Endometriosis and its effect on Infertility

Endometriosis is a common gynaecological condition in which the tissue that forms the endometrium lining (also referred to as “uterine lining”) grows outside the uterus such as on the bladder, bowel, fallopian tubes, ovaries or on the lining of the abdomen [1].

About 3 to 10% of women of reproductive age are affected by endometriosis [2]. Endometriosis symptoms in women can range from painful menstrual periods, lower abdominal pain, pain during sexual intercourse, etc. However, it is also possible that a woman suffering from endometriosis does not show any symptom.

In some extremely rare cases, endometriosis can occur in men as well. Over history, there have only been a few cases registered related to endometriosis in men. This condition in men can be described as uterine like mass endometriosis attached to the urinary bladder and extends into the inguinal canal area in men suffering from cirrhosis (a late stage of scarring of the liver) [3].

Endometriosis Symptoms

Endometriosis is a chronic condition whose primary symptom is pelvic pain. However, about 20% to 25% of the women suffering from this condition are asymptomatic (showing no symptoms) [4]. Cramps during menstrual periods is also a common symptom of endometriosis however, the pain is far worse than a normal period cramp and it may also increase over time.

Other common endometriosis symptoms are mentioned below.

• Dysmenorrhea (Painful Periods): In the case of endometriosis, pelvic pain and cramps begin way before periods and tend to extend for several days into the period. A woman may also suffer from abdominal and lower back pain.
• Excessive Bleeding: One might also experience heavy periods or bleeding between periods.
• Pain with urination or bowel movements: You might also feel pain during urinating or pooping.
• Pain with intercourse: Another common symptom of endometriosis is pain during or after sexual intercourse.
• Infertility: Endometriosis can also lead to infertility and is discovered in most cases while a woman goes through diagnosis for infertility.
• Other symptoms: Other endometriosis symptoms that a woman may experience are diarrhoea, constipation, fatigue, nausea or bloating during periods.

Mentioned below is the rate of occurrence of some of the common symptoms of endometriosis [5].

1. Dysmenorrhea: 60% to 80%
2. Excessive painful intercourse: 40% to 50%
3. Chronic pelvic pain: 40% to 50%
4. Infertility: 30% to 50%
5. Severe pain during periods, bleeding in between periods or irregular periods: 10% to 20%

The intensity of the symptoms of endometriosis and the chances of its diagnosis increases with age and the most common age of its diagnosis is 40 years. Also, it takes several years for endometriosis to develop after your first period. Furthermore, the symptoms of endometriosis may also improve with pregnancy and go away when you reach menopause (if you are not taking synthetic or artificial estrogen).

Endometriosis Causes

The exact cause of endometriosis has not been found yet. However, retrograde menstruation is believed to be one of the main causes of endometriosis [5]. Some of the most common causes detected in women suffering from endometriosis are mentioned below.

• Retrograde menstruation: In retrograde menstruation, the period blood containing endometrial cells flows back into her body. These cells stick on the pelvic organs and grow causing endometriosis [6].
• Embryonic cell transformation: In this condition, hormones like estrogen may transform embryonic cells (cells in their earliest stages of development) into endometrial like cells.

This condition may also explain the reason for endometriosis in men. All the embryos start off with female characteristics and start developing into male or female organs around week 7 of the pregnancy. Due to the presence of the female characteristics in the early stages, it can be speculated that endometriosis can occur in men [7]. However, more research is needed in this area to know how or why this happens.

• Transformation of peritoneal cells: Experts also believe that “induction theory” in which the hormones or immune factors promote the transformation of peritoneal cells (cells that form the inner lining of the abdomen) into endometrial like cells which may lead to endometriosis.
• Endometrial cell transport: The blood vessels or lymphatic system may also transport endometrial cells to other parts of the body.
• Surgical scar implantation: It is also possible that after a surgery like a hysterectomy or C-section endometrial cells attach themselves to the surgical cut and start growing causing endometriosis.
• Immune system disorder: Due to immune disorder the body may fail to recognise and destroy endometrial like tissue that is growing outside the uterus.

Risk factors associated with Endometriosis

A relatively small inconvenience like getting early periods to something serious as infertility can put at a risk of getting endometriosis. Hence it is necessary to consult a doctor as early as possible once you start observing any of the symptoms. Some of the risk factors associated with endometriosis are mentioned below.

• Infertility
• Menopause starting at an early age
• Menstrual periods starting at an early age
• Short menstrual cycles (periods starting within 27 or fewer days)
• Heavy bleeding during periods
• Long periods that last for over a week
• Low BMI (body mass index)
• Abnormalities in the reproductive tract
• Having high levels of estrogen or a long period of exposure to estrogen produced by the body
• If you have a family history of women suffering from endometriosis
• If you have any condition that prevents the menstrual flow following the normal passage to get out of the body

Complications due to Endometriosis

Endometriosis can lead to many complications, some of them can be severe. Endometriosis can result in the following complications.

