisnotverydifferentfromnormal.Themoreseveretheendometriosis,thesmallerthechanceofgettingpregnantnaturally.ThisisbecausetherearemoreadhesionsthattraptheeggandpreventitfromgettingdowntheFallopiantube.100womenwithoutendometriosis,allstarttryingforababyAttheendofoneyear,84willbepregnant.

100womenwithminimalmildendometriosis,allstarttryingforababyAttheendofoneyear,75willbepregnant.

100womenwithmoderateendometriosis,allstarttryingforababyAttheendofoneyear,50willbepregnant.

100womenwithsevereendometriosis,allstarttryingforababyAttheendofoneyear,25willbepregnant.

Endometriosis,FertilityandPregnancy

Endometriosis UK is a registered charity No. 1035810. Company Limited by Guarantee No: 2912853 2

GradeorseverityofendometriosisEndometriosisisclassifiedintominimal,mild,moderateandsevereusingtheAmericanFertilitySocietyRevisedClassificationofEndometriosis(AFS)score.Thisclassificationhelpstopredictthechanceofgettingpregnantnaturallyanddoesnotalwaysagreewiththedegreeofpain.Itispossibletohaveseverepainwithminorendometriosisandminorpainwithsevereendometriosis.Atthiscurrenttime,noothertestorinvestigationcangivethesamedetailedinformationaslaparoscopy.Thepelvisiscarefullyinspectedatlaparoscopy.Ascoreisworkedoutfromtheareaaffectedbyendometriosis,whethertherearecystsofendometriosisontheovariesandwhetherthereisscartissueoradhesionsstickingtissuestogether.Whydoesendometriosiscauseinfertility?Scartissue(adhesions)issimilartocobwebsandcanbefine,ordense.Adhesionsaremorecommoninmoderateandsevereendometriosis.Thisscartissuedistortsthepelvicanatomy.Iftheovaryiswrappedinadhesions,thereleasedegggetstrappedandisunabletoreachthetube.ThetubesandovariesdangledowninanotherimportantareacalledthePouchofDouglas.Ifthispocketiscoveredbyadhesions,thenthechanceofgettingpregnantisalsolower.Itislessclearwhyminimalormildendometriosiscausesinfertility.Inminimalmildendometriosis,theremaybespotsofendometriosis,andminimalornoscartissue.Evidencethatminimalmildendometriosisaffectsfertilitycomesfromstudiesofwomenhavingdonorinseminationbecauseofmalefertilityproblems.Itwasfoundthatwomenwithminimaltomildendometriosishadlesschanceofconceivingthanwomenwhohadnoendometriosis.Thestudywasbiasedbecauseonly11womenhadendometriosisandnotallthemenwerecompletelyinfertile.Ifendometriosisislinkedwithfertility,thentreatmentofendometriosisshouldimprovethechanceofpregnancy.ThishasbeenprovenbyalargeCanadianstudy(Marcouxetal1998)thatreportedthatsurgicaltreatmentofminimaltomildendometriosisincreasedthechanceofgettingpregnantnaturallycomparedtodiagnostic(lookandsee)laparoscopy.Exactlyhowtheendometriosiswastreated(laser,excision(cuttingout)ordiathermy)didnotappeartomatter.Theoriesforwhyminimaltomildendometriosiscausesinfertility:

Toxinsinperitonealfluid(naturallyoccurringfluidwithinthebodycavity) Problemswitheggtransportdownthefallopiantube Anabnormalimmuneresponse(antibodies) Failureoftheeggsac(follicle)toreleaseitsegg(luteinisedunrupturedfolliclesyndrome).

WhathappensifIdecidetodonothingaboutmyendometriosis?Studiesthathaveanotreatmentarmtocomparewithactivetreatmentprovideusefulinformationaboutwhathappenstoendometriosiswithouttreatmentovertime.Overall,itisthoughtthatendometriosisslowlygetsworseovertime.

