E

ndometriosis is a fairly common reproductive condition, affecting millions of women. Its symptoms vary, but typically involve extreme pain or abnormal bleeding during menstruation, and sometimes can cause pain during or after sexual intercourse.

The disease tends to worsen over time, if untreated, and is a leading cause and contributing factor to infertility among women. The good news, however, is that endometriosis can often be successfully treated and many women are able to conceive '€” either through laparoscopic or robotic surgery and assisted reproductive technologies or naturally.

Endometriosis is when the womb lining responsible for menstruation (or endometrium) is found outside the womb, usually in the pelvis and around the womb, ovaries and fallopian tubes.

The condition is often under-diagnosed as it may also be present in women with symptoms unrelated to periods or those who experience minimal discomfort. When endometriosis penetrates the muscle tissue or myometrium of the womb, it is called adenomyosis. Often adenomyosis co-exists with endometriosis.

Research has shown that infertility can affect up to 40 percent of women suffering from endometriosis. Although a direct correlation between endometriosis and infertility has not been ascertained, women who suffer from the condition find it harder to conceive than those who do not. So how exactly does endometriosis impair fertility?

When endometrial tissue forms on organs other than the uterus, the body tries to prevent this tissue from creating further problems by coating it with scar tissue, which may stick to nearby tissue or organs, such as the ovaries or fallopian tubes, and hinder their functions. When this adhesion occurs with the fallopian tube or the ovary, their positions are displaced and the egg or the sperm cannot travel the proper way to be fertilized.

When endometrial tissue grows inside the fallopian tubes, there is no avenue for the tissue to shed itself. With time, the inner wall of the tube becomes so damaged that the journey of the egg from the ovary to the uterus cannot occur successfully. Such kind of scarring may also occur on the ovaries, which can pose difficulties during ovulation and releasing an egg.

Prostaglandins are hormones secreted by the endometrium that can trigger many bodily functions, including ovulation, menstrual cramps and contraction of the uterus during birth.

In the case of endometriosis, prostaglandin secretion is extremely high and may occur at times when it is not required. This can manifest various problems while trying to conceive as well as during pregnancy. For instance, excess prostaglandin in the system can cause the body to think it is time to start menstruating. However, during pregnancy, this extra prostaglandin can predispose to a miscarriage.

Endometriosis does not equal infertility. Often, women with endometriosis will conceive without any difficulty. Others will only be diagnosed with the condition after they have had one or more children. However, it is still believed that endometriosis is one of the leading causes for female infertility. If you know you have endometriosis and you are having problems conceiving, seek help sooner rather than later.

There are a number of treatments for pain and infertility related to endometriosis and, they include pain medication, ranging from over-the-counter remedies to prescription drugs for mild to moderate endometriosis, and common hormones, used if the endometriosis areas are small and the pain is minimal. They are not suitable if the main issue is infertility, where surgery is the most important treatment.

Surgical treatments range from minor to major surgical procedures, and are usually the best choice for severe cases of endometriosis. Laparoscopy is a minimally invasive way to diagnose and treat endometriosis without large cuts to the abdomen. The objective is to treat endometriosis without harming the healthy tissue. Recovery is much faster. This is the most important procedure to improve the chance of falling pregnant.

Laparotomy is resorted to when complex surgical procedures, which cannot be accomplished through laparoscopic or robotic surgery. It requires a longer recovery time, often up to one to two months.

Robotic surgery allows the surgeon to perform more complex surgeries without an open laparotomy. Major surgery is a last resort for endometriosis treatment. While surgery does not guarantee that the endometriosis will not return or that the pain will go away, it can go a long way in attenuating the intensity of the pelvic or menstrual pain, improves fertility and enhances the success rates of in-vitro fertilisation (IVF).

Women known to have endometriosis are often treated with fertility drugs, artificial insemination or in vitro fertilisation. These treatments may be successful even when some endometriosis tissue remains within the patient.

Fertility drugs are the primary line of treatment for women who are unable to get pregnant due to ovulation disorders. These medications regulate or encourage ovulation. Generally, they work like natural hormones, such as follicle-stimulating hormone (FSH) and luteinising hormone (LH) '€” to grow follicles to be ready for ovulation. Drugs like Clomid have been used for a long time in infertility treatments, as they help in inducing ovulation when ovulation does not occur naturally.

It causes the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg.

Many studies have shown that even from the mild form to the severe forms of endometriosis that surgery to clear as much of the disease by skillful surgeons is very effective in improving the chance of a pregnancy occurring or making fertility treatments like insemination and IVF more efficient.

In the case of endometriosis, some women have difficulty conceiving due to presence of scar tissue or the abnormal secretion of certain hormones and toxic effects of the endometriosis producing certain chemicals that affect sperm and egg functions. Through the use of fertility drugs, either orally or by injection, ovulation is enhanced or the chances of pregnancy increase.

Intrauterine insemination (IUI) has been helpful, particularly when used with oral or injectable fertility medications combined with the introduction of sperm directly into the uterus. Sometimes, controlled ovarian hyper stimulation (COH) with IUI is an effective treatment. It works by stimulating the ovaries to produce more eggs followed by insertion of the sperm into the uterus. Once pregnant, some women report improvement of symptoms, although these may return once the pregnancy is over.

IVF, for those suffering from any stage of endometriosis, can be helpful as the complete procedure of fertilisation takes place outside the body, thereby reducing the chances of endometrial tissue affecting fertilisation.

If necessary, ICSI (intracytoplasmic sperm injection) to inject a single sperm directly into an egg can also be used with IVF where many '€œpurified'€ sperms are put around the egg for one of them to penetrate the egg.

Patients with advanced endometriosis frequently have decreased ovarian reserve due to endometriotic cysts and prior surgeries to remove them that inevitably damages normal ovarian tissue reserves. IVF becomes the best and sometimes the only option to achieve a healthy pregnancy in such cases.

Nair is a senior consultant obstetrician, gynecologist and fertility expert at Mount Elizabeth Medical Centre.