• Infertility: Endometriosis can lead to fertility issues. If you are having trouble conceiving for about a year then it is advised to consult a doctor. In many cases, endometriosis is observed during the diagnosis for a cause of infertility. In these type of cases, endometriosis is considered to be one of the contributing factors towards infertility.

Furthermore, in some cases, if a woman has a diagnosed case of endometriosis she may later have issues with her fertility as well.

• Cancer due Endometriosis: Women with endometriosis have higher chances of suffering from ovarian cancer. However, studies suggest that the chance of a woman having ovarian cancer in her lifetime is very low even though endometriosis increases that chance it is still relatively low. Another rare form of cancer called adenocarcinoma can also occur due to endometriosis.

Endometriosis can cause infertility in many ways. Many studies show that 30% to 50% of women suffering from endometriosis are infertile. Also, about 25% to 50% of women suffering from infertility have endometriosis [8]. It is also associated with a lower live birth rate. It is believed that it is due to the impact of endometriosis on ovaries and fallopian tubes.

Effect of endometriosis on Ovarian function which can impact infertility

Studies have shown that endometriosis can damage the ovarian tissue which can adversely affect the ovarian function. It can cause inflammatory reactions resulting in endometriomas. Endometriomas (also called chocolate cyst or endometriosis cyst) is a type of ovarian cyst that forms when the endometrial tissue grows in the ovaries. Endometriomas may cause damage to the ovarian tissue. It is also associated with a major risk of follicle loss [9]. The symptoms of endometriomas in pelvic pain and dysmenorrhea.

Endometriosis can also cause mechanical damage to the ovarian function such as - hampered blood circulation, stretching and compression of ovarian tissue, impaired neovascularization (formation of new blood vessels).

Both inflammatory reaction and mechanical damage may result in infertility.

Effects of endometriosis on ovarian reserve resulting in Infertility

Ovarian reserve is a term used to define the capacity of an ovary to produce eggs that are capable of fertilization. The ovarian reserve declines in women as they grow older. Many studies have found that endometriosis can reduce ovarian reserve especially in women with severe endometriosis. Which means that endometriosis can speed up the process of decrease in ovarian reserve resulting in early menopause which may hamper the infertility of a woman.

Blockage in fallopian tubes due to endometriosis

Sometimes, endometriosis can also cause a blockage in the fallopian tubes. Fallopian tubes are narrow ducts which connect the ovaries to the uterus. When an egg is released by the ovary it travels through one of the fallopian tubes to the uterus. The egg meets the sperm in the fallopian tube during conception and the fertilised egg then passes to the uterus. If the fallopian tubes are blocked the eggs won’t be able to get fertilised by the sperm hence restricting conception.

Whenever you go to a doctor with problems like pelvic pain, dysmenorrhea, excessive bleeding, infertility, etc they usually start with a pelvic exam for the diagnosis of the condition. In order to get a proper diagnosis of endometriosis or related infertility, the following exams are performed by a doctor.

• Pelvic Exam:

All the doctors start with a basic pelvic exam. During a pelvic exam, a doctor tries to manually feel any bulge, cyst, or any abnormalities like abdominal masses, enlargement, reduced organ mobility and any scars or lesions in your pelvic region. However, it is not possible for the doctor to feel small areas of endometriosis unless it has formed a cyst.

• Ultrasound:

An ultrasound uses high-frequency sound waves to create a picture of the inside of the body. An ultrasound may not be able to definitively tell if you have endometriosis or not but it is always preferred as the first imaging test by the doctors. However, it may be able to detect the presence of endometriomas(a type of cyst). It can also detect other signs of infertility like cysts in the ovaries, swollen fallopian tubes, etc.

• Magnetic Resonance Imaging (MRI):

MRI uses magnetic fields and radio waves to create detailed images of the internal organs and tissues within the body. Using high-resolution imaging it can detect superficial endometrial implants (implants existing on the surface of an organ), adhesions, as well as ovarian disease. It also helps with the surgical planning for the doctor as is usually used before surgeries like laparoscopy [10].

• Laparoscopy:

Laparoscopy can be considered as the golden standard for diagnosing endometriosis. It can detect the existence as well as the intensiveness of the disease. The procedure can tell the location and size of the endometrial implants. According to the relevance, the doctor can either perform surgery during laparoscopy to treat endometriosis or take a tissue sample for biopsy for further testing.

There are several medications, home remedies and surgeries available for treating endometriosis. For mild symptoms, you may stick with home remedies however if the intensity of the symptoms increase it is advised to visit a doctor for a proper diagnosis accompanied by medical or surgical treatment.