Endometriosis,FertilityandPregnancy

Endometriosis UK is a registered charity No. 1035810. Company Limited by Guarantee No: 2912853 3

Inastudyofwomenwithendometriosiseithertreatedwithadrugcalledgestrinoneorplacebo,laparoscopyaftersixmonthstreatmentshowedthattheendometriosishadimprovedorresolvedinallthewomentreatedwithgestrinone.Inthe17womenwhoweretakingplacebo,endometriosisimprovedin9women,butworsenedin8.Inthreewomen,thisincludedtheappearanceofnewadhesionsaroundthetubesandaroundtheovaries.Thisstudyshowsthatendometriosiscangetbetteraswellasgetworseinwomenwithouttreatment.Isthereanytreatmenttoslowtheprogressionofendometriosis?Ifyouaretryingtogetpregnant,thereisnotreatmentcurrentlyavailabletoslowtheprogressionofendometriosis(allmedicaltreatmentsapartfromsomepainkillerscanbeharmfultotheunbornchildandyouareadvisedtousebarriercontraceptionduringtreatment).Ifyouareplanningafamilysometimeinthefuture,butnotjustnow,theCombinedOralContraceptivePill(COCP)mayhelptoslowtheprogressionofendometriosis.Itreducespain,iswelltoleratedandcanbecontinuedlongtermforthecontrolofsymptoms.Inhealthynonsmokingwomen,theCOCPcanbecontinueduntilthemenopause.TheCOCPhasneverbeenfullyassessedwithlaparoscopybeforeandaftertreatment.However,incomparativestudies,ithasprovedaseffectiveasthegonadotrophinreleasinghormoneagonist(GnRHa)inthetreatmentofpainassociatedwithendometriosisandwithoutthesideeffects.Doesdrugtreatmentimprovefertility?Drugtreatment(medicaltreatment)forendometriosisdoesnotimprovefertility,eitherduringoraftertreatment.Itisonlyindicatedfortreatmentofpainassociatedwithendometriosisorasapreparationforsurgery.

Ingeneral,medicaltreatmentisbasedonhormonesorantihormonesandiscontraceptive.Theaimofmedicaltreatmentistoshrinkthehormonedependentendometriotictissues.Mostpreventpregnancy,butcontraceptionisadvisedthroughouttreatmentbecausethedrugscanharmanunbornbaby(teratogenic)andthecontraceptiveeffectofthetreatmentshouldnotbereliedon.

Medicaltreatmentofendometriosisproducesnoimprovementinpregnancyratescomparedtonoactivetreatment(expectantmanagement).Researchhasshownthatmedicaltreatmentwithdanazol,buserelin,medroxyprogesteroneacetateorgestrinonewasnomoreeffectivethanplaceboornoactivetreatmentinimprovingpregnancyrates.

Perhapsmostimportantlyofall,ithasalsobeenshownthatcompleteeliminationofendometriosisbymedicaltreatmentdoesnotreturnfertilitytonormal.Doessurgicaltreatmentimprovefertility?Surgicaltreatmentofendometriosisimprovesfertilityandhelpspain.

Endometriosis,FertilityandPregnancy

Endometriosis UK is a registered charity No. 1035810. Company Limited by Guarantee No: 2912853 4

