Endometriosis, Fertility and Pregnancy
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Endometriosis, Fertility and Pregnancy Endometriosis UK is a registered charity No. 1035810. Company Limited by Guarantee No: 2912853 1 Introduction This leaflet covers endometriosis and fertility. It provides information for women who have been diagnosed with endometriosis who would like to know if and how this can affect their fertility, and for women who have been trying to conceive and have been diagnosed with endometriosis during their investigations. The sections cover surgical, medical and fertility treatment including in‐vitro fertilisation (IVF or test‐tube baby). There is a detailed reference list and suggestions for further reading at the end of the leaflet. Medical terms have been highlighted in italics. Endometriosis and fertility Endometriosis is a common gynaecological problem. It does not necessarily cause infertility or pain. Minimal to mild endometriosis is common and it is far more likely that you will have no difficulty conceiving naturally. With increasing severity of endometriosis, scar tissue (adhesions) becomes more common and the chance of natural conception decreases. There is an association between infertility and endometriosis, but cause has not been fully established. Even with severe endometriosis, natural conception is still possible. The main factor that influences fertility is a woman’s age. Fertility starts to rapidly decline after the age of 38 when the rate at which egg sacs ( follicles) disappear from the ovaries accelerates. In addition, the rates of miscarriage and chromosomal abnormalities, such as Down’s syndrome, increase as women age. The reason for this is that a woman is born with her lifetime supply of eggs (oocytes) within her ovaries. They undergo maturation and ovulation, but no new eggs are produced. A man produces new sperm every three months and can father a child into old age although there is evidence emerging that the chance of miscarriage also relates to the man’s age. Will I be able to conceive naturally if I have endometriosis? Anatomical distortion and adhesions caused by endometriosis, particularly in moderate and severe disease, reduces the chance of natural conception. The chance of conceiving with minimal to mild endometriosis is not very different from normal. The more severe the endometriosis, the smaller the chance of getting pregnant naturally. This is because there are more adhesions that trap the egg and prevent it from getting down the Fallopian tube. 100 women without endometriosis, all start trying for a baby At the end of one year, 84 will be pregnant. 100 women with minimal‐mild endometriosis, all start trying for a baby At the end of one year, 75 will be pregnant. 100 women with moderate endometriosis, all start trying for a baby At the end of one year, 50 will be pregnant. 100 women with severe endometriosis, all start trying for a baby At the end of one year, 25 will be pregnant.
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Transcript of Endometriosis, Fertility and Pregnancy
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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.
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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.
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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.
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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.
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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
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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.
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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.
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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 [email protected] www.endometriosisuk.org
