Endometriosis Infertility Treatment

What is Endometriosis?

Endometriosis is a disorder  where tissue resembling the uterine lining (endometrium) implants and grows outside the uterus in places it doesn’t belong. Common locations of endometriosis growth include the ovaries, fallopian tubes, and pelvic lining (peritoneum), but it can spread to other areas as well.  We have a comprehensive page on endometriosis, symptoms and treatment here (click), and this page is dedicated to explaining endometriosis infertility.

Endometriosis Infertility: Physical Obstructions

Adhesions and Scarring: Research has indicated endometrial tissue growing outside the uterus triggers an inflammatory response,  leading to the formation of scar tissue and adhesions that bind organs.  Also, adhesions can cause fallopian tubes to become blocked or stuck to other structures, preventing the passage of sperm, egg, or even a fertilized embryo from traveling along its journey.   Additionally, adhesions can severely kink or distort ovaries, disrupting egg maturation and release, or even trapping them within the ovary itself.

Endometriomas:  Large, blood-filled ovarian cysts called endometriomas can form on the ovaries due to endometriosis.  These cysts displace healthy ovarian tissue, effectively disrupting the ovary’s ability to produce viable eggs.  Endometriomas can also rupture, releasing irritating substances, creating further inflammation, and hindering ovulation. If IVF is performed in the presence of an endometrioma, the egg retrieval surgery may be complicated by an infection as endometriomas may get infected. 

Disrupted Pelvic Anatomy:  The aforementioned endometriosis produced adhesions can bind and restrict the movement of pelvic organs, disrupting the delicate process of ovulation.  In severe cases, adhesions can even attach to the uterus, distorting its shape and potentially hindering embryo implantation.

Direct Blockage within Fallopian Tubes:  Sometimes, endometrial tissue grows directly inside the fallopian tube, creating a physical obstruction, preventing sperm from reaching an egg or the fertilized egg from reaching the uterus.

The degree of physical obstruction caused by endometriosis varies greatly depending on the extent and location of the growths and though physical obstructions play a significant role, endometriosis-related infertility is often a combination of factors. Since endometriosis is an inflammatory disease, inflammation caused by the lesions create a hostile environment in the pelvis. This interferes with ovulation, fertilization and implantation. Studies have shown that endometriosis inflammation not only reduces spontaneous pregnancy rates, but also IVF pregnancy rates. 

Endometriosis Infertility: Hormonal Disruption

Excess Estrogen Production: Endometriosis lesions themselves can produce estrogen, leading to abnormally high levels in the body and the endometriosis itself may interfere with the liver’s ability to properly metabolize excess estrogen, contributing to a buildup.  This results in a high level of estrogen which can disrupt ovulation, impact egg quality, and create an unfavorable environment within the uterus for implantation.

Progesterone Resistance: The totality of the inflammation caused by endometriosis can lower the body’s sensitivity to progesterone, a hormone crucial for a healthy menstrual cycle and pregnancy maintenance.  This can not only disrupt ovulation but also proper growth and receptivity of the uterine lining for implantation, and increases the risk of miscarriage.

Disrupted Follicle Development: Endometriosis can impact follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels, essential for proper egg development and ovulation, resulting in poor follicle growth and limiting egg production or quality.

Indirect Impacts: The sometimes severe pain from endometriosis elevates stress hormones, which can impact hormonal balance and ovulation.  Treatment with hormonal medications can sometimes unintentionally create further temporary imbalances as the body adjusts.

Scientists are still exploring the intricate details of how endometriosis impacts hormonal regulation and the specific hormonal disruptions caused by endometriosis vary between individuals.

Endometriosis Infertility: Disrupted Implantation

Inflammation and a Hostile Uterine Environment:  Endometriosis causes the body to release inflammatory substances that create a hostile environment in the uterus. This inflammation is thought to directly damage the developing embryo and interfere with signaling for proper implantation.  Inflammation can also affect the development of the endometrium (uterine lining) itself. This can lead to a lining that’s thinner, less receptive, or out of sync with where it should be in the menstrual cycle for successful implantation.

Progesterone Resistance: Progesterone is a hormone crucial for preparing the uterus to receive an embryo. Without sufficient progesterone the uterine lining won’t become receptive, even if a healthy embryo is present.   The inflammation caused by endometriosis can create progesterone resistance, where the cells in the uterus don’t respond properly to the hormone.

Altered Immune Response:  Implantation is a complex process requiring a balanced immune response and endometriosis triggers immune system changes that can tip the scales. This may cause the body to reject an embryo as foreign, rather than nurturing it.

Abnormal Uterine Contractions: Endometriosis may be associated with increased or erratic uterine contractions, potentially disrupting the delicate process of implantation, or even dislodging an embryo that has just implanted.

Implantation failure in women with endometriosis is usually due to the combined effects of a hostile uterine environment, hormonal imbalances, and potential issues with the embryo itself.  Not every woman with endometriosis will have severe implantation difficulties and vary strongly depending on the severity and location of the disease.