Theaimofsurgicaltreatmentistodestroyorcutout(excise)endometrioticnodulesandreleaseadhesions.Ovariancysts(endometriomata)generallyrecurafterdrainagealoneandneedtobeformallyremovedbyremovingthecyst,ordrainingthecystanddestroyingthelining.Surgicaltreatmentofendometriosishelpsthechanceofgettingpregnant.Researchhasshownthatsurgicaltreatmentofminimaltomildendometriosisimprovesthechanceofpregnancycomparedtodiagnosticlaparoscopy(lookandsee)(Marcouxetal.,1998).Endometriosiswastreatedbycuttingout(excision),destructionbyheat(electrocautery)orlaser.Thedifferenttypesoftreatmentallappearedjustasgoodaseachother.Inthetreatedgroup,50of172(31%)becamepregnantwithin36weekscomparedto29of169(18%)inthediagnosticgroup.Themiscarriagerateinbothgroupswas20%.Criticismsofthestudywerethatthetypeofsurgicaltreatmentvaried.Onlythetypicalblueblackspotsofendometriosiswereincludedandwenowrecognisemanymoreappearancesofthedisease.Somewomenalsohadtreatmentofadhesions,andsomeweretoldwhattreatmenttheyhadhadondischargefromhospital,whichmayhaveintroducedabias.However,asaresultofthisstudy,itisreasonabletowaitaboutayearaftertheoperationtoseeifyouwillgetpregnantnaturallybeforegoingontofertilitytreatment.Asmallerstudyfoundnodifferencebetweensurgicaltreatmentanddiagnosticlaparoscopy(Parazzini,1999).Inthetreatedgroup,10of51(19.6%)and10of45(22.2%)inthelookandseegroupbecamepregnantwithinoneyearfollowinglaparoscopy.Itispossiblethatthelackofdifferenceinthisstudywasduetothesmallernumberofwomen(notenoughstatisticalpower).CombinationofmedicalandsurgicaltreatmentMedical(drug)treatmentaftersurgicaltreatmentmaydelaythereturnofpainsymptomsinawomanwhodoesnotwishtostarttryingtoconceiveimmediately.Ifsurgerywastotreatsignificantpainandawomandoesnotplantohaveafamilyimmediately,postoperativemedicaltreatmenthasbeenshowntodelaythereturnofsymptoms.Differenttypesofmedicaltreatmentallproducedthesameresult.Researchhasshownthecombinedcontraceptivepilltakenaftersurgeryprovidespainreliefforuptoayearaftersurgery.WhattypeoffertilitytreatmentshouldIchoose?Thereareseveraltypesoffertilitytreatmentavailable.Whattypeoffertilitytreatmentdependsontheseverityofendometriosis,thewomansage,howlongthecouplehavebeentryingtoconceive,whetherthecouplehaveconceivedinthepastandwhetherthereareotherfertilityfactorssuchasblockedtubesorspermproblems.Themaindrawbacksoffertilitytreatmentincludeoverstimulationoftheovaries(ovarianhyperstimulation)andhighordermultiplepregnancy(tripletsormore).Carefulmonitoringofthetreatmentcycleandlimitingthenumberofembryosreplacedcanreducethesedrawbacks.

Endometriosis,FertilityandPregnancy

Endometriosis UK is a registered charity No. 1035810. Company Limited by Guarantee No: 2912853 5

OI(Ovulationinduction)Theaimofovulationinductionistoregulateirregularperiods,stimulatingtheovariestoreleaseanegg(oocyte)eachmonth.Itissuitableforyoungwomenwithhealthyfallopiantubes,whodonotovulateregularly,haveminimalormildendometriosisandwhosepartnerhasgoodnumbersofhealthysperm.IUI(Intrauterineinsemination)Intrauterineinsemination(IUI)ofpartnerordonorspermissuitableforyoungwomenwithhealthyfallopiantubes,whoovulateregularly,haveminimalormildendometriosisandwhosepartnerhasgoodnumbersofhealthysperm.IUIboostsmalefertilitybypreparingandsortingthespermsothatonlythehealthiestareused.Spermareinsertedintothewombthroughthecervixtimedwithovulation,sothattheyareascloseaspossibletothereleasedegg.OvarianstimulationwithIUIOvarianstimulationandIUIorsuperovulationandIUIboostsawomansfertilitysothatsheproducesseveraleggsinonemonth(usually3or4).ItismoreeffectivethaneithernotreatmentorIUIaloneinwomenwhohavenotconceivednaturallyandwhohaveminimalormildendometriosis(Hughes1997).Alivebirthrateof1015%pertreatmentcyclecanbeexpected.IUIislessexpensiveandlessinvasivethanIVForGIFTandshouldbeconsideredinitiallyinsuitablepatients.About80%ofcoupleswhowillconceivewithIUI,dosointhefirst46cycles.After3or4unsuccessfulIUItreatments,IVForGIFTshouldbeconsidered.GIFT(GameteIntrafallopiantubeTransfer)Theeggsarecollectedfromthewomansovaries,usuallybylaparoscopy.Thehealthiesteggsaremixedwithspermbeforebeingplacedinsidethefallopiantube.FertilisationtakesplaceintheFallopiantube.GIFTissuitableforwomenwithhealthyfallopiantubeswhoseendometriosisisnotsevere;thosewhohavefailedtoconceivebyIUI;olderwomen;womentryingtoconceivealongtime;andcoupleswithseveralfactorscausinginfertility.IVF(InVitroFertilisation)orTesttubebabyandEmbryoTransferIVFandembryotransferisanestablishedandsuccessfultreatmentforendometriosisrelatedinfertility.IVFissuitableforwomenwithdamagedorblockedtubes;womenwithmoderateorsevereendometriosis;womenwithminimalormildendometriosiswithapartnerwhohasspermproblems;andwomenwhohavefailedtoconceivebyIUI.Gonadotrophinreleasinghormoneagonists(GnRHa)removethebodysnaturalovariancycle.ThisimprovestheIVFsuccessratesbyreducingthenumberofcancelledcyclesandpreventingprematureovulationoftheeggsdevelopingwithintheovaries.Prolonged(atleast60days)treatmentwithGonadotrophinreleasinghormoneagonistsbeforeIVFinwomenwithmoderateorsevereendometriosisresultsinhigherpregnancyrates(Nakamuraetal.1992).GnRHatreatmentwillalsohelprelievepain.ManypublishedtrialshavereportedpoorIVFsuccessratesinwomenwithmoderateorsevereendometriosiscomparedtowomenwithminimalormilddisease.However,IVFwithGnRHa

