Endometriosis Associated Infertility! Now What? Part 3

If you didn’t catch Part 1 or Part 2 of this Endometriosis Blog Series, check them out! Part 1 covers all the symptoms, causes, and diagnostic details. Part 2 dives into conventional and integrative therapeutic strategies. Part 3 explores Endometriosis-Associated Infertility.

Just as a disclaimer, it’s ALWAYS important to work with a qualified, personal healthcare provider that can guide you along a path that fits your unique situation. Check the links below if you haven’t found that person yet!

Honestly, the more I learn about endometriosis, the more of an enigma it becomes. However, it is very clear the primary symptoms are infertility and pain. With that said, I get so many questions from clients about why Endometriosis affects fertility and what can be done to support their desire to have a baby.

The prevalence of endometriosis in the general population is 1-6 (.8%-6%)^1-3 out of every 100 women, but in women with subfertility, the prevalence is much higher, ranging anywhere from 20-50 (20-50%)^4,5 out of every 100 subfertile women. Endometriosis is, therefore, a frequent cause of infertility. The issue is often magnified because Endometriosis often occurs in combination with other factors that reduce fertility.

Though, unlike pain, the greater the number and extent of endometrial lesions, the greater the degree of reduced spontaneous fertility.⁶ Keeping in mind, half of all women with minimal or mild endometriosis will likely be able to conceive naturally.⁷

Causes For Reduced Fertility With Endometriosis¹⁷

• Adhesions
  • Tissues can stick together in response to endometrial lesions and inflammation. This can alter your anatomy in ways that can prevent ovulation, fertilization, implantation, and growth of a baby.
• Anti-endometrial antibodies
  • These cells can bind to the uterine endometrium disrupting embryo implantation.
• Chronic inflammation
  • Inflammatory molecules are released from lesions and remain elevated, contributing to adhesions, decreased ovarian response⁸, sperm damage (motility^9,10 & DNA¹¹), impaired embryo development¹², and altered embryo implantation.¹²
• Disrupted uterine and fallopian tube muscular contraction
  • The coordinated contraction of the uterus and fallopian tubes to move sperm toward an egg can be altered, which decreases the chance of fertilization.16
• Hormonal imbalance and altered follicle development
  • There can be altered communication between the brain and the ovaries, which may discourage ovulation or disturb the development or quality of eggs.13,15
• Progesterone resistance
  • The responsiveness of the uterine endometrium to progesterone is often decreased, which alters the juicy, sticky nature required for implantation.¹⁴

One or more of these causes could be contributing to subfertility if you have endometriosis.

Endometriosis Associated Infertility | Therapeutic Options

Conventional Therapeutic Options

As you can imagine, conventional therapies for endo have to be a bit more strategic for women trying to become pregnant. Medication therapy usually falls into one of two categories¹⁷:

• hormonal and ovulatory suppression to decrease endometrial lesions
• stimulation of follicle growth and ovulation

Neither option seems to work all that well in isolation from other procedures (i.e., surgery, IVF, and IUI).^17,18

In minimal or mild endo, excision and ablation laparoscopic surgery has been shown to improve fertility, both clinical pregnancy rate, and live births. However, one round of IVF, without surgery, will usually have a similar success rate.²⁰ So, if having a baby is the goal, skipping the surgery and doing IVF may be the better option. Intrauterine insemination (IUI) is also an option, but with more modest outcomes.¹⁷ Obviously, it would be important to discuss all of the details and options with your provider.

Moderate or severe endo, the extent of changes to pelvic anatomy, and the presence of endometriomas make decisions about surgery and assisted reproduction more complicated. There aren’t any rigorous studies that I know of comparing fertility in these women with and without surgery. Depending on the case and the expert, excision surgery may or may not be attempted before IVF.^18,20 There is some controversy regarding medication-induced suppression of lesions before surgery and whether removal of endometriomas (endometrial lesions on the ovaries) reduces ovarian reserve, which could further decrease fertility.¹⁷ It is, however, clear that IUI doesn’t seem to be a good option.¹⁷

Naturopathic, Functional & Integrative Therapeutic Options

Check out all of the integrative strategies that I use described in Part 2 of this series. They are similar for women with endometriosis-associated infertility but are always personalized. I generally feel that co-management with a reproductive endocrinologist or other conventional endometriosis specialist offers the most well-rounded, effective care.

I always hope that my posts are supportive of your journey. There are additional resources and references below. Leave me a comment, check back often, and reach out if you need a partner in this process! Thanks so much for reading. 🙂

If you haven’t done so already check out Part 1 and Part 2 of this Endometriosis Blog Series!

Additional Resources

Naturopathic, Integrative & Functional Medicine Providers

If you’re looking for help with endometriosis and interested in working with me, I’m available via virtual consult. Schedule a FREE 15-Minute Discovery Call today! Alternatively, if you would like to find a practitioner in your area, see the resources below.

