How does endometriosis impact fertility?

If a gynaecologist is asking a patient to get pregnant in order to treat endometriosis, it is a red flag, says Dr. Abhishek Mangeshikar, a Mumbai-based endometriosis excisional specialist at the Indian Centre for Endometriosis.

He says it is one of the biggest myths about endometriosis that pregnancy cures it. Dr. Mangeshikar spoke to Femoai about the impact of endometriosis on fertility, and how is the disease different from conditions such as adenomyosis and PCOS.

Edited excerpts:

What is the incidence of endometriosis?

The statistics are difficult to come by. It is believed that it is one in 10 but it depends on how many women come forward and how many of them are diagnosed. The incidence is probably a lot higher than that. There is no true way to understand the incidence. My opinion may be a little biased because I only treat endometriosis.

Infertility is one of the common concerns for those suffering from endometriosis. Talk to us about the relationship it has with fertility and pregnancy.

Let’s start at one of the biggest myths about endometriosis, which is that pregnancy cures endometriosis. This was linked to a study in the 80s, wherein a woman underwent a Cesarean section and there was a disappearance of the cysts post the procedure. This led to an assumption that pregnancy cured endometriosis. Based on that, pharmacological treatments have been to either create a state of estrogen suppression, which is kind of tricking the body into thinking it’s pregnant, or tricking the body into thinking it’s undergoing menopause.

A lot of gynaecologists will tell the patient go get pregnant and that their endometriosis will go away. Now, we know that is not true. But unfortunately, it is still something I’ve heard patients tell me that other doctors have recommended to them. And that is a big red flag when they’re getting endometriosis treatment. If somebody tells you to get pregnant to sort that out, it’s a big problem.

According to some studies, about 30% of women with endometriosis have difficulty conceiving. Compared to the amount of women that are in pain, that’s only one-third. Now that we know that ovarian cysts have a negative toxic effect on the quality of the eggs, that may decrease fertility. So yes, you should get your cysts removed.

There is a good paper by a colleague of mine who is in Bordeaux. His name is Prof. Horace Roman, and he has probably done one of the largest series of studies on endometriosis in the world. He has studied patients with bowel endometriosis, I’m talking about lesions on the rectum and the sigmoid colon, and he has done a full surgery on patients to treat these. These surgeries were also for fertility. A good bunch of these patients conceived naturally, almost 70-80%, and the rest were required to go into Assisted reproductive technology (ART) like in-vitro fertilisation (IVF).

What that means is that correcting the disease is going to be correcting the anatomy, and removing the disease is automatically going to enhance pregnancy outcomes. We have to understand that the endometriosis disease creates an inflammatory environment, which is going to hinder fertility and pregnancy.

There is also new work to show that some women with endometriosis, who were part of studies, also presented with disorders of the placenta. The data on that is coming out slowly now. There’s always a big debate between IVF and endometriosis specialists, because the fertility specialists sometimes believe that they will get the patient pregnant directly through IVF. However, this debate will rage on because you can always cherry pick which studies you want to look at and find the evidence that suits your protocol.

How is endometriosis different from conditions like adenomyosis, PCOS, or hyperplasia, conditions that it is commonly confused with?

Let’s start at adenomyosis because it is the most closely related one. Adenomyosis is a disorder of the muscular wall of the uterus known as the myometrium. The endometrium is the lining and the myometrium is the wall of the uterus, the outer layer is called the serosa. 

When there is tissue resembling endometriosis, or resembling the endometrium, found in the muscular wall of the uterus, that is known as adenomyosis. If it’s continuously spread throughout the wall of the uterus, it is diffused adenomyosis, if it’s localised to one area like a fibroid, but doesn’t have clean margins like a fibroid, it’s called focal adenomyosis or an adenomyoma. It’s like a fibroid of adenomyosis; a myoma is a fibroid and this is an adenomyotic fibroid. Adenomyosis is more difficult to treat.

There is a paper, by a French surgeon Donnez, which says that all alecto-vaginal or ectocervical endometriosis, all your lesions of the posterior compartment, which is the rectal nodules, are a result of adenomyosis of the cervix. So, that is disease that is dropping down, infiltrating the rectum and the vagina, it’s not originating from the back of the cervix. That is what adenomyosis is.

Polycystic ovary syndrome (PCOS) is a condition in the ovaries; it causes the ovaries to enlarge due to hormonal imbalance. In PCOS, instead of one follicle maturing every month, there are multiple follicles reaching different stages of maturity, which causes an increase in insulin levels and a disorder. It predisposes women to weight gain and also makes it more difficult for them to lose weight.

Women with PCOS have a high production of testosterone and they get hyper testosterone symptoms like acne. There is a link between PCOS and endometriosis; due to hormonal imbalance there is endometriosis and different levels of estrogen and progesterone. We have seen a lot of endometriosis and PCOS cases overlapping each other. 

Endometrial hyperplasia is just thickening of the endometrium; hyperplasia just means overgrowth.

Sources:

Pregnancy Rates After Surgical Treatment of Deep Infiltrating Endometriosis in Infertile Patients With at Least 2 Previous In Vitro Fertilization or Intracytoplasmic Sperm Injection Failures, Pauline Breteau , Isabella Chanavaz-Lacheray , Chrystele Rubod , Mélusine Turck , Sophie Sanguin , Ionut Pop , Benoit Resch , Horace Roman 

High postoperative fertility rate following surgical management of colorectal endometriosis, Horace Roman, Isabella Chanavaz-Lacheray, Marcos Ballester, Sofiane Bendifallah, Salma Touleimat, Jean-Jacques Tuech, Marilena Farella, Benjamin Merlot

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