Am I infertile because I have endometriosis?
Probably not, women diagnosed with endometriosis are not all infertile. In medical terms, infertility is defined as not reaching pregnancy after 1 year of regular intercourse. It is estimated that 60-70% of women with endometriosis are fertile and can get pregnant spontaneously and have children. Therefore, women not wanting to get pregnant should discuss their options for contraception with their doctor.
A proportion of women with endometriosis and fertility problems will stay involuntarily childless, but there are no exact data on how many. Of the women with fertility problems, a proportion will get pregnant, but only after medical assistance, either surgery or medically assisted reproduction (IUI or IVF). There is no evidence that hormonal treatment or alternative treatment enhances the chance of spontaneous pregnancy in women with endometriosis.
There is no best option for aiding infertile women with endometriosis to get pregnant. The decision on which option to take, surgery of medically assisted reproduction, should be based on type of disease, the doctor’s preferences and the patient’s preferences.
There is also no evidence that women with endometriosis have a higher risk of complications in pregnancy (birth defects, miscarriages), but please inform your doctor or midwife of a diagnosis of endometriosis.
Studies have shown that surgery (with removal of endometriotic lesions) can enhance the chance of spontaneous pregnancy in women with peritoneal endometriosis.
In women with ovarian endometrioma, surgery is one of the options to enhance the chance of spontaneous pregnancy. However, surgery in women with ovarian endometrioma can result in damage to the ovary. Your doctor should discuss this risk with you.
There is no strong evidence that surgery improves spontaneous pregnancy rates in women with deep endometriosis.
There is no evidence that taking hormonal treatment before or after surgery helps in increasing the chance of pregnancy in women with endometriosis associated infertility.
Although women with endometriosis can get pregnant, some women suffer from infertility.
For women with fertility problems, medically assisted reproduction can be an option. Medically assisted reproduction includes a number of procedures with the aim of getting pregnant, including intrauterine insemination and assisted reproductive technologies.
In intrauterine insemination, the sperm of the partner is injected into the uterus of the woman at the time when an egg is released and ready for fertilisation. The appropriate time is determined by performing ultrasound, by measuring hormonal levels or regulated by injection of synthetic hormones (controlled ovarian stimulation).
If you have minimal or mild endometriosis and decide to get pregnant, your doctor may advise intrauterine insemination with controlled ovarian stimulation to increase your chance of pregnancy. Some studies have shown that performing intrauterine insemination with controlled ovarian stimulation within 6 months after surgery could increase the chance of pregnancy.
Intrauterine insemination is also an option in women with ovarian endometrioma or moderate or severe endometriosis, but there are no studies that have investigated this.
Intrauterine insemination is not an option in the following cases:
- the woman has a problem with her fallopian tubes, meaning that the egg has problems to reach the uterus (tubal function is compromised)
- the woman’s partner has fertility problems (for instance low sperm count, reduced sperm quality)
- in case other treatments have failed.
In these cases, assisted reproductive technologies should be used.
An important proportion of women with moderate or severe endometriosis will need assisted reproductive technologies (ART) when they decide to become pregnant.
Assisted reproductive technologies are procedures where the egg and sperm are collected from the body and put together in a test-tube to be fertilised. Later, the fertilised egg or embryo is transferred to the uterus.
Before the eggs, which have to be mature, can be removed from the woman’s body, she receives hormonal stimulation of the follicles to produce mature eggs. This is also known as in vitro fertilisation or IVF.
Intracytoplasmic sperm injection or ICSI is a similar technique but in the lab, a single sperm is injected into the egg with a needle instead of putting the egg with many sperm cells in a test tube as in IVF. ICSI is mostly performed when the sperm is of low quality.
Assisted reproductive technologies can help women with endometriosis to get pregnant.
In women with endometrioma, the use of preventative antibiotics at the time of oocyte retrieval, to avoid infections, seems reasonable.
There is some evidence that taking a GnRH agonist for a period of 3 to 6 months prior to treatment with IVF improves the chance to get of pregnant in infertile women with endometriosis.
There is no strong evidence that performing surgery before starting ART is effective to increase the chance of pregnancy. However, there is also no evidence that surgery decreases chances of pregnancy. Hence, your doctor may advise surgery if you have significant pain or if s/he cannot reach the ovaries during ART in case of large ovarian endometrioma.
There is no evidence of increased cumulative endometriosis recurrence rates after ovarian stimulation for IVF/ICSI in women with endometriosis, meaning that undergoing ART does not necessarily worsen your endometriosis.