• Dr. Tamara Darragh
• American Association of Naturopathic Physicians
• The Institute for Functional Medicine

Endometriosis Resources

• Nancy’s Nook Endometriosis Education (Facebook Group): This group is serious about educating individuals and practitioners about Endo. They have a helpful list of surgeons across the US that specialize in excision surgery.
• Endometriosis.org
• American College of Obstetricians and Gynecologists: Frequently Asked Questions About Endometriosis
• Endometriosis Association

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References

1. Moen MH, Schei B. Epidemiology of endometriosis in a Norwegian county. Acta Obstet Gynecol Scand. 1997;76:559–62.
2. Abbas S, Ihle P, Ko€ster I, Schubert I. Prevalence and incidence of diagnosed endometriosis and risk of endometriosis in patients with endometriosis-related symptoms: findings from a statutory health insurance- based cohort in Germany. Eur J Obstet Gynecol Reprod Biol. 2012;160:79–83.
3. Fuldeore MJ, Soliman AM. Prevalence and symptomatic burden of diagnosed endometriosis in the United States: national estimates from a cross-sectional survey of 59,411 women. Gynecol Obstet Invest. 2016
4. Mahmood TA, Templeton A. Prevalence and genesis of endometriosis. Hum Reprod. 1991;6:544–9.
5. Meuleman C, Vandenabeele B, Fieuws S, Spiessens C, Timmerman D, D’Hooghe T. High prevalence of endometriosis in infertile women with normal ovulation and normospermic partners. Fertil Steril. 2009;92:68–74.
6. Guzick DS, Silliman NP, Adamson GD, Buttram VC Jr, Canis M, Malinak LR, et al. Prediction of pregnancy in infertile women based on the American Society for Reproductive Medicine’s revised classification of endometriosis. Fertil Steril. 1997;67:822–9.
7. Olive DL, Stohs GF, Metzger DA, Franklin RR. Expectant management and hydrotubations in the treatment of endometriosis-associated infertility. Fertil Steril. 1985;44:35–41.
8. Opøien HK, Fedorcsak P, Polec A, Stensen MH, Abyholm T, Tanbo T. Do endometriomas induce an inflammatory reaction in nearby follicles? Hum Reprod. 2013;28:1837–45.
9. Punnonen J, Teisala K, Ranta H. Increased levels of interleukin-6 and interleukin-10 in the peritoneal fluid of patients with endometriosis. Am J Obstet Gynecol. 1996;174:1522–6.
10. Yoshida S, Harada T, Iwabe T. A combination of interleukin-6 and its soluble receptor impairs sperm motility: implications in infertility associated with endometriosis. Hum Reprod. 2004;19:1821–5.
11. Mansour G, Aziz N, Sharma R, Falcone T, Goldberg J, Agarwal A. The impact of peritoneal fluid from healthy women and from women with endometriosis on sperm DNA and its relationship to the sperm deformity index. Fertil Steril. 2009;92:61–7.
12. Pellicer A, Oliveira N, Ruiz A, Remohı J, Simon C. Exploring the mechanism(s) of endometriosis-related infertility: an analysis of embryo development and implantation in assisted reproduction. Hum Reprod 1995;10(Suppl 2):91–7.
13. Cahill DJ, Hull MG. Pituitary-ovarian dysfunction and endometriosis. Hum Reprod Update. 2000;6:56–66.
14. Bulun SE, Cheng YH, Yin P, Imir G, Utsunomiya H, Attar E, et al. Progesterone resistance in endometriosis: link to failure to metabolize estradiol. Mol Cell Endocrinol. 2006;248:94–103.
15. Dmowski WP, Rao R, Scommegna A. The luteinized unruptured follicle syndrome and endometriosis. Fertil Steril. 1980;33:30–4.
16. Leyendecker G, Kunz G, Wildt L, Beil D, Deininger H. Uterine hyperperistalsis and dysperistalsis as dysfunctions of the mechanism of rapid sperm transport in patients with endometriosis and infertility. Hum Reprod. 1996;11:1542–51.
17. Tanbo T, Fedorcsak P. Endometriosis-associated infertility: aspects of pathophysiological mechanisms and treatment options. Acta Obstet Gynecol Scand 2017; 96:659-667.
18. Brown J, Farquhar C. Endometriosis: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2014;3: CD009590.
19. Prescott J, Farland LV, Tobias DK, Gaskins AJ, Spiegelman D, Chavarro JE, et al. A prospective cohort study of endometriosis and subsequent risk of infertility. Hum Reprod 2016;31:1475–82.
20. Rolla E. Endometriosis: advances and controversies in classification, pathogenesis, diagnosis, and treatment [version 1; peer review: 4 approved]. F1000Research 2019, 8(F1000 Faculty Rev):529