Fertility Treatment for Endometriosis:

Endometriosis may cause infertility. If you are trying to conceive your doctor may prescribe you different types of fertility treatments depending on the severity of your condition. These fertility treatments can range from fertility medication to assisted reproductive technology (ART) like In vitro fertilization (IVF).

The treatment of fertility due to endometriosis is done based on how severe is the condition in women. Depending on the severity found during the evaluation, treatment is provided. Endometriosis is evaluated in the following stages [11]:

• Stage I: In stage I endometriosis (minimal disease) the patient has few small endometrial implants with no scar tissue.
• Stage II: In stage II endometriosis (mild disease) the patient has more endometrial implants involved but less than 2 inches of the abdomen is involved and there is no scar tissue.
• Stage III: In stage III endometriosis (moderate disease) the patient may have deep endometriosis and they might also have endometriomas in the ovaries. Scar tissue might also be present in the tubes or around the ovaries.
• Stage IV: In stage IV endometriosis the patient has several endometrial implants, endometriotic cysts in the ovaries, possible scar tissue between rectum and uterus and around the fallopian tubes and ovaries.

Fertility treatment for women suffering from State I and Stage II endometriosis:

Women with stage I and stage II endometriosis may become pregnant on their own. Endometriosis at these stages rarely results in infertility. However, surgical and medical treatment can help increase the pregnancy rate in women with endometriosis at these stages.

Medical Treatment

Initially, a doctor may start with fertility medications to enhance your chances of conceiving. The whole idea of these medications is to slow down the growth of the endometrial implants and prevent any new implants of the endometrial tissue. However, it is not a permanent fix and the symptoms may return after the treatment has stopped.

Some of the medical treatments offered by the doctors are:

• Hormonal contraceptives: The doctors may prescribe Vaginal rings, birth control pills and patches which help control the hormones responsible for the build-up of endometrial tissue each month. It can also help reduce pain due to endometriosis.
• Progestin therapy: Progestin therapies like intrauterine devices with levonorgestrel, contraceptive implant, progestin pill, contraceptive injection, etc can stop the menstrual periods as well as the endometrial growth which help relieve the symptoms of endometriosis.
• Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists: These medicines block the ovarian stimulating hormones, lessens the production of estrogen and stops menstrual periods. All of this results in the endometrial tissue to shrink.
• Aromatase Inhibitors: It is a class of medication used to reduce the production of estrogen in your body. Generally, doctors prescribe it with a progestin or combination hormonal contraceptive in order to treat endometriosis.

If this method doesn’t work, the doctors might move on to surgical treatment.

Conservative Surgery for Endometriosis

Conservative Surgery is one of the best options for women who are trying to get pregnant while suffering from endometriosis. This surgery removes endometriosis implants while preserving the uterus and ovaries. This surgery can also reduce the pain occurring due to endometriosis however the pain may come back.

This surgery can be performed laparoscopically as well as through traditional abdominal surgery for more extensive cases.

Both the treatments mentioned above can effectively treat stage I and II endometriosis. If these treatments don’t work, an ART method called Intrauterine Insemination (IUI) may be used.

Fertility treatment for women suffering from State III and Stage IV endometriosis:

Stage III and Stage IV endometriosis can be a bit challenging to treat through fertility medications. For a better chance at attaining fertility, a patient at stage III and stage IV requires surgical treatment (mentioned above) and if the surgical treatment doesn’t work the doctor may decide to go with IUI treatment. In most cases, surgical or IUI treatment results in the woman conceiving within a year. If the conception didn’t happen within a year, then a doctor might suggest In vitro fertilization as the next step of treatment.

In vitro fertilization (IVF) is also an ART treatment in which the eggs of a woman are fertilised in a laboratory with the help of the sperm in a laboratory. This treatment shows promising results for conception in women with stage III and stage IV endometriosis.

Other treatment for endometriosis:

Hysterectomy with Oophorectomy for Endometriosis treatment:

If getting pregnant is not your concern then you can also choose to go for surgeries like hysterectomy and oophorectomy. These surgeries can effectively treat endometriosis however, you won’t be able to get pregnant after that.

Hysterectomy is the surgical removal of the uterus and Oophorectomy is the surgical removal of one or both ovaries. Hysterectomy along with oophorectomy was once considered to be one of the most effective methods of treating endometriosis.

The surgery can treat symptoms of endometriosis like uterine cramping and heavy bleeding. However, the doctors nowadays are moving away from this approach sticking with less invasive procedures and focusing more on carefully removing the endometrial tissue.