Endometriosis Infertility: Reduced Sperm Function 

Hostile Environment in the Female Reproductive Tract: Endometriosis increases inflammatory chemicals (cytokines) in the peritoneal fluid (surrounding reproductive organs), semen, and within the female reproductive tract. This creates a hostile environment for sperm. Presence of more white blood cells in these fluids is a sign of inflammation and can have harmful effects on sperm.

Direct Damage to Sperm: Endometriosis inflammation leads to the production of reactive oxygen species (ROS) which cause oxidative stress, damaging sperm DNA and overall structural integrity. Inflammation can also reduce sperm motility (ability to swim), limiting their ability to reach the egg to achieve fertilization.

Indirect Impacts: The inflammation in endometriosis can also disrupt hormonal balance in men, affecting processes involved in sperm production and function.  Pain from endometriosis can indirectly impact sperm health. It often leads to reduced sexual activity and increased stress, factors known to negatively affect sperm quality.Immune System Dysregulation: Endometriosis may trigger immune system imbalances that could mistakenly target sperm cells.  Scientists are still actively researching the exact mechanisms by which endometriosis-related inflammation impacts sperm function.  The severity of sperm function impairment can vary depending on the extent of endometriosis and individual factors.

Endometriosis Infertility: Painful Intercourse

Endometriosis-related pain can significantly hinder sexual activity, decreasing the frequency of intercourse and therefore impacting conception.

Types of Pain:

• Dysmenorrhea (Painful Periods): Severe cramps, pelvic pain, and back pain during menstruation can make sex unthinkable.
• Dyspareunia (Painful Intercourse): Endometriosis can cause deep pain during or after sex, ranging from mild discomfort to severe, debilitating pain. This often depends on the location and depth of endometriosis lesions.
• Chronic Pelvic Pain: Many women with endometriosis experience persistent pelvic pain, even outside of their periods. This can make intercourse consistently uncomfortable or impossible. Endometriosis can sometimes cause pain during bowel movements or urination if it affects these areas, further impacting intimacy.

How it Hinders Sexual Activity:

• Physical Discomfort: The pain itself makes sexual activity extremely challenging, and sometimes unbearable.
• Anticipation of Pain: Fear and anticipation of pain during intercourse can significantly decrease desire and arousal.
• Emotional Impact: Chronic pain, along with fertility struggles, can lead to anxiety, depression, and low self-esteem. This heavily affects a woman’s sex drive and enjoyment of intimacy.
• Relationship Strain: Painful sex complicates any relationship. It can create tension, resentment, and a feeling of disconnect between partners.

The degree to which pain impacts sexual activity differs significantly depending on the extent of endometriosis and individual pain thresholds.  It’s important to communicate openly with a partner and healthcare providers to find a path to managing pain and restoring sexual intimacy.  Let me know if you’d like some resources on navigating this aspect of endometriosis or information on specific pain management options.

Conditions Women with Endometriosis May Have Impacting Fertility

Autoimmune Disorders:  Women with endometriosis have a higher predisposition for developing autoimmune conditions compared to the general population. This is thought to be linked to shared underlying immune system dysregulation.   Conditions like rheumatoid arthritis, lupus, thyroid disease (Hashimoto’s or Graves’), and inflammatory bowel disease (Crohn’s, ulcerative colitis) occur more frequently in women with endometriosis.  Some autoimmune disorders directly impact fertility, and others have medications that can interfere with conception or healthy pregnancy progression.

Pelvic Inflammatory Disease (PID): Women with endometriosis are more susceptible to PID, which is an infection of the upper reproductive tract.  If untreated, PID can cause severe scarring within the fallopian tubes and pelvic area, directly impacting fertility.

Ovarian Cancer: While the overall risk remains low, women with endometriosis, especially certain subtypes of ovarian endometriosis, have a slightly increased risk for certain types of ovarian cancer.  Some ovarian cancer treatments can significantly impact future fertility due to the removal of ovaries or damaging effects of chemotherapy/radiation on the eggs.

Chronic Pain Conditions:  Fibromyalgia: This chronic pain disorder is highly associated with endometriosis.  Pain management may rely on medications that should be avoided when trying to conceive, further complicating fertility efforts.

Mental Health Conditions:  Depression and anxiety are substantially more common in women with endometriosis due to the chronic pain, infertility, and overall burden of the disease.  Mental health struggles can indirectly impact fertility by affecting stress levels, relationships, and general well-being.

Early diagnosis and proactive management of endometriosis along with any co-existing conditions is crucial. A multi-disciplinary approach involving gynecologists, fertility specialists, and other relevant providers can maximize chances of achieving and maintaining a healthy pregnancy.  Please let me know if you’d like further detail on any of the conditions mentioned, or wish to discuss their specific fertility impacts.  The degree to which endometriosis causes infertility is linked to the extent and location of endometrial growths. Some women with mild endometriosis struggle to conceive, while others with severe cases get pregnant with minimal challenges.

