Endometriosis is a painful, chronic condition in which the endometrium – tissue from the membrane that normally serves as the lining of the uterus – grows outside the uterus. The disease affects millions of women around the world and is one of the potential causes of infertility in women. Some women after several unsuccessful attempts to conceive decide to undergo a fertility evaluation. Based on the results of the fertility evaluation and diagnostic laparoscopic surgery, a doctor may diagnose endometriosis. However, sometimes women can be diagnosed with endometriosis without any plans to have children, after experiencing pelvic pain or severe menstrual cramps.
But can women with endometriosis actually have children? Yes, they can.
The possibility exists, though successful conception is not guaranteed. Some women with endometriosis may require surgery or certain treatments to ensure fertility.
Some specialists believe that many couples with unexplained infertility actually have undiagnosed mild endometriosis. The information provided below applies as to those diagnosed with endometriosis, as to those with unexplained infertility.
How Common Is Infertility Among Women with Endometriosis?
Existing research studies provide various answers to this question.
Estimated 30 to 50 percent of women diagnosed with endometriosis are infertile. According to the definition of infertility, women with this condition are unable to conceive with sexual intercourse after one year or more.
Sometimes, women who are not able to have children may have undiagnosed endometriosis. In fact, endometriosis is six to eight times more common among infertile women, than those who are capable of conceiving. Mild endometriosis is also suspected in about 25 percent of couples diagnosed with unexplained infertility. This is because diagnosis of endometriosis requires invasive diagnostic laparoscopic surgery.
However, one of the major symptoms of endometriosis is pelvic pain, therefore, this disease is not likely to be associated with unexplained infertility cases where the symptom is not present.
Can Women with Endometriosis Get Pregnant Naturally?
Such a condition as endometriosis does not necessarily cause infertility, and it is actually possible for women with endometriosis to conceive naturally, without any fertility treatment.
Although every individual case requires specific approach and you will need to discuss the issue with your doctor, specialists generally advise trying to get pregnant on your own first, even if you have been diagnosed with endometriosis.
Thus, it is recommended to try to conceive naturally for about six months. In case, all the attempts are unsuccessful, medical help will likely be needed.
Another option is contact a fertility specialist without waiting these extra six months. This applies more to women older than 35 years, since their natural fertility already declines faster and endometriosis reduces the chances of the successful conception.
Again, it is always better to discuss everything with your doctor.
Does Endometriosis-Induced Pain Treatment Affect a Woman’s Fertility?
It is quite common to treat pain symptoms related to endometriosis with birth control pills, but, obviously, if you are planning to get pregnant, this treatment is not suitable for you.
Birth control drugs work by suppressing the hormones that feed into endometrial deposits, which helps to reduce uncomfortable and painful symptoms. However, these pills do not cure or treat endometriosis itself.
If a woman experiences moderate to severe endometriosis, endometrial lesions or cysts can be surgically removed to reduce pain. Repeated surgeries, however, may lead to scar tissue, which in turn may increase the risk of infertility or even make the pain worse.
Very severe endometriosis is not common but it is possible. Women with extremely severe cases of the disease may need to have their uterus, ovaries, or part of the ovaries removed. Such an operation has a direct impact on your future fertility.
Nevertheless, endometriosis cannot be cured by surgical removal of the reproductive organs either – pain can still be present.
Therefore, before deciding to undergo a surgery, make sure to discuss everything in detail: the process, potential complications, risks, benefits, etc.
Why Is It Difficult to Get Pregnant with Endometriosis?
The impact that endometriosis has on fertility is not completely understood.
In some cases, endometriosis causes ovarian cysts and blocking of the fallopian tubes by endometrial scar tissue, which makes the reason for infertility clearer. However, these symptoms are not always present – a woman may have endometriosis without any ovarian cysts or blocked fallopian tubes, but still experience some level of infertility.
Researchers identify several theories on how endometriosis affects fertility in women.
Theory #1: Distortion or blockage of organs of the reproductive system.
Endometrial lesions may lead to the development of scar tissue, or adhesions, which may affect the reproductive organs and their functional abilities. Those adhesions may also block the fallopian tubes, which prevents sperm from reaching the egg.
Theory #2: General body inflammation.
Increased general inflammation of the body has been recently associated with infertility in women. Researchers are now looking for the possible connections between the two conditions.
Increased body inflammation is a typical symptom in women with endometriosis. However, it is not yet understood whether the inflammation is caused by endometriosis, or the levels of endometriosis are increased by the inflammation. Neither is it clear how exactly this is all related to fertility problems.
Theory #3: Embryo implantation related complications.
Apart from causing the endometrial tissue to grow outside of the uterus, endometriosis can also affect the endometrium itself. Generally, women diagnosed with endometriosis have lower embryo implantation rates.
It is possible that lower rates of embryo implantation result from poor egg quality. This theory is based on a research that found that embryo implantation rates in women who have endometriosis and use donor eggs are equal to those in women without endometriosis.
Theory #4: Lower egg and embryo quality.
Researchers have found that endometriosis may be causing poor egg quality. Women with endometriosis also tend to produce embryos that develop slower than average.
In addition, when a woman with endometriosis donates an egg to a woman without the condition, the quality of the resulting embryos, as well as the implantation rates tend to be lower.
How Different Stages of Endometriosis Affect Fertility?
Such a condition as endometriosis has various stages of development that are used for the description and evaluation of the severity of endometriosis. Those are Stage I, Stage II, Stage III and Stage IV. While Stage I endometriosis is a mild form of the disease, Stage IV is the most severe one.
The level of endometriosis is determined based on the location, amount, and depth of endometrial lesions.
