Updates in the Field of Endometriosis: Fertility

Endometriosis is often associated with infertility; however, the mechanism underlying this relationship remains at large.

Key Points

Highlights:

• This chapter explains the link between endometriosis and infertility.
• Evans and Decherney discuss success associated with various fertility treatments.

Importance:

• Individuals with endometriosis often face the prospect of infertility, which can prevent them from leading their ideal lives. Understanding the relationship between endometriosis and fertility as well as understanding ways to conceive in the face of such adversity will allow women suffering from this disease the chance to start a family if they so desire.

What’s done here?

• The authors gathered and consolidated information pertaining to the relationship between endometriosis and fertility. They interspersed this knowledge with relevant research.

Key points:

• Physical Barrier
  • The exact molecular mechanism that causes endometriosis to lead to decreased fertility is not well understood. It is hypothesized that the pelvic adhesions can lead to tubal disease and altered oocyte release and subsequent ovum transport, which can impair fertility.
  • The threat of infertility is greater at later stages of the disease.
• Hormonal and Cell Mediated Alterations
  • The levels of macrophages, metalloproteinases, proteases, prostaglandins, peritoneal fluid, and cytokines within the aforementioned peritoneal fluid are raised in an individual with endometriosis. The following conditions that affect fertility can also be present in a woman who has endometriosis: luteinized unruptured follicle syndrome, luteal phase abnormalities, varied follicle growth, and unnatural luteinizing hormone surges.
  • Various inflammatory cytokines and autoantibodies to endometrial receptivity can lead to infertility for a variety of reasons.
  • Peritoneal fluid in women with endometriosis can adversely affect sperm motility and ciliary function of the fallopian tubes.
• Fertility and Medical Treatment
  • Certain hormonal therapies used to treat endometriosis can grossly affect fertility since these treatments inhibit ovulation; however, some studies have shown that these therapies can prove beneficial for in vitro fertilization (IVF). These treatments include: progestins, combination estrogen and progestin contraceptive pills, gonadotropin releasing hormone (GnRH) agonists/antagonists and danazol.
  • Researchers are unsure of the effect the following therapies have on fertility: aromatase inhibitors, selective estrogen receptor modulators, progesterone antagonists, and selective progesterone receptor modulators.
• Fertility and Surgical Treatment
  • It is not necessary to use laparoscopy to diagnose asymptotic endometriosis patient whose source of infertility is unidentified since the patient would not gain many benefits from the procedure. This is particularly true for individuals in the earlier stages of endometriosis. There has been some improvement in fertility for individuals with severe endometriosis who have undergone laparoscopy.
  • A cystectomy is better than cyst drainage since the former has lower rates of recurrence; however, the surgeon should exercise caution and retain as much of the ovarian tissue as possible because a loss of ovarian tissue can increase infertility.
  • Some sources suggest that any endometriomas be removed prior to IVF/ICSI in an asymptotic patient.
• Ovulation Induction and Intrauterine Insemination (IUI) With Endometriosis
  • Individuals suffering from endometriosis tend to have higher rates of pregnancy when opting for ovulation induction with IUI. This is higher than the pregnancy rates found for women with endometriosis using expectant management or women without endometriosis who have unexplained infertility.
• Assisted Reproductive Technology and Endometriosis
  • IVF cycle stimulation does not affect an individual’s symptoms or quality of life differently depending on whether or not they have endometriosis.
  • Abnormal anatomy in stage III/IV endometriosis patient adversely affects fertility. Age, embryo quality, and embryo implantation are all factors that influence IVF outcomes.
  • In vitro fertilization, embryo transfer (IVF-ET) is recommended for individuals with severe endometriosis who have undergone more than 1 surgery as it results in better pregnancy outcomes.

This summary is a part of the future of endometriosis research, whic summarises the progress made in this field. The developments have been delineated in a 2017 issue of Clinical Obstetrics and Gynecology. For updates specific to a given topic namely surgery, genetics, epigenetics, and fertility, one can consult the issue above of Clinical Obstetrics and Gynecology or please look at the summaries for each topic, found in Endonews.

Lay Summary

Infertility can be a significant problem for many women who are suffering from endometriosis. In their chapter titled “Endometriosis and Fertility,” Evans and Decherney discuss the role of endometriosis in infertility and examine the usefulness of various fertility treatments.

The first two subsections of this chapter attempt to elucidate the molecular mechanisms that underlie endometriosis and cause infertility. The first explanation points towards physical barriers that result in infertility and are a byproduct of endometriosis. The authors also state that the hormonal and cell mediated alterations that are caused by endometriosis can also lead to infertility.

The next part of the chapter warns women about the risks of using various therapies as they can prevent pregnancy. These therapies are largely hormonal treatments, which include progestins, combination estrogen, and progestin contraceptive pills, gonadotropin releasing hormone (GnRH) agonists/antagonists and danazol.

The authors then proceed to discuss the effects of endometriosis related surgery on infertility. They also discuss surgical techniques that should be used when a surgeon is attempting to maximize a patient’s ability to reproduce.

The last parts of the chapter examine various fertility treatments. Research shows that ovulation induction and intrauterine insemination (IUI) results in better rates of pregnancy. Studies have also shown that certain variables like age and embryo quality tend to dictate pregnancy outcomes. 

Please note that the full chapter on fertility and endometriosis can be found in a 2017 issue of Clinical Obstetrics and Gynecology. For updates specific to other given topics namely surgery, genetics, epigenetics, imaging, and fertility preservation, one can consult the aforementioned issue of Clinical Obstetrics and Gynecology or look at the summaries found on Endonews. Endonews also provides an all-encompassing summary.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/28742581