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Why does endometriosis cause infertility!

Infertility can be one of the consequences of Endometriosis. Women are not only dealing with a debilitating disease but they are also in fear of not being able to have children. But let’s not paint a gloomy picture here. It is fortunate that not all women who have endometriosis are infertile. (If all women who had endometriosis were infertile then birth rates would drop considerably and a rush to find successful treatment for this disease would, hopefully, be implemented.) According to medical statistics it is estimated that infertility can affect around 40% of women with Endometriosis

Interestingly, it has been found that between 30 to 40 percent of women undergoing laparoscopy as part of an infertility evaluation are found to have Endometriosis. This is when women are finally diagnosed with the disease by default. There appears to be a number of mechanisms by which Endometriosis impacts on fertility. Scarring or adhesions in the pelvis, for example, may cause infertility. The fallopian tubes and ovaries may adhere to the lining of the pelvis or to each other, restricting their movement. The scarring and adhesions that takes place with Endometrisois may mean that the ovaries and fallopian tubes are not in the right position, so the transfer of the egg to the fallopian tubes cannot take place. Similarly, Endometriosis can cause damage and/or blockage to the inside of the fallopian tube, impeding the journey of the egg down the fallopian tube to the uterus.

Another factor which could cause infertility for women with Endometriosis, may be the over-production of prostaglandins. These are hormones which play and important role in the fertilization and implantation of the embryo. An excess of prostaglandins may interfere with these processes. Because Endometriosis often causes painful intercourse, couples may fail to have intercourse during the woman’s most fertile time, which will obviously impede the possibility of conception. The endometrium is the tissue that lines the inside of the uterine cavity. Endometriosis is a disease state in which some of this tissue has spread elsewhere - such as to the ovaries, or elsewhere in the abdominal cavity.

Endometriosis causes pain in some women and can also cause infertility. 5-10% of all women have endometriosis. Most of these women are not infertile. 30-40% of infertile women have endometriosis.

Diagnosis of endometriosis

The only way to be sure whether a woman has endometriosis is to perform a surgical procedure called laparoscopy that allows us look inside the abdominal cavity with a narrow scope.

Sometimes we strongly suspect that the disease is present based on the woman's history of very painful menstrual cycles, painful intercourse, etc., or based on the physical examination of the woman or ultrasound findings.

The large majority of cases of endometriosis are mild.

Women with any stage of endometriosis (mild, moderate, or severe) can have severe lower abdominal and pelvic pain - or they might have no pain or symptoms whatsoever. Although mild endometriosis is associated with infertility in some women, many fertile women also have mild endometriosis. A cause and effect relationship between mild endometriosis and infertility has not been established. It might be that infertility and delayed pregnancy predisposes women to developing endometriosis, rather than the endometriosis causing the infertility.

Abdominal Adhesions and Infertility

As the Endometriosis implants grow and develop in the abdomen, the body tries to surround them with fibrous connective tissue (scar tissue). The body does this in an attempt to isolate the implants and prevent them from doing harm. Adhesions can also be formed during surgery when abdominal tissue is traumatized.

These fibrous growths also have the effect of making the implants stick to adjacent tissue, and in some case organs can be ‘glued’ together. Also the blood from internal bleeding from the implants can forms adhesions, so that an implant may be stuck to several different tissues. For example, an Endometriosis implant on the top of the uterus may cause the ovary and small intestine to become attached at the site of the implant.

If the adhesions caused by Endometriosis pinch off the fallopian tube or if they cause blockage to the opening of the fallopian tube, they could obstruct the merger of egg and sperm and prevent fertilization and conception. Also ectopic pregnancy is more common with Endometriosis, if the embryo can't travel to the womb. This type of obstruction can be easily diagnosed and surgically corrected.
However, this does not explain how patients with just a few Endometrial implants and no adhesions can become infertile. Adhesions can also cause pain, as internal organs which normally slip and slide are firmly glued together. For example, if the bowel is stuck to a tender, painful ovary, flatulence could cause pain.

Secretions from implants

The normal Endometrium which lines the womb is a very active and vital tissue that secretes a wide variety of nutrients and hormones required for normal conception. The endometrial implants also secrete these same substances, but instead of depositing them into the lumen (center) of the womb as normal, the endometrial implants release their chemical secretions into the abdominal cavity. Some of these substances are potent hormones which could interfere with fertility.

Prostaglandins

One major group of hormones secreted by the normal endometrium is that of the prostaglandins. Prostaglandins are oil-based hormones found in nearly all the tissues of the body and are required for many bodily processes, including several stages of the menstrual cycle and pregnancy. Prostaglandins are required for ovulation, regression of the corpus luteum (i.e., ending the monthly menstrual cycle), sperm motility, immune interaction, contraction of the uterus at birth and menstrual cramps. Endometriosis implants and the endometrium of the uterus are the richest source of prostaglandin production in the body. However, the problem with Endometriosis implants includes:
- Prostaglandins are released into the abdomen instead of inside the womb.
- Prostaglandins release by the implants seem to be out of phase with their release by the uterus. Prostaglandins are produced at the wrong time sending the wrong message. For instance, there is a normal surge in prostaglandin F production at the end of the menstrual cycle, causing the effect of the copus luteum of the ovary to die down and signaling the start of a new menstrual cycle. The implants of Endometriosis produce their own prostaglandin surge several days after that of the womb lining. This may be one of the main causes of very early miscarriage.
If a women is a few days pregnant then the Endometriosis implants producing prostaglandin F would incorrectly signal the ovary to start a new menstrual cycle, causing the womb lining with the implanted egg to be expelled - and the consequence is an early miscarriage. Prostaglandins also play an important role in the contractions of womb and fallopian tubes. During the normal menstrual cycle, the gentle contraction of the womb and fallopian tube aids the movement of egg and sperm to the outer third of the fallopian tube where fertilization occurs. High concentrations of endometriosis implants may prevent fertilization. An excess of PGF2 and PGE2 could cause contractions that are too strong and expel the egg too quickly.

