Impaired fertility potential in endometriosis patients

Reproductive problems in endometriosis may be caused by a variety of factors including pelvic adhesions, decreased oocyte quality, abnormal tubal function and sperm motility and alterations in endometrial receptivity.

Key Points

Highlights:

• Endometriosis may affect the reproduction in almost all aspects, ovarian reserve, impact of appropriate surgery, quality of oocyte, embryo and endometrium along with the quality of life during fertility treatment are the most important issues.

Importance:

• Endometriosis patients should be evaluated and managed carefully considering the possibility of infertility.

What’s done here?

• Endometriosis has been evaluated starting from its definition, clinical presentation, underlying pathophysiologic mechanisms and endometriosis-associated fertility problems.
• The management alternatives for endometriosis and protective measures against infertility in these patients are summarized.
• Impact of ovarian surgery on ovarian reserve and its consequences have also been detailed by the authors.

Key results:

• Infertility can be encountered in up to 50% of women with endometriosis and, up to 50% of women with infertility can be diagnosed with endometriosis.
• Some classifications have been developed to determine the extension and stage of endometriosis and to predict which women are at higher risk for infertility.
• While the revised American Society for Reproductive Medicine (rASRM) classification defines the disease in four stages as minimal, mild, moderate, or severe, Endometriosis Fertility Index (EFI) estimates fertility outcomes in endometriosis patients.  
• Maternal age and ovarian reserve are the most important determinants for fertility in women having endometriosis.  
• In vitro fertilization is the most preferred and effective treatment modality in endometriosis patients as surgical approach of endometriosis may result in a detrimental effect on ovarian reserve and so unwanted reproductive consequences.
• IVF outcomes depending on disease stage, number and quality of oocytes are satisfactory in endometriosis patients.
• Endometrial receptivity doesn't seem to be affected by endometriosis.

Lay Summary

Infertility is frequently encountered in endometriosis patients because of anatomic distortion, alterations in endometrial receptivity, diminished tubal peristalsis and sperm movements.

Garcia-Fernandez and García-Velasco, from Edinburgh, UK and Madrid, Spain, published a mini-review titled “Endometriosis and Reproduction: What We Have Learned” in the "Yale Journal of Biology and Medicine".

The authors aimed to evaluate all aspects of the relationship between endometriosis and infertility, and suggest preventive measures.  Even though disease stage and presence of endometrioma are negatively correlated with fertility, it is unpredictable which women are at higher risk. While the revised American Society for Reproductive Medicine (rASRM) classification defines the disease in four stages as minimal, mild, moderate, or severe, this scoring system does not show a good correlation with fertility. Endometriosis Fertility Index (EFI) considering female age, years of infertility, prior pregnancy status, least function score, and AFS (American Fertility Society) score can be used for this aim and higher EFI score (>7) is associated with higher chance for spontaneous pregnancy postoperatively.

As in all women, age and ovarian reserve are also the most important determinants of fertility for women with endometriosis. Surgical management of endometriosis may result in lower antral follicle count, lower number of developing follicles and higher risk of "no response to the ovarian stimulation" in the operated ovary compared the contralateral healthy ovary. In vitro fertilization overcomes some mechanisms that lead to infertility in endometriosis patients including removal of oocytes from toxic peritoneal environment, bypassing tubal factor, and improvement of endometrial receptivity. Endometriosis patients should be counseled about fertility preservation as an attractive alternative.  

“Fertility preservation could be discussed with the patient prior to their surgery so they could vitrify their oocytes and have a valid alternative to have children in case surgery and/or disease progression compromises their ovarian reserve” the authors added.

Research Source: https://pubmed.ncbi.nlm.nih.gov/33005121/