Endometriosis,FertilityandPregnancy

Endometriosis UK is a registered charity No. 1035810. Company Limited by Guarantee No: 2912853 6

treatmentaftersurgicaltreatmentresultsingoodpregnancyandlivebirthrates,comparabletoothercausesofinfertility.Nationaldatastatisticsquotea26%livebirthrateperIVFcyclestartedforwomenbelowtheageof38and14%forwomenofallages.Thisfigureislower,becauseageitselfisasignificantfactorreducingfemalefertility.Thepresenceofsmallendometrioticovariancysts(endometriomata)doesnotdecreasethesuccessofIVF.However,thereisanincreasedriskofdevelopingapelvicinfectionfollowingtransvaginalegg(oocyte)collection.Itisgenerallysuggestedthatendometrioticcystsover4cmindiameterareremovedsurgicallypriortoIVF.ICSI(intracytoplasmicsperminjection)ICSIisusedwithIVF.Asinglespermisinjectedintotheegg,givingitthebestchanceoffertilizing.Itisoftenrecommendedifthereisalowspermcountorifotherproblemshavebeenidentifiedwiththesperm.Itcanalsobeusedifthereareveryfeweggscollectedfromthewomentomaximisefertilisation.Invitromaturation(IVM)Invitromaturationisanewtechnique.About300childrenhavebeenbornaroundtheworldfromthistechnique.Thereisnoevidencetosuggestthatitisunsafe,neitheristhereenoughevidencetobecertainthatitisasafetreatment.Eggscollectedfromtheovariesarematuredinthelaboratorybeforebeingfertilisedbysperm.ItisdifferentfromIVFbecausetheeggsareimmaturewhentheyarecollected.Thismeansthatthewomanneedstotakefewerfertilitydrugs.PGD(PreimplantationGeneticDiagnosis)Preimplantationgeneticdiagnosisteststheembryosforspecificproblems.Itisusedtotestforaspecificserious(oftenlethal)geneticproblemscarriedwithinafamily.Thehealthyembryosarebereplacedbyembryotransfer.ThedrawbacksarethatIVFisrequiredtocreateembryosthatcanbetestedandtheremaybenohealthyembryostoreplace.PGS(PreimplantationGeneticScreening)PreimplantationgeneticscreeningteststheembryosforcommongeneticconditionssuchasDownssyndrome.Healthyembryosarereplacedbyembryotransfer.ItwasthoughtthatscreeningwouldbenefitoldermotherswhohaveahigherchanceofhavingababywithDownssyndrome.ThedrawbacksarethatIVFisrequiredtocreateembryosthatcanbetestedandtheremaybenohealthyembryostoreplace.EggorspermdonationDonatedeggsorspermcanbeusedinfertilitytreatment.Thismayberecommendedwhentreatmentisunlikelytobesuccessfulifyouweretouseyourowneggsorsperm.Donorspermcanalsobeusedforwomenwhodonothaveamalepartner.TheGovernmenthaschangedthelawarounddonationinApril2005.Childrenbornfromeggs,spermorembryosdonatedafterApril2005will,whentheyare18,beabletofindoutwhothedonorwas.