If you have mild symptoms of endometriosis there are many natural treatments that you can try to treat them. You can also plan your daily diet and routine to reduce the endometriosis symptoms. Some of the natural treatments for endometriosis are mentioned below.

Indian foods for endometriosis treatment

Turmeric: Turmeric is known to have anti-inflammatory properties and has a compound called curcumin that has shown impressive results in slowing the growth of endometrial cells. Turmeric is not only an ingredient filled with goodness but it is also an ingredient that is easily found. Being Indians, you can find turmeric tucked away in your kitchen. You can take this turmeric in many ways that may help you reduce the endometriosis symptoms.

• As we Indians usually do, include turmeric in the curries and other food you prepare
• Turmeric can also be taken with milk just before you sleep
• You can also start drinking turmeric tea; it is easily available in top online shopping websites

Green Tea: Green tea as similar properties to progesterone which can help refrain aromatase (which is associated with estrogen activity). Also, it can help suppress the growth of blood vessels that feed endometrial growth.

For best results, you can drink green tea in the morning or early at night. The best time to drink green tea at night is 2 hours before going to bed because this is the time your metabolism is at its lowest and green tea can speed it up. You can also drink green tea in between meals. For example, you can drink it 2 hours before or after your meal, this will maximize your nutrient intake and iron absorption. This will not only help you with endometriosis but will also help you live a healthy lifestyle.

Omega-3 Fatty Acids rich foods:

Omega-3 fatty acids are found in fish like sardine, salmon, mackerel, and anchovies are believed to be beneficial for women with endometriosis. These fatty acids turn into anti-inflammatory prostaglandins and they also appear to suppress inflammatory prostaglandins derived from red meat and fats in dairy products.

Unfortunately, till now omega-3-fatty acids are not available in any of the vegetarian sources but that does not mean vegetarian women have to worry there are a lot of other vegetarian foods which can help you manage endometriosis some of them you can find in this section itself. Also, you can always go for omega 3 fatty acids supplements. They are available at every pharmacy in India and can also be found online.

Isoflavone rich food: Isoflavones are plant-based chemicals that may help reduce endometriosis. Food like soybeans, pistachios, chickpeas, peanuts, etc is rich in this chemical. There are many isoflavone foods that you can find in your kitchen. Some of the foods rich in isoflavone are Moong Dal, Chana Dal, Toovar Dal, Masoor Dal, Urad Dal, Rajma, Chickpeas, Soybeans and many more.

Chamomile: Chamomile is a European plant of the daisy family. It is believed that this plant can help reduce endometriosis symptoms like cramps and pain due to endometriosis. In India, chamomile is sold as dried flowers, seeds, flavoured tea, etc. You can find chamomile food products in online shopping and grocery stores.

Resveratrol rich food: Resveratrol is a plant-based nutrient. It is believed to treat endometriosis by restricting the production of aromatase (which is associated with estrogen activity) and COX-2 enzymes (which is associated with pain) in the body. Red wine, peanuts, dark chocolate, blueberries, black grapes, mulberries, and cranberries are rich in resveratrol.

Lifestyle changes for treating endometriosis

Low-Fat Diet: Many studies have suggested that chemicals like polychlorinated biphenyls (PCBs) and dioxins may increase the risk of having endometriosis. Saturated fats, especially red meat and high-fat dairy have high levels of polychlorinated biphenyls (PCBs) and dioxins. Hence reducing the consumption of such fats may help treat endometriosis.

You may want to reduce the consumption of red meats like lamb, beef, pork and high-fat dairy products like whole milk, whole milk curd and buttermilk.

Instead, stick to a low-fat diet which contains more fruits and green and leafy vegetables. You can add the following foods in your diet.

• Food rich in fibres like legumes, cauliflower, whole grains, sweet potatoes, pumpkins, ladyfinger, etc
• Food rich in iron like soybean, almonds, cashews, peanuts, pumpkin seeds, spinach broccoli, etc
• Food rich in essential fatty acids like salmon, walnuts, sardines, flax seeds, etc

Acupuncture: Acupuncture is a treatment for pain which involves the insertion of tiny needles. In a study published in 2017, it was found that acupuncture can also help with abdominal pain and pelvic pain. It can also help reduce endometrial growth. It may help with reducing pain if done for 4 to 6 weeks however, more research is needed in this area.

Massage Therapy: It is believed that massage therapy can relieve the symptoms of massage therapy. In 2010, a small study was conducted with 23 women with endometriosis. All of the women showed a significant reduction in pelvic pain after a massage therapy of 6 weeks.

Progesterone Cream: A progesterone cream is derived from either soy or Mexican wild yam. Some alternative doctors prescribe this cream to treat the symptoms of endometriosis. It is believed that this cream can restrain the growth of endometrial cells and the development of blood cells that feed the uterine growth.