Endometriosis and Fertility

Endometriosis affects 1 in 10 women in the reproductive age group. It is a condition where tissue from the uterine lining is found outside the uterus. These tissues continue to respond to hormonal changes in the menstrual cycle and bleed during periods, causing pain and inflammation.

Many women either have no symptoms, or suffer for many years mistaking endometriosis for “normal” painful periods before seeking medical attention. The longer endometriosis has been around, the greater the adverse effects on your fertility.

How can endometriosis affect your fertility?

• Endometriotic ovarian cysts: reduce ovulation, damage ovarian tissue. Ironically, surgery to remove these cysts (ovarian cystectomy) also has a risk of reducing ovarian reserve further. This is the reason why surgery should be timed in accordance with one’s fertility plans.

• Reduction in ovarian reserve: chronic inflammation in the pelvis results in poorer egg quality and ovarian reserve. For women with endometriosis who go on to assisted reproductive techniques e.g. in-vitro fertilisation (IVF), they face reduced success in achieving pregnancy.

• Distortion of pelvic anatomy: inflammation and scarring due to endometriotic deposits can cause hydrosalpinx (swelling and blockage of fallopian tubes). This prevents sperm from meeting the egg. Fluid build-up in the swollen tubes has also been shown to have toxic effects on the embryo. 

• Painful sex: endometriosis can cause pain on deep penetration due to the distortion of pelvic anatomy and inflammation, This may affect your frequency of sex and relationship with your partner in the long-term. 

How can treatment for endometriosis improve your fertility?

For women with severe endometriosis that has affected fertility, surgery is usually recommended. A few key points:

• The aim of surgery is to excise and clear endometriosis (as opposed to conservative management): the purpose of this is to address your pain and fertility.

• Surgery can also help restore your pelvic anatomy and optimise access to your ovaries (this may be important for egg retrieval should you need IVF in the future)

• If you have hydrosalpinx and are keen to proceed with IVF, it is recommended to remove your tubes at the same time to eliminate the possibility of toxic effects of the fluid in your swollen tubes on the embryos. However, this means you will not be able to conceive naturally.

• The interval between surgical clearance of endometriosis and you getting pregnant should ideally be short as possible. Assisted reproductive techniques e.g. intrauterine insemination with ovarian stimulation or in-vitro fertilisation (IVF) can be considered.

• Hormonal injections (GnRH agonist) can be given 3-6 months before assisted reproductive techniques to improve success rates.

• If you do not plan to get pregnant for some time after your surgery, you should go on medical hormonal suppressive treatment. This is to reduce the risk of endometriosis recurring until you are ready to try conceiving.