Endometriosis and pregnancy

Endometriosis is a relatively common condition in women, but it is still not fully understood. It is thought that it affects around 1 in 8 women during their reproductive years. During normal menstruation, the endometrial lining of the uterus builds up and is shed each month. Ideally, this lining is restricted only to the uterus but it can also grow in other areas of the pelvis. Nodules of endometrial lining can collect on the ovaries, the bowel, the bladder, the cervix and vagina as well as the fallopian tubes.

During ovulation these areas of endometrial tissue can also be stimulated because they are sensitive to hormonal influences. Without any means of being released from the body, collections of blood and fluid are retained, which causes patches of scarring and adhesions to form.

This commonly leads to pelvic pain occurring both during the menstrual period and in-between. Painful intercourse (known as dyspareunia), bowel and bladder problems and infertility are other frequent symptoms.

Symptoms of endometriosis

There is a range of symptoms which can be attributed to endometriosis. Some women have very distinct signs, while for others their symptoms are more vague. Depending on the stage of a woman’s menstrual cycle e.g. during ovulation or menstruation, her symptoms may be more obvious.

• Pain in the pelvic region which can come and go.
• Painful sexual intercourse.
• Constipation, bloating, bowel discomfort, diarrhoea and general gut discomfort.
• Heavy periods, passing clots, irregular bleeding cycles
• Feeling worn down, tired and a lack of energy.
• Infertility and ectopic pregnancy.
• Back pain and a sense of “dragging” discomfort.
• Rectal pain.
• Urinary discomfort, passing urine which is blood stained.
• Pain mid-cycle relating to ovulation. This is known as mittelschmerz.
• Heavy periods or irregular cycles.

Because the symptoms of endometriosis can be so vague and mimic so many other disorders, having it correctly diagnosed can take some time. The associated bowel symptoms can mimic Irritable Bowel Syndrome; (IBS) and the pelvic discomfort shares a similar pattern with Pelvic Inflammatory Disease; (PID). For many women it’s not until they want to start conceiving and experience fertility problems that they learn they have endometriosis. Some American studies indicate that it can take up to ten years for a woman to be correctly diagnosed with endometriosis, with an average age of 27 being the most common.

Diagnosis of endometriosis

Diagnosis is only made when the endometriosis can be seen during a laparoscopy or laparotomy. Samples of tissue are excised and sent to the laboratory for examination. If they are identified as endometrial cells then a formal diagnosis of endometriosis is made.

How exactly does endometriosis cause infertility?

• Because the fallopian tubes are so small, almost microscopic in size, it does not take much for them to become blocked. Any interruption to the eggs smooth passage along the tube reduces the likelihood of successful fertilisation.
• Developing thickened adhesions stops the egg from migrating along the tube and also the sperm from finding its way upwards and along the fallopian tube to the egg.
• Adhesions can also anchor the ovaries and tubes so they are misplaced from their normal position in the pelvis.
• Endometriosis can also “coat” the ovary which inhibits the egg from being able to find its way into the tubes.
• Just as endometrial tissue in the uterus produces blood, when this tissue is located on the ovary, menstruation occurs. Without having any means of escaping, this old blood forms into cysts on the ovary which further impact on normal ovulation.
• Some researchers believe that the hormones and chemicals which are released due to pelvic inflammation are antagonistic towards sperm. This theory also applies to problems with the smooth migration of the egg as it makes its way from the ovary to the uterus.
• In some cases of endometriosis there appears to be a chemical or hormonal influence from the endometrial cells themselves. This impacts on conception itself and also the early development of the embryo.
• In some women there may also be an interruption to regular ovulation. If there are not as many eggs being produced and ovulation is irregular, then the overall chances of conceiving are reduced.
• Endometriosis may also have an influence on the quality of the eggs, so their chances of being fertilised and developing normally are reduced from the very start.

It’s worth remembering that not all women with endometriosis will be infertile. Only around 1/3 will experience some degree of infertility. In fact, many fertile women have endometriosis; though only when scarring is extensive is there an impact on their fertility.

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 thought that endometriosis is one of the leading causes for female infertility.

What causes endometriosis?

There are many theories about what causes it, but there is no one definitive explanation.

• Some researchers believe that during menstruation, some of the blood “backs up” into the fallopian tubes and escapes into the abdomen. In a percentage of women, particularly those with issues relating to their immunity, this sets up an immune response.
• Women who have problems with their thyroid seem to be more at risk of developing endometriosis.
• There also appears to be a genetic component to developing endometriosis. It has been proven that women who have this condition are more likely to have daughters who develop endometriosis.
• Another possibility is that very early in embryonic development the endometrial cells, which should be restricted to the lining of the uterus, form outside the uterus onto and around the other organs and tissues.
• There may also be an environmental influence on the chances of developing endometriosis, but exactly how and in what way is unknown.

How can I prevent getting endometriosis?

There is no way to prevent getting this condition. Genetics, individual factors and hormones can all have an influence, though ultimately there is no one known reason why it occurs. Some women experience problems from when they start menstruating. With the benefit of hindsight they can recall as teenagers having had debilitating pain during their periods, but just passed this off as normal experience.

Will falling pregnant fix my endometriosis?

No, this is a myth. It used to be thought that pregnancy was the cure all for endometriosis but this has been proven not to be the case. It is true that there is usually an improvement of symptoms and relief from endometriosis discomfort during pregnancy. In the majority of women, there is a recurrence of their endometrial symptoms within a couple of years after childbirth.

Treatment for endometriosis

There are a few options when it comes to treating endometriosis.

• Managing the pain and discomfort is only a temporary measure but does not treat the cause or condition. Over the counter analgesia may be sufficient. Alternately, pain relief medication which is only available via prescription may be required.
• Another common treatment option is to take medication which stops ovulation from occurring. This can be the oral contraceptive pill or a combination of hormonal compounds including those containing progesterone.
• Surgery is another treatment option and, where possible, is done via keyhole surgery. Excision of the lesions where endometrial cells have collected can be very effective, as can freeing up any adhesions which are causing displacement of organs and tissues from their normal positions. But surgery is not always effective, particularly in cases of severe endometriosis. In fact, some researchers believe that surgery can, instead of increasing the chances of conceiving, actually reduce them.
• Excising the blood filled cysts on the ovaries, whilst removing the problem, can also run the risk of removing some of the ovarian tissue itself. Apart from further impacting on normal ovulation, this can lead to premature menopause. Removing endometrial tissue from the pelvis and organs requires skill and precision and is not without risk. Any operation carries a chance of complications; though for many women, having a chance of reducing their pain and increasing their chances of conceiving is worth it.
• In women who have completed their families and whose lives are being affected by endometriosis, hysterectomy is another option. This should only be considered as a last resort when the pain and symptoms of endometriosis are impacting significantly on every day functioning.

What about surgery for endometriosis?

Surgical treatment sometimes becomes necessary to alleviate pain and discomfort. If the endometrial cells are interfering with fertility, a laparoscopy can be performed and the cells removed. This is generally done under “keyhole” size incisions, though occasionally a larger surgical cut, known as a laparotomy needs to be done.

If surgery is not successful, IVF may become the only realistic option to assist with conception.

For all its inconveniences and pain, it is worth noting that endometriosis in itself, is not life threatening.

Support for endometriosis is available through:

• Endometriosis New Zealand – Information and support line 0800 733 277