Endometriosis is a condition where the uterine lining (endometrium) grows on pelvic structures outside the uterine cavity. In early-stage endometriosis there is usually little, if any, visible evidence of anatomical distortion sufficient to compromise the release of an egg (ovulation) or its transportation from the ovary to the fallopian tube. In contrast, advanced endometriosis is characterised by the presence of pelvic adhesions sufficient to distort normal pelvic anatomy and interfere with fertilisation as well as egg/embryo transportation mechanisms. Women who have this condition are much more likely to experience infertility. There are several reasons for this:
- In its most severe form, the condition is associated with scarring and adhesions in the pelvis, resulting in damage to, or blockage of, the fallopian tubes, thereby preventing the union of sperm and eggs.
- Endometriosis is associated with the presence of toxins in peritoneal secretions. As sperm and egg(s) travel towards the fallopian tubes they are exposed to these toxins which compromise the fertilisation process. It is also associated with abnormalities of the woman’s immune system which interfere with the ability of the fertilised egg to attach (implant) to the uterine wall. It also has a negative effect on the mucous created by the cervix.
- In about 25-30% of cases, the condition is associated with ovulation dysfunction.
- There is even evidence that endometriosis itself is a symptom of an underlying hormonal imbalance which may be impacting fertility.
Until quite recently, we really had no clue as to how reproductive problems associated with endometriosis evolve. Recent medical research has helped shed light on the subject and offers promise with regard to the future treatment of infertility/reproductive failure associated with this condition.
Since the diagnosis of endometriosis can only be made by identifying it at the time of surgery, the extent of the disease is based upon where it is located and the extent of the damage it has caused. One perplexing issue is that there is poor correlation between the severity of this illness and the resulting symptoms. There is correlation however with the “stage” of endometriosis and its impact upon fertility. Reproductive specialists divide patients into one of four levels based upon what is seen at the time of their surgery.
Factors Influencing Outcome Following Fertility Treatment
In cases of severe endometriosis, pelvic/tubal adhesions that interfere with egg transportation to the fallopian tube and/or ovarian “chocolate” endometriotic cysts (endometriomas) of the ovary certainly contribute to infertility. However, this does not explain the reduced fecundity (chance of conceiving) in women with mild to moderately severe endometriosis, where anatomical barriers to fertility are usually absent. We believe that the two key factors that explain the obstacles created by infertility are those related to its toxicity and its relationship with the immune system.
“Toxins” in the peritoneal fluid. “Toxins” that impair fertilisation of the egg are present in the peritoneal secretions of most women who have endometriosis. Impaired fertilisation is a feature of endometriosis regardless of its severity. This explains why women with endometriosis are about three times less likely to conceive per month of trying and why procedures such as intrauterine insemination do not substantially increase the chances of pregnancy over no treatment at all. It also explains why in vitro fertilisation (which relies upon removing eggs through aspiration of the ovarian follicles before they can be affected by peritoneal toxins), by bypassing this handicap improves pregnancy rates dramatically, making it the treatment of choice for most endometriosis patients with infertility.
Treatment should include surgery and improving the immune system. This includes managing time-urgency perfection stress (www.timeurgency.com).
– with thanks to Dr Rodrigues from Medfem fertility clinic