Endometriosis is a condition with a negative impact on fertility, but in certain cases a pregnancy can be achieved. What should someone with endometriosis who wants a pregnancy know?
Endometriosis is a benign, chronic pathology that patients face throughout their lives, therefore early diagnosis and correct management are essential.
Endometriosis is a common disease among young women, but it can affect women of any age. It is estimated that 1 in 10 women suffer from endometriosis, with approximately 176 million women in the world with this diagnosis.
Can endometriosis affect fertility?
Current data show that between 25% and 50% of infertile women have endometriosis and that 30-50% of patients with endometriosis are infertile.
A couple without fertility problems has a 15-20% chance of getting pregnant within a month, but in patients with endometriosis these chances are reduced to 2-10%.
Current medicine has not been able to fully explain the relationship between endometriosis and infertility, however several mechanisms have been described.
-Endometriosis is responsible for the appearance of adhesions on the ovaries and fallopian tubes that can mechanically prevent ovulation, the capture of the ovum by the fallopian tube and its transport to the uterine cavity. Patients with severe stages (III-IV) require surgical intervention that can restore normal anatomy and sometimes restore fertility.
-Analysis of pelvic fluid reinforced the idea that endometriosis is an inflammatory disease, as higher concentrations of pro-inflammatory cells were identified in women with endometriosis compared to healthy women. This inflammation has negative effects on the egg, sperm, fallopian tubes and embryo.
Patients with endometriosis may more frequently have anovulatory cycles, i.e. cycles in which ovulation did not occur.
– Several studies evaluated the quality of oocytes and embryos of patients with endometriosis and concluded that oocytes may have a poorer quality and embryos a slower evolution.
If a couple who wants a child cannot conceive, what should they do?
The monthly pregnancy rate for a couple with normal fertility is 15-20% compared to 2-10% for a couple with a partner suffering from endometriosis. Thus, the expectant attitude is sometimes against the patient.
For patients with endometriosis, who are under 35 years old and have unprotected sexual contact for more than 12 months and for those over 35 years old and have unprotected sexual contact for more than 6 months, an active attitude is recommended in order to obtain a pregnancy.
It is good to address this aspect with the attending gynaecologist and later to contact an assisted human reproduction centre. When establishing a therapeutic strategy, we must take into account a number of factors: the age of the patient, the duration of infertility, the symptoms and the stage of endometriosis.
For patients with very low ovarian reserve (AMH < 0.5 ng/dl), the IVF procedure will be urgent, surgical intervention on the ovaries will be avoided due to the risk of reducing the ovarian reserve, which could require the subsequent call for donated oocytes.
The IVF procedure should be considered in patients with endometriosis and infertility when:
- artificial insemination procedures have failed for 6 months
- an endometriosis in stages III-IV
- impairment of tubal function
- the association of male infertility
- other treatments to get pregnant have failed
Assisted human reproduction procedures have increased the chances of endometriosis patients to achieve a pregnancy and are a solution, sometimes the only solution for those patients with severe disease, where the rate of achieving a spontaneous pregnancy is extremely low.
What are the stages of endometriosis that have the greatest impact on getting pregnant?
We could say that endometriosis is a strange disease because when it comes to the intensity of the pain, studies say that it does not correlate with the severity of the disease, but instead when we analyse infertility we know that it correlates with the stage of the disease, so we expect that patients with severe stages III-IV more frequently associate infertility.
Although endometriosis affects fertility at multiple levels, more so in stages III and IV, the distortion of pelvic anatomy can be a primary cause of infertility. Thus, the restoration of the pelvic anatomy through a correctly performed surgical intervention could represent the main benefit in order to obtain a pregnancy.
A study conducted at the Royal Hospital for Women, Sydney in patients with severe stage III-IV endometriosis who underwent ovarian surgery and deep endometriosis lesions recorded an increased pregnancy rate of 73%. Of these, 63% got pregnant spontaneously and 37% through assisted human reproduction procedures.