Endometriosis,FertilityandPregnancy

Endometriosis UK is a registered charity No. 1035810. Company Limited by Guarantee No: 2912853 7

SurrogacySurrogacyiswhereanotherwomancarriesthebabyforyou.ThebabycanbeconceivedbyIUIusingthesurrogateseggsandyourpartnerssperm.Alternativelythesurrogatecanhaveembryotransferwithembryoscreatedfromyoureggsandyourpartnersspermorfromeggsdonatedfromanotherwomanandyourpartnerssperm.Surrogacyisaverycomplicatedlegalareaandyouwillneedtogetlegaladvicebeforegoingahead.Surrogacymaybetheonlyoptionforwomenwhohaveamedicalconditionthatmeansthatitisimpossibleordangerousforthemtoundergoapregnancyorgivebirth.PregnancyandEndometriosisEndometriosiscancausedelayingettingpregnant,butonceyouarepregnant,pregnancyisexpectedtobenodifferentfromnormal.Therearereportsofwomenwhohadmorepaininthefirstfewmonthsofpregnancy.Ingeneral,painimproves,butmayreturnaftergivingbirthasperiodsreturn.ComplementarytreatmentsTherearenumerouscomplementarytherapiesavailable.Alackofresearchevidencemakesitdifficulttorecommendcomplementarytreatments.Acupuncture,homeopathyandherbalmedicinemayhelp.Selfhelpgroupscanhelpsufferersimprovetheirsymptoms.

Endometriosis,FertilityandPregnancy

Endometriosis UK is a registered charity No. 1035810. Company Limited by Guarantee No: 2912853 8

MedicalReferencesMarcouxS.,MaheuxR.,BerubeS(1987).Laparoscopicsurgeryininfertilewomenwithminimalormildendometriosis.CanadianCollaborativeGrouponEndometriosis.NewEnglandJournalofMedicine;337:21722.SuttonC.J.,EwenS.P.,WhitelawN.,HainesP(1994).Prospectiverandomiseddoubleblindcontrolledtrialoflaserlaparoscopyinthetreatmentofpelvicpainassociatedwithminimal,mildandmoderateendometriosis.FertilityandSterility62:696700.SuttonC.J.,PolleyA.S.,EwenS.P.,HainesP(1997).Followupreportonarandomisedcontrolledtrialoflaserlaparoscopyinthetreatmentofpelvicpainassociatedwithminimaltomoderateendometriosis.FertilityandSterility68:10704.FurtherinformationaboutfertilitytreatmentFreefromTheHumanFertilisation&EmbryologyAuthority.Thepatientsguidetoinfertility&IVF.HumanFertilisation&EmbryologyAuthority,PaxtonHouse,30ArtilleryLane,LondonE17LS.FreefromTheHumanFertilisation&EmbryologyAuthority.ThepatientsguidetoIVFclinics.HumanFertilisation&EmbryologyAuthority,PaxtonHouse,30ArtilleryLane,LondonE17LS.InfertilitytheFactswrittenbyMelanieDavies,LisaWebber&CarolineOverton.Published2008byOxfordUniversityPress.

Helpline:08088082227DateforreviewSeptember2010EndometriosisUK.50WestminsterPalaceGardens,ArtilleryRow,London,SW1P1RR,t:02072222781 info@endometriosisuk.org www.endometriosisuk.org