14 Mar World Endometriosis Day, what is its role in infertility?

This Monday, March 14th, World Endometriosis Day is celebrated around the world, with the aim of giving visibility to a disease suffered by 10% of the general population, most of them during their childbearing age.

Approximately 176 million women of reproductive age worldwide are considered to have endometriosis. So, at Reproclinic we want to take advantage of this moment to talk to you about endometriosis and how it affects fertility.

Before we get into the symptoms and other questions about this disease, we want to explain what it consists of. It is a frequent, benign, chronic and estrogen-dependent pathology. It is characterized by the presence of endometrial tissue outside its usual location in the uterine cavity, which induces a chronic inflammatory reaction in the area where these implants are located.
Its symptoms, such as pelvic pain, severe dysmenorrhea (pain with menses), dyspareunia (pain with sexual intercourse) and infertility, significantly compromise the quality of life of patients.
Other times, however, there are no symptoms, and it is discovered accidentally during a laparoscopy or exploratory surgery. It is difficult to make an early diagnosis of this disease, so it is likely that, in its early stages, the number of new cases is underestimated.

In general, there is a significant delay in the diagnosis of endometriosis. In our country, as in the United Kingdom, it is estimated at around 8 years. This delay is fundamentally due to the fact that the symptoms of endometriosis overlap with those of other pathologies and the relative absence of non-invasive tests for its diagnosis.

Endometriosis symptoms

• Dysmenorrhea (pelvic pain during menstruation).
• Chronic pelvic pain (not clearly related to the menstrual cycle).
• Dyspareunia (pelvic pain with sexual intercourse).
• Infertility.
• Cycle disturbances, irregular uterine bleeding.
• Tiredness, irritability (generally associated with the other symptoms).
• Others (less frequent): Dyschezia (pain-discomfort with defecation), dysuria (pain-discomfort with urination), rectal bleeding (rectal bleeding) during menstruation…

Etiopathogenesis

Although there is no known cause of Endometriosis, several theories are proposed that would justify its appearance:

• Retrograde menstruation: states that endometriosis results from the backward movement of menstrual flow through the fallopian tubes and into the peritoneal cavity, rather than the vagina. This menstrual flow, which contains endometrial cells, would be implanted in areas such as the fallopian tubes, the peritoneum, the bladder, etc, causing inflammation and the symptoms described.
• Coelomic metaplasia: this study advocates the transformation of peritoneal cells to endometrial cells. The cause of this modification? It could be due to inflammation, hormonal changes or environmental stimuli. This theory would explain why some women who have endometriosis do not have a period.

Accompanying the two hypotheses discussed, different factors could influence and accelerate their development:

• Alteration of the immune system: some studies have been able to corroborate how the immune system plays a very important role in the appearance of endometriosis.
• Genetic causes: there are cases in which the woman, who suffers from this disease, also has a family history.
• Environmental factors: they would act as endocrine disruptors, and can be food and respiratory, fundamentally.

Endometriosis and fertility, what is their relationship?

A high percentage of patients with infertility present endometriosis, in different degrees. And the mechanisms by which fertility decreases are several:
– Distortion of the pelvic anatomy.
– Alteration of the immune system.
-Injury to the fallopian tubes.
– Inflammation in the pelvis.
– Decrease in the quantity and quality of the ovules.
– Difficulty for embryo implantation.

Diagnosis of Endometriosis

1. Clinical

   Given the suspicious symptoms described, we must think about this entity, and more so depending on the time it takes to diagnose this disease, which may be decisive in preserving the fertility of patients.

2. Imaging tests

   Currently, the imaging diagnosis of endometriosis is based on two techniques: transvaginal ultrasound and Magnetic Resonance Imaging (MRI). Both allow the diagnosis of ovarian cystic endometriosis and deep infiltrative endometriosis. At the moment, it is not feasible to make an adequate diagnosis of peritoneal endometriosis using these imaging techniques, although in certain circumstances its existence can be intuited.

3. Laparoscopy

   It allows diagnosing any degree of endometriosis, and has the great advantage that it makes it possible to intervene and treat the lesions in the same diagnostic act.

Treatment of Endometriosis

1. MEDICAL TREATMENT

   Given that endometriosis is an essentially estrogen-dependent disease, in which regression of lesions and improvement of symptoms with hormonal deprivation and the use of gestagens have been demonstrated, the medical treatment of endometriosis is based on the use of anovulatory (the contraceptive pill), gestagens and drugs that suppress ovarian activity such as GnRH agonist analogs.

2. SURGICAL TREATMENT

   It should be reserved for very selected cases, considering that it is not without risk, it can decrease ovarian reserve and it has not been clearly shown that it increases the chances of achieving pregnancy after surgery.

Assisted reproduction treatments in patients with Endometriosis

Artificial Insemination: It can be effective for young women (under 37 years of age) who have mild endometriosis, normal ovarian reserve, healthy fallopian tubes and, obviously, if we have a suitable seminogram.

IVF with own ovules: It is the recommended treatment for those patients who present affectation-obstruction of the fallopian tubes, regardless of their age. Likewise, patients over 37 years of age, and patients with low ovarian reserve, may be direct candidates for their own IVF, without even trying previous inseminations.
IVF with egg donation: Patients with very low ovarian reserve, older than 43 years, patients with previous unsuccessful IVF cycles of their own, can opt for this treatment, which implies accepting the contribution of a donor in their reproductive project. It offers very high chances of success.

At Reproclinic, apart from these treatments, we also recommend women with endometriosis to vitrify their eggs in their mildest stage, preferably before the age of 36. Over the years, between the ages of 30 and 40, the ovarian reserve decreases, and with endometriosis this decrease can be accelerated. If there is no reproductive project in the short term, it is an excellent opportunity to save eggs that will be more and of better quality the sooner they are vitrified, and in the future they will maintain the quality they had when they were extracted.

If you want more information on how to deal with infertility together with our professionals, do not hesitate to contact us.