Endometriosis and Infertility - What's the Connection?
Endometriosis is a condition that I don’t discuss very often on PathtoFertility. And not because it’s not important or pertinent to the topic of infertility, fertility and fertility treatment, but because it’s such a difficult conversation. And it’s little understood in terms of prevention or even on-going care. Still, it’s time. So, straight from the Reproductive Medicine Associates of CT (RMACT) website, here’s the first installment of information about Endometriosis.
Endometriosis is a gynecologic condition in which tissues similar to the lining of the uterus (called “endometrial stroma and glands” – normally located only inside the uterus) are found elsewhere in the body. Endometriosis lesions can be found anywhere in the pelvic cavity: on the ovaries, the fallopian tubes, the pelvic sidewall and the uterosacral ligaments. Other less common sites include the bladder, bowel, intestines, colon, appendix, and rectum.
These lesions, termed “endometriosis implants”, respond to female hormones like estrogen and progesterone, just like the endometrial lining does. They can even bleed in microscopic amounts just like a menstrual period. This bleeding leads to local irritation and inflammation in the sites of implantation. The inflammation causes scarring to occur which can bind-up pelvic organs to the point of dysfunction and pain. A few examples of this are:
- The fallopian tubes can become scarred to the point of blockage and prevent sperm and egg interaction. In extreme cases, reproductive organs are fused together and do not function properly.
- The ovaries can become filled up with endometriosis cysts (called an endometrioma). These are called “chocolate cysts” because the congealed blood inside looks like chocolate syrup. These can have deleterious effects on egg production and ovulation.
- Any organ that has endometriosis and scarring on it can experience pain from inflammation and adhesions to other organs.
Women with endometriosis typically present with pelvic pain, infertility or a pelvic mass (usually an endometrioma, “chocolate cyst”). The most common symptom of endometriosis is pelvic pain. The pain often correlates to the bleeding days of a menstrual period, but a woman with endometriosis may also experience pelvic pain at any time. For many women, the pain of endometriosis is so severe and debilitating that it impacts their lives in significant ways. All of these symptoms point towards endometriosis, but the only true way to diagnose the condition is through a surgical exploration of the abdominal cavity, called laparoscopic (or “minimally invasive”) surgery.
Endometriosis and Fertility
In terms of fertility, there is a strong association between endometriosis and infertility, but a true “cause-and-effect” relationship has not been firmly established. It is estimated that in untreated women with endometriosis who are trying to conceive, the monthly fecundity (chance of pregnancy each month) is 2-10%, compared to 15-20% in the general population. Some studies have suggested that 30%-50% of women with endometriosis have difficulty conceiving.
There are several proposed mechanisms for endometriosis causing infertility that include:
- The distorted pelvic anatomy from scarring and adhesions can alter the function of the fallopian tubes, ovaries and uterus.
- Inflammation in the abdominal and pelvic cavity can irritate the normal delicate environment required for fertilization and implantation.
- Hormonal disturbances from endometriosis can impair ovulation and the hormones necessary for implantation and support of the embryo in early pregnancy.
In terms of treatment, it is important to clarify your goals. Some patients do not wish to conceive and just want amelioration of their pain. If this is the case, there are medical treatments (such as anti-inflammatory medications) and hormonal manipulations such as birth control pills and injections called leuprolide acetate, (Lupron®), that can control the painful effects of endometriosis, but they will not help in conception. Surgical destruction and removal of endometriosis has also been shown to decrease pain for longer periods of time, but repeat surgery may be required in the future.
For patients wishing to conceive, the best scientific evidence points to the need for an aggressive treatment plan. This will likely include stimulating medications to induce ovulation of several eggs per month in conjunction with intra-uterine inseminations (IUI). Often patients with endometriosis need advanced treatments such as injectable medications (gonadotropins) and frequently IVF. It is the experience of many fertility specialists (called Reproductive Endocrinology & Infertility specialists) that endometriosis results in much greater fertility problems than the severity of the endometriosis suggests. This is likely due to the harmful inflammatory and immunologic effects that are hard to quantify outside research investigations.
It is important to clarify your goals. The diagnosis and care of patients with endometriosis is often a complex situation that requires specialized training, patience, and skill. Improving your quality of life, while helping you conceive and build your family, is our top concern.
Resources to learn more about endometrosis:
Next week, listen to Dr. Shaun Williams, board certified reproductive endocrinologist from Reproductive Medicine Associates of CT speak passionately about Endometriosis.
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International Women's Day 2013
Today, as my friend Pamela reminded me, is International Women's Day. She called, as only one of your best friends can, at what I consider a rather unG~dly hour. Still, her timing was perfect.
I had just finished watching a video from Endometriosis.org, an international platform that has comprehensive and informative information about endometriosis, a disease that affects one in ten women. Their video is one of the best quick overviews that I've seen in quite a while, explaining what and how endometriosis can affect women and what one can do about it. So while I was enjoying this video, with the audio in a lovely english (British? Swedish?) accent, I heard about International Women's Day.
Yep, even with a foot of snow on a gorgeous March morning, the planets do align.
Raising Endometriosis Awareness for Women
What better way to acknowledge International Women's Day and March being Endometriosis Awareness Month than with an international organization?
