Endometriosis: Understanding fertility related issues

The incidence of endometriosis is two to 10 percent in the general population and upto 50 percent in couples with fertility related issues

By Dr Shanujeet Kaur

Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction. Endometrium is the inner lining of the uterus which sheds every month, resulting in menses (or periods). The same endometrium is also responsible for implantation of the embryo and causing pregnancy.

In endometriosis, this endometrium starts to grow in organs such as ovaries and fallopian tubes, outer layers of uterus and sometimes in urinary bladder, intestines, lungs etc. The incidence of endometriosis is two to 10 percent in the general population and upto 50 percent in couples with fertility related issues.

The hormonal changes in the menstrual cycle affect the misplaced endometrial tissue, causing the area to become inflamed and painful. This means the tissue will grow, thicken and break down. Over time, the tissue that has broken down has nowhere to go and becomes trapped in your pelvis which can later cause irritation, scar formation, adhesions, in which tissue binds your pelvic organs together, severe pain during your periods and later leads to fertility related problems.

How it is diagnosed: Symptoms to watch out for

Women suffering from endometriosis report to their gynaecologist with one or more of the following most common symptoms: The 5 Ds:

Dysmenorrhoea or painful periods. This can also be pain in the lower abdomen before and during menstruation.

Deep dyspareunia or painful intercourse.

Dysfunctional uterine bleeding—abnormal or heavy periods.

Difficulty in conceiving—infertility.

Dyschezia—painful or difficult defecation.

Pain, during periods, pelvic pain not related to periods, progressively increasing pelvic or period pain, and infertility are the major distressing factors that severely affect the quality of life of patients having endometriosis.

How can this condition be evaluated?

Clinical and radiological evaluation

Bimanual pelvic examination of the patient reveals a few signs to the gynaecologist which are corroborated with transvaginal ultrasound TVS. TVS may reveal a chocolate cyst (endometrioma) in one or both the ovaries. The ovaries may be placed close to each other behind the uterus, or the uterus could be enlarged especially its muscular layer when it is called adenomyosis and so on. Rarely an MRI may have to be done to confirm the pelvic endometriosis.

Role of Laparoscopy

Laparoscopy is a minimal access surgical technique where vision is achieved with the help of a telescope. Laparoscopy is the gold standard for diagnosis of endometriosis and has the benefit of treating the disease at the same time.

How endometriosis can cause fertility-related issues

There are four reasons for decreased fertility

Ovulatory infertility: Altered growth of follicles due to inflammation and hence altered ovulation or hindrance in ovulation.

Tubal factor infertility: Endometriosis causes inflammatory reaction which causes abnormal fusion between ovaries, tubes, uterus and bowels. The tubes may become distorted, swollen and unhealthy

Abnormality in the endometrial receptivity: The inner lining of the uterus fails to provide a favorable environment for implantation.

Immunological infertility: The inflammatory reaction in the pelvis due to endometriosis releases many negative factors called reactive oxidative species-ROS- that cause oxidative stress to both the oocytes (eggs) and sperms. The gametes (eggs and sperms) are very sensitive to this oxidative stress and cannot function properly.


If the disease is minimal or mild, tubes are open, good semen parameters, the age of female partner is less than 32 years and duration of infertility is less than three years, then controlled ovarian stimulation combined with intrauterine insemination of semen (IUI) is the treatment of choice.

This treatment can be repeated upto three to six cycles, addition of further cycles of IUI does not benefit the couple and they need to proceed for in vitro fertilisation or IVF.

In moderate and severe disease: Surgical resection of endometriomas (chocolate cyst) and burning down of all endometriotic spots in the pelvis, meaning that complete removal of endometriosis if possible, should be the aim to improve chances of conception.

The surgery is followed by either IUI or directly to IVF/ICSI (test tube conception)if at the time of surgery the tubes are found to be damaged due to the disease.

A word of caution here is that endometriosis is an ongoing process till a woman is menstruating every month and so it has a high recurrence rate. Hence it is wise to follow up the surgery with either IUI or IVF within six months of surgery. It is important to get yourself examined if you are suffering from pain in the pelvis either related or unrelated to periods, that is affecting your quality of life or if your facing difficulty in conceiving as endometriosis could be a diagnostic possibility and it needs to be treated sooner than later to give you maximum chances of achieving a pregnancy.

(The writer is Senior Consultant – Gynecologist and fertility expert at Cloudnine Group of Hospitals, Chandigarh.)

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