Speaking about the risks of infertility, the stages of endometriosis do affect a woman’s fertility to some extent. Thus, women with Stage I and II endometriosis have normally more chances to conceive naturally than women with Stage III or IV. This means that having lower levels of endometriosis, a woman can try to get pregnant on her own first. However, with final stage endometriosis it would be wise to proceed directly to IVF treatment.
Yet, lower stages of endometriosis do not imply higher chances of successful fertility treatment: women diagnosed with Stage II may undergo numerous failed IVF treatments and women with Stage IV may conceive after the first treatment program.
It is worth noting that pregnancy success depends on other fertility factors too, including male infertility issues. Therefore, you should not put too much hope on the level of endometriosis.
Endometriosis-Induced Pain and the Chances of Pregnancy
In fact, the severity of pain symptoms caused by endometriosis does not affect a woman’s chances of conceiving, as it is not proportional to the severity of the disease itself. Intense pain may be caused as by severe endometriosis, as by milder forms of the condition.
How much pain a woman with endometriosis experiences rather depends on the location of the endometrial deposits.
Again, the intensity of the pain does not decrease or increase the odds for pregnancy success.
How Is Endometriosis-Related Infertility Treated?
IVF treatment has been considered the most effective per cycle treatment for infertility caused by endometriosis. However, this is not the only option available. Although IVF does increase the chances of getting pregnant, this method of treatment is expensive and invasive.
Anyway, it is always better to discuss your situation with your health care provider. Based on such factors as your age, the stage of endometriosis you have, and your actual cause of infertility, the doctor will provide you with a specific treatment plan.
When it comes to fertility medications, in case of endometriosis, they do not actually show a significant improvement in pregnancy rates, compared to expectant management – trying to conceive without medical help. Therefore, these drugs are not normally recommended alone.
Women diagnosed with Stage I or II endometriosis are often prescribed with fertility medications, for instance Clomid or gonadotropins, combined with intrauterine insemination (IUI) as a starting point.
Clomid usually has less risks of conceiving multiples or developing OHSS (ovarian hyperstimulation syndrome), compared to other medications known as gonadotropins. For this reason, specialists often try Clomid first.
When the combination of the medications and IUI do not help, the following recommendation is in vitro fertilization, or IVF.
In some cases, endometriosis-induced fertility problems are treated with IVF directly without trying to conceive naturally or without treatment with medicaments. This applies mainly to women diagnosed with Stage III or IV endometriosis, women over 35 years of age, couples with fertility issues not related to endometriosis (for instance, male factor infertility), or to women with Stage I or II endometriosis preferring IVF instead of wasting time and trying other methods.
In addition, there are couples who choose not to pursue IVF treatment, and there are also many of those who simply cannot afford it.
How Effective Is Fertility Treatment in Women with Endometriosis?
There was a trial that studied women with unexplained infertility, often suspected mild form of endometriosis, as well as endometriosis that was surgically corrected. According to this study, almost 10 percent of women treated with Clomid and IUI managed to conceive in one cycle, while the rate of pregnancy among untreated women was slightly more than 3 percent.
Another study of 49 randomly chosen women diagnosed with Stage I or II endometriosis analyzes the effectiveness of the treatment with gonadotropins combined with IUI. Again, the participants were divided into two groups. The first group of women received three cycles of the treatment, while the second group continued trying to conceive naturally during six months. The results showed that pregnancy rate per cycle among women from the first group was 15 percent compared to 4.5 percent among women from the second group.
Speaking about the success rates of IVF solution, one study analyzing women with endometriosis found that the average pregnancy rate per cycle was 22.2 percent, which is slightly lower the average success rates of the same treatment among women with non-endometriosis infertility.
In fact, women who have endometriosis generally have lower pregnancy rates, lower implantation rates and lower egg retrieval numbers, than those with other infertility causes.
It is often difficult to analyze the effectiveness of in vitro fertilization in women with endometriosis, as the condition rarely comes alone. In most cases, endometriosis is accompanied by additional fertility factors.
Thus, one study analyzed two groups of couples facing IVF treatment – those with endometriosis alone as a cause of their infertility, and those with endometriosis added to other infertility causes.
The study found that IVF-treated couples with endometriosis alone have similar or higher live birth rates than couples with infertility not related to endometriosis. On the other hand, those suffering from several infertility factors including endometriosis have the lowest success rates among infertile couples.
The effectiveness of in vitro fertilization also depends on other factors including your age and the type of additional fertility problems you have, which is why each particular case has to be discussed with a doctor.
Can Surgical Treatment Help with Infertility in Women with Endometriosis?
When the pain symptoms caused be endometriosis are too severe, the endometrial deposits can be removed surgically, even directly after the diagnosis.
In certain cases, especially when a woman faces a severe form of endometriosis, such a surgery can actually help to improve fertility, or increase the chances of the successful fertility treatment. This only applies to one-time surgery – repeated operations do not seem to affect fertility.
When it comes to mild to moderate forms of endometriosis, research has shown small but significant improvement in live birth rates among women with State I or II endometriosis who had gone through surgical treatment.
As it was mentioned earlier in the article, a lot of unexplained infertility cases are suspected to be caused by mild endometriosis. In these cases, the surgery is a controversial topic.
For instance, if the pain symptoms are not present, the surgery is not likely to help improve fertility, and the potential risks of surgery are higher than the chances of success – one study has found that 40 endometriosis surgeries result in one pregnancy on average. Besides, the success is only possible, if the woman actually has endometriosis.
Diagnostic surgery for endometriosis, as well as the removal of endometrial deposits may lead to certain side effects, including increased endometriosis symptoms, painful adhesions causing harm to fertility, and further fertility damage. In addition, removal of endometrial ovarian cysts may result in reduced ovarian reserves.
If you think that a surgical treatment might be an option for you, discuss your case with your doctor.