H. Roman also reports a high pregnancy rate after surgery even in patients with severe forms of colorectal endometriosis. The probability of getting pregnant at 12 months was 33.4%, at 24 months 60.6%, at 36 months 77% and 86.8% at 48 months.
Publications such as the one led by H. Lee reported a low percentage of pregnancies achieved postoperatively for stage IV patients, 20% compared to stage III, 53.3%.
A research conducted in Beijing, China, published differences in obtaining a pregnancy after surgery according to the severity of the disease: grade I- 53.6%; grade II- 32.0%; grade III- 48.3% and grade IV- 33.3%. The lowest level is found in the group of patients with grade IV.
Once a pregnancy is obtained, how will it proceed?
Patients who also suffer from endometriosis should know that during the 9 months of pregnancy they will not have to perform additional tests compared to the usual ones.
The results of the studies that evaluated the rate of pregnancy complications in patients with endometriosis are contradictory, some of them attest to a higher rate for spontaneous abortion, placenta praevia, preeclampsia, bleeding during pregnancy and premature birth, while other numerous studies have demonstrated that there is no association between endometriosis and a high-risk pregnancy.
Most of the time, the pregnancy will proceed without complications, however, pregnant women with endometriosis may have some risks. The exact mechanism responsible for the slightly higher rate of complications during pregnancy in patients with endometriosis is not known. It is considered that the more intense inflammation, the contractility of the uterus and the presence of endometrial tissue outside the endometrium could be responsible for the occurrence of complications.
What is the period of pregnancy with the greatest risk?
Regarding the evolution of the pregnancy, the first and last trimester are the periods with the greatest risk. In the first trimester there is a higher risk of spontaneous abortion, and in the third trimester complications such as bleeding, preeclampsia, foetal growth restriction may occur, sometimes leading to premature birth.
Regarding endometriosis, the specialised literature indicates the second half of pregnancy and labour as the periods with risk of complications. Spontaneous cyst rupture or ovarian torsion may occur in patients with endometriomas. Cases of spontaneous intra-abdominal haemorrhage, uterine rupture or bowel perforation in patients with severe forms have also been described.
How do we give birth, naturally or by caesarean section?
There is no data in the literature that requires caesarean birth in patients with endometriosis. However, there is a slightly higher incidence of caesarean delivery than in the general population. The doctor will take into account all the obstetrical factors and together with the patient will decide the mode of birth. For patients with low rectal resections, caesarean birth is preferable to avoid possible complications at the anastomosis level.
What happens with endometriosis during pregnancy and breastfeeding?
Pregnancy can cure endometriosis is a myth, unfortunately. Patients should not consider pregnancy as a strategy for the management or treatment of endometriosis.
According to studies, the symptoms and evolution of endometriosis can be different from patient to patient. Women who suffered from intense pain during menstruation, during pregnancy due to the lack of menstruation can notice an improvement in the quality of life.
One of the drugs used to reduce the symptoms associated with endometriosis and to slow down the rate of development is progestin, which is a synthetic version of progesterone. During pregnancy, increased levels of progesterone are synthesized, thus explaining why the disease does not evolve most of the time during this period.
On the other hand, another hormone at maximum levels during pregnancy is estrogen, endometriosis being an estrogen-dependent disease, this phenomenon can explain why some patients still face the evolution of the disease during pregnancy.
Especially those patients who have chronic pelvic pain may feel the pain intensification due to the growth of the uterus, the traction of the ligaments that anchor it in the pelvis and additional pressure on the existing endometriosis lesions.
However, most of the time, patients with endometriosis confirm the reduction of painful symptoms during pregnancy and breastfeeding and, unfortunately, the symptoms reappear with the resumption of menstruation.
Even if sometimes the journey to the magical moment when you hold your baby in your arms can be long and difficult, don’t forget that you will succeed, and we doctors are with you.