What is endometriosis and how it affects fertility?

Does endometriosis cause infertility? Well, very simply put unfortunately yes. It could do that. Let’s talk about the diagnosis at first a little bit and we’ll start with the linguistics. Endometrium, endometriosis is the uterine lining of the uterine cavity from the Greek “endos” meaning inside and “metros” is the uterus. So this is the lining or the layer of cells that have a very specific ability by reacting sensitively to the hormonal levels and the hormonal changes during the menstrual cycle. Under the influence of estrogen these cells grow, under the influence of progesterone they get an increased blood flow and eventually during menstruation they necrotize (they get washed away) and the whole process starts again. When these cells appear elsewhere in the organism and this could be in the belly, in the pelvis, in the ovaries, in the rectum, in the bladder, then they can cause problems because they still react the way we just described: they grow under the influence of estrogen, they eventually can bleed during the menstruation but there is no room actually for that blood to go and for the tissue to go. So they usually create a locus that can be painful or that can bother the patient. One of the most difficult situations is regarding fertility when such a locus actually grows in the ovary itself and it can eventually significantly lower the ovarian reserve or cause a loss of the ovary all together. So it might be difficult for the patient to ovulate or it might be difficult for us to get ripe, healthy eggs via an ovarian stimulation.

Endometriosis is a very strange disease, it happens when the lining of the endometrium or the lining of your womb travel to outside the womb itself and this means that every time you get menstruation, these spots of endometriosis, outside your body, will start to bleed and once it started to bleed inside your tummy or whatever the place it will be on, your body will deal with it like a wound in your hand or a scratch in your hand and then start to secrete some inflammatory markers, some healing tissues, fibrous tissue to close this wound and it will cause after that scars and this scars can, if it’s in your tummy, it will be sometimes very disfiguring. The most common places for this endometrial cells or the lining of the womb to be in, is the tubes, ovaries, maybe neural sacral ligament, it may be on reaching the diaphragm, it may reach any other place in your body. So, it has a deleterious effect on the pelvis itself as anatomy and it makes a problem with the function of your body in general.

How it affects the fertility, now, sometimes worse with the reproductive age as the glands are active but if a woman has decided to have a pregnancy very early in the age, maybe it is possible and we have seen it many times, that maybe such women never have any problem even if they are grade IV later but they have already done their families, completed already at a very young age but if the disease is advancing faster than the planning of the family for the women then, it can cause problems. There is a very interesting point about how it affects fertility. For many many years we have this repeated studies which tell us that endometriosis affects everything, endometriosis affects the egg quality, endometriosis affect the lining of the womb and hence it affects the implantation and in the endometriosis, if the IVF is being done it can affect the fertilization or later it can also have more implications in the early pregnancy, however, recent studies are coming up in which the focus and the attention is being shifted so, probably this is all circumvented when we have a tested genetically normal embryo so, for example, we do have some weak studies, we don’t have very large or powerful studies yet but we do have week studies, actually one of the studies is published in Fertility and Sterility, February 2021 and the paper’s name is “gone with the wind” and the conclusion is the whole understanding that endometriosis can affect as at so many levels like I explained earlier, the whole effect can probably be circumvented and bypassed, if at all, we are in a situation that we have done the pre-genetic testing of the embryo and we have a euploid – that is the genetically normal tested embryo so, as long as an endometriosis woman has a genetically tested normal embryo, her fertility might not be affected that badly – is the probability of the new conclusions of the coming studies. We do not know yet but endometriosis can definitely affect fertility starting from sometimes the woman is not even able to have a frequent sexual intercourse so so the problem could be as simple as that.

Endometriosis is a condition that’s defined by the presence of tissue like the lining of the womb outside of the womb and the most common places that it’s found are within the pelvis. Often on the walls of the pelvis or within the ovaries themselves and because that tissue is found sort of in an unnatural abnormal place, we think it then changes the environment and maybe impacts upon the function of the ovaries. It may impact upon the implantation of the embryo in certain early stages of pregnancy. We don’t really fully understand why there’s this link between infertility and endometriosis.
In terms of the stages of endometriosis, there are four stages of the condition that can be documented and really staging is just done by the surgeon when they view the endometriosis at the time of, for example, keyhole surgery and they document where that endometriosis is, what organs it’s involving in and this produces a score that can be used to in research, it can be used to help better manage patients with endometriosis as well. But it’s also fraught with quite a lot of discussion amongst endometriosis experts because a lot of people believe it’s not particularly helpful and instead a lot of people believe that we should talk about subtypes of endometriosis. At the moment we know there are three subtypes of pelvic endometriosis: superficial peritoneal disease which is the commonest one, ovarian disease and deep disease.

Yes, endometriosis can affect fertility but not all women with endometriosis have difficulty conceiving. We grade endometriosis into different grades minimal, mild, moderate and severe so, the early stages of endometriosis which are the minimal and mild, seven out of ten ladies will conceive naturally with no need for any help. The more advanced endometriosis is, the more difficulty the lady will be facing in order to achieve a pregnancy and help might be required to achieve a pregnancy. The way endometriosis can affect fertility is in different ways actually. It can affect the quality of the eggs if the endometriosis is mainly present in ovaries causes endometriosis cyst, we call them chocolate cysts and it can affect also by the tubal function by causing some scarring and adhesions on the tubes and can block the tubes and then, the meet of the egg with the sperm and the fertilized egg transportation through the tube can be affected and and also it can affect the implantation of the fertilized egg inside the womb because when the lady has adenomyosis, when the endometriosis is in the muscle of the womb, it can affect the endometrial disc we call it where the baby implants inside the uterus so, implantation can be affected. On top of that, of course, many ladies with endometriosis have significant difficulty during intercourse because of pain and that they try to avoid it and this, of course, will affect fertility as well.