Surgery can remove endometrial growths and improve the chances of conception, sometimes significantly.  Hormonal medications might help manage symptoms but may not improve fertility prospects.  IUI and IVF often provide a path to pregnancy for women with endometriosis-related infertility issues. However, often times the management plan consists of a combination of fertility treatment as well as surgery.  To learn more, visit our page wherein we compare and contrast IUI vs IVF.

Endometriosis & Pregnancy: Treatment

A treatment plan for women with endometriosis seeking pregnancy is multifaceted and highly individualized.  The severity of endometriosis and the specific location of lesions plays an enormous role in determining paths of treatment.  Younger women might have more latitude to consider less invasive approaches first, while age can necessitate faster intervention.  Additionally, it’s also essential to screen and rule out infertility causes in either partner before proceeding along this journey. Here’s an outline of potential components of a treatment plan to achieve pregnancy if you are coping with endometriosis. 

Managing Symptoms & Improving Overall Health:  NSAIDs, hormonal therapies (birth control pills, etc.), or other pain-relief methods to support quality of life and facilitate intimacy.  Some women find an anti-inflammatory diet and targeted supplements (consult a specialist) help manage endometriosis and boost fertility potential. Stress exacerbates endometriosis symptoms and negatively impacts fertility. Techniques like mindfulness, yoga, or therapy can be beneficial.

Directly Targeting Endometriosis to Improve Fertility: Laparoscopic Surgery: Often the first line especially of pain is a factor.. Excision (completely removing lesions) offers better fertility outcomes than ablation (burning lesions).   Most patients who have appropriate excision of endometriosis won’t need another surgery in the future. However, in approximately 25% of patients, the endometriosis may grow back, and another surgery may be required in the future. This does not mean that surgery is unnecessary as most of the time, surgery helps significantly improve the quality of life in addition to fertility potential. Women who undergo appropriate excision of endometriosis have improved chances of pregnancy, both naturally and with Assisted Reproductive Techniques (ART).

Assisted Reproductive Techniques (ART): Intrauterine insemination (IUI) can work if the endometriosis is mild, combined with medications to stimulate ovulation.  In Vitro Fertilization (IVF) is often the most successful approach for moderate to severe endometriosis infertility as it bypasses some challenges created by the disease.

No single treatment guarantees pregnancy success and factors such as a woman’s age and the overall severity of the disease play an enormously significant role.  As this journey can be emotionally draining, seeking support groups or counseling is helpful for all involved.  Choosing when to use surgical intervention, medication, or IUI / IVF depends on the individual circumstances of each case. Generally, less invasive treatments are tried first, with progression to more complex ones if necessary.

Research has indicated the amount of endometriosis identified at the time of laparoscopy may be linked to future fertility.  Mindful of this the American Society for Reproductive Medicine (ASRM) has a widely used classification staging system for evaluating endometriosis.  The ASRM staging classifies endometriosis based on the location, depth, size, and extent of the endometrial implants. While not perfect, the ASRM stage system gives an indication of severity which helps determine surgical plan.

• Stage I endometriosis (minimal): Examples of What This Could Look Like.
• -A couple of tiny spots of endometriosis found on the pelvic lining.
• -One or two very small, shallow implants on an ovary.
• -Filmy adhesions between organs that do not cause significant distortion.

• Stage II endometriosis (mild): Examples of What This Could Look Like.
• -A few scattered, shallow implants on the surface of the ovaries.
• -Small endometriosis spots on the pelvic lining and ligaments.
• -Minor adhesions between organs that are not severe.

• Stage III endometriosis (moderate):  Examples of What This Could Look Like.
• -Multiple deep implants on the peritoneum and surrounding pelvic organs.
• -An endometrioma (cystic lesion) on one ovary with superficial implants scattered around the pelvis.
• -Significant adhesions causing the ovary to be stuck to the pelvic sidewall.

• Stage IV endometriosis: (severe): Examples of What This Could Look Like.
• -Deep endometriosis lesions infiltrating the bowels or bladder.
• -Large endometriomas on both ovaries with extensive surrounding adhesions.
• -Significant pelvic scarring, potentially obstructing the fallopian tubes or distorting the uterus.

(women at stage III-IV endometriosis can improve the likelihood of pregnancy with Laparoscopic Excision Surgery but in some situations the fallopian tubes are blocked, and/ or scar tissue is severe, thus if pregnancy is not achieved within 6 – 12 months after surgery in vitro fertilization, IVF, is generally recommended ).

There’s no real correlation between the ASRM stage and the severity of endometriosis pain. Some women with minimal disease have severe pain, and vice versa. While helpful, the ASRM stage isn’t a perfect predictor of fertility. Other factors, like the specific location of lesions, play a role.  In general, higher stages often necessitate more aggressive treatments, including advanced surgery. Stay mindful the ASRM stage classification is a  tool, and age, fertility goals, symptoms, alongside with the stage are taken into account when making treatment recommendations.