Early Miscarriage

The most common time for a miscarriage to occur is during the first three months of pregnancy. During this time, the embryo is developing into a fetus and is undergoing dramatic changes, including the formation of most of its internal organs. This is a critical period of development that requires an appropriate nutrient-rich environment, a healthy placenta and a very delicate balance between the various hormones involved in pregnancy.
However, the real problem of a an early miscarriage, is that if it occurs during the first six weeks of pregnancy there is a good chance that women may not even be aware that they were pregnant. They may think their period was late.
Regardless of whether or not there is a high miscarriage rate in Endometriosis patients, it is imperative to eat the right sort of nutrient-rich food to try to ensure the maintenance of a pregnancy. Nutrition in both parents, even before pregnancy has a profound effect on the state of the egg and sperm, as well as on the nature of the secretions within the peritoneal cavity. Choice of foods, particularly fats and oils, may be a crucial factor as these affect the production of prostaglandins, cell membranes, steroid hormones, and neurotransmitters etc.

Fertility and the Alert Immune System

In order to achieve pregnancy, sperm has to enter the body. This sperm can be judged as 'alien' by a women's immune cells, because it is 'non-self'. If pregnancy is achieved, the women's immune system has to adapt to the presence of 'alien' tissue growing inside her for nine months.
However, there will be some mechanism in nature, which tells the female immune system that this alien tissue is not a danger, in order to avoid damage to the embryo. Perhaps when the immune system is malfunctioning in Endometriosis, this mechanism fails and causes an immune attack on the embryo and sperm, thought to lead to infertility. Correcting or strengthening the immune system may help to achieve fertility for women with Endometriosis.
Therefore, some experts consider infertility associated with mild endometriosis to really be "unexplained infertility".

Severe endometriosis

Severe endometriosis causes pelvic scarring and distortion of pelvic anatomy. The tubes can become damaged or blocked and the ovaries often contain cysts of endometriosis (endometriomas) and may become adherent to the uterus, bowel or pelvic side wall. Any of these anatomic distortions can result in infertility.
In some cases the eggs in the ovaries can be damaged, resulting in decreased ovarian reserve and reduced egg quantity and quality.

Treatment of endometriosis

Treatment for endometriosis associated with infertility needs to be individualized for each woman. There are no easy answers, and treatment decisions depend on factors such as the severity of the disease and its location in the pelvis, the age of the woman, length of infertility, and the presence of pain or other symptoms. Some general issues regarding treatment are discussed here:

Treatment for mild endometriosis

Medical (drug) treatment can suppress endometriosis and relieve the associated pain in many women. Surgical removal of lesions by laparoscopy might also reduce the pain temporarily.
However, several well-controlled studies have shown that neither medical or surgical treatment for mild endometriosis will improve pregnancy rates for infertile women as compared to expectant management (no treatment). There are a few more recent studies that did show a benefit to surgical treatment of mild endometriosis. This is interesting because previous studies have shown no benefit.
For treatment of the infertility associated with mild to moderate endometriosis, controlled ovarian hyperstimulation with intrauterine insemination is often attempted and has a reasonable chance to result in pregnancy if other infertility factors are not present.
If this is not effective after about 6 cycles (maximum), then in vitro fertilization should be considered.

Treatment for severe endometriosis

Several studies have shown that medical treatment for severe endometriosis does not improve pregnancy rates for infertile women.
Some studies have shown that surgical treatment of severe endometriosis does improve the chances for pregnancy as compared to no treatment. However, pregnancy rates remain low after surgery - some studies have reported pregnancy rates of 1.5-2% per month.
Some physicians advocate medical suppression with a GnRH-agonist such as Lupron, Synarel, or Zoladex for up to 6 months after surgery for severe endometriosis before attempting conception. Although at least one published study found this to improve pregnancy rates as compared to surgery alone, other studies have shown it to be of no benefit. This is one of many issues regarding endometriosis that there is not universal agreement about among infertility specialists.
Unfortunately, the infertility in women with severe endometriosis is often resistant to treatment with ovarian stimulation plus intrauterine insemination. If the pelvic anatomy is very distorted, artificial insemination would probably be futile. These women will often require in vitro fertilization in order to conceive.
Although the studies of in vitro fertilization for women with severe endometriosis do not all show similar results, pregnancy rates are usually good if the woman is relatively young (under 40) and if she produces enough eggs during the ovarian stimulation.