Medical Care

Barriers to Pregnancy: Endometriosis

Learn the relatively unknown yet nonetheless common gynecological problem endometriosis

Text by: GHT | 12 March 2012

Although it is one of the most common gynaecological problems, endometriosis is still a fairly “unknown” condition, and it often takes some time to diagnose it. It causes many women severe pain that affects their quality of life, including their ability to start a family. As with other chronic illnesses, women ought to arm themselves with information about the subject and the best treatment options available, so that they can live the best-possible life.

What Is Endometrosis?
Endometriosis is the result of tissue that normally lines the interior of the uterus – known as endometrium – being displaced onto its exterior. There, it reacts to female sex hormones, and it thickens, breaks down and eventually bleeds during each menstrual cycle. Unfortunately, the displaced tissue is trapped with no way to exit the woman’s body. The situation often goes unnoticed and causes no symptoms; yet sometimes scar tissue forms and grows together to develop adhesions. When that happens, it becomes inflamed and cysts develop, resulting in great discomfort and difficulty in becoming pregnant, especially if the ovaries or fallopian tubes are affected.
Endometriotic tissue and cysts usually form in the pelvic and lower abdominal cavity (the tummy), on the outside wall of the womb and lower pelvic cavity, and on the ovaries and in the pocket-like “pouch of Douglas” between the womb and rectum at the end of the bowel.

What Is the Cause?
There are a number of theories about the cause of endometriosis in women, but scientists aren’t sure. One is that there is something wrong with the interplay of the hormones or the immune system. Normally, the latter ensures that tissue which should grow in a certain part of the body cannot grow elsewhere. This uncertainty highlights the confusion about how endometrial tissue can form outside the womb.
Another likely explanation is a process called “retrograde menstruation”, in which menstrual blood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity, instead of out of the body. Displaced endometrial cells stick to the pelvic walls and the surfaces of pelvic organs, where they grow and continue to thicken and bleed over the course of the menstrual cycle. However, that isn’t necessarily the main cause.
“There are many theories, but retrograde menstruation may be the most likely,” says Dr. Kaberi Banerjee, Senior Consultant in Gynaecology and IVF Specialist at Max Healthcare, New Delhi, India.

The Symptoms
The most common signs and symptoms of endometriosis include:

1 Periods that are so painful (dysmenorrhea) that low doses of painkillers don’t help, and a women is unable to perform her daily activities and work. The pelvic pain and cramping may begin before and extend several days into the period, and it may include lower-back and abdominal pain. That sometimes radiates out to the woman’s back and down her legs, and it is often associated with nausea, vomiting and diarrhoea.

2 Pain during or after sexual intercourse, normally described as burning or cramp-like.

3 Painful bowel movements or urination, normally during a woman’s period.

4 Excessive bleeding, occasional heavy periods, and bleeding in between periods.

Endometriosis can sometimes be mistaken for other conditions that cause pelvic pain, such as pelvic inflammatory disease (PID) or ovarian cysts. It can also be confused with irritable bowel syndrome (IBS), which causes bouts of diarrhoea, constipation and abdominal cramping. IBS can accompany endometriosis, which may complicate the diagnosis.

Endometriosis and Infertility
Twenty-five to 35% of infertile women have endometriosis. According to various studies, around 75-80% of those women can succeed in becoming pregnant. In contrast, women without endometriosis have a 20-25% chance of pregnancy each month, which drops to 7-10% a month if they have mild endometriosis. Women with severe endometriosis (extensive scarring, blocking of fallopian tubes and ovarian cysts) are likely to find it difficult to conceive without treatment