If you're not getting your period regularly, are you seeing that as a blessing? I'm a woman, I get it's easier not to get your period, but this is a sign that you may not be ovulating regularly either. If you are not ovulating or menstruating then chances are you are not fertile during those times. Again, this may seem like a blessing as it would prevent an unwanted pregnancy.
I don't want to be a buzz kill, far from it, but while you may not even be trying to become pregnant right now, these things are a cause for concern. If in fact, the last thing that you want is to become pregnant, these are still causes for concern.
One reason to be concerned is because of your fertility in the future. While you may not want to become pregnant right now, there are ways to protect your fertility for the future. Using birth control methods that also protect you against sexually transmitted diseases is one way to ensure becoming pregnant when you do want to.
Another reason to be concerned about your fertility and reproductive system is that if you are not menstruating and ovulating regularly (menstruating every 22-32 days), then that is a sign that something is not working properly. Whether or not you are trying to conceive, you do want to make sure that you do not have a medical condition that needs to be treated. Your reproductive system is a system like any other in your body; it needs to be functioning in a healthy way.
Some examples of reproductive disorders or conditions are; PCOS (Polycystic Ovarian Syndrome); Endometriosis; Sexually transmitted diseases; menstruation dysfunction; endocrine disorders; pathological obesity; PID (Pelvic Inflammatory Disease); Premature ovarian failure; other hormone imbalances.
Education and information are empowering. Understanding how our reproductive systems work and what is healthy and what is not can help us make the best medical decisions for ourselves and for our futures.
If you are not menstruating regularly or are unsure of whether you are ovulating or have not had a pap smear and are sexually active, please see a Gynecologist. A Gynecologist is specially trained in all aspects of reproductive health and can help make sure that you are healthy. They can also help you, so that in the future when you are wanting a child, that can be your choice as well.
Infertility itself is not a diagnosis. It does not specify what or where the problem is in the inability to conceive. An infertility diagnosis can be many things. Here is some information on one diagnosis that has not been talked about in this blog before. Endometriosis is not only a reason that you may be unable to conceive, it is also a reason that you may be living in pain. Here's what the Reproductive Medicine Associates of CT has to say about it:
Endometriosis is a gynecologic condition in which tissues similar to the lining of the uterus (called "endometrial stroma and glands"-- normally located only inside the uterus) are found elsewhere in the body. Endometriosis lesions can be found anywhere in the pelvic cavity: on the ovaries, the fallopian tubes, the pelvic sidewall and the uterosacral ligaments. Other less common sites include the bladder, bowel, intestines, colon, appendix, and rectum.
The Endometriosis Association (EA) is an international organization that was founded in 1980 by Mary Lou Ballweg and Carolyn Keith. Here is what they have to say about themselves:
The Endometriosis Association was the first organization in the world created for those with endometriosis. As an independent self-help organization of women with endometriosis, doctors, and others interested in the disease, it is a recognized authority in its field whose goal is to work toward finding a cure for the disease as well as providing education, support, and research.
The Endometriosis Association is one of the few non-profits that I am aware of in the field of infertility that has such comprehensive and far reaching information specifically linked to their particular disease. Part of the reason is the amount of time that they have been in existence and the exponential way in which EA has grown in their thirty years. Mary Lou Ballweg is still at the helm as the President/Executive Director and is as passionate today as she was in the very beginning. (For a free packet of information call 1-800-992-3636.)
Tel: (414) 355-2200/ Fax: (414) 355-6065
Important work is being done on Endometriosis and EA is up to date with the information on their website, as well as actively supporting the research being done. Vanderbilt University Medical Center is in the news for having received a multi million dollar grant from the National Institute of Health (NIH):
The multi-million dollar effort has a two-pronged approach the establishment of a National Institutes of Health-funded center for research in endometriosis and a research initiative sponsored by the Endometriosis Association in which Vanderbilt will serve as the primary North American research site
Another excellent website, a place where you can trust the information that you are reading is Endometriosis.org, founded in 2005 by international advocates and professionals in the field. Lone Hummelshoj is the founder, publisher and editor in chief. She has on her peer review board some of the greatest talent in the field. The board truly reads like a who's who in the field of Endometriosis.
From an article that Lone wrote, it is clear that she understands what living with Endometriosis is like. Here is what she has to say:
Endometriosis is a mystery - an enigma! We do not know the origin of the disease. We do not know why it causes such extreme symptoms in some women, and not in others. The treatment options can be - let's be honest: a bit "hit and miss". And, unfortunately, because endometriosis is associated with menstruation, sex, infertility, and pain (all taboo subjects in most societies) it is a disease that is not well known, understood, or accepted in the general public.
If you are suffering from Endometriosis, whether because it is causing infertility or because the disease is causing you pain, these two resources are wonderful places to gather reliable information. Well researched, peer reviewed clinical research from the top professionals in the field. In addition both of these websites address the emotional and psychological effects of the disease, as both founders of these organizations have had first hand knowledge of how Endometriosis affects women.
If Endometriosis is your diagnosis, please let us know. We know that there's more to this diagnosis than just a name or even infertility. That you may be living in pain. An overriding theme to this blog is that you are not alone. The last place that we want you to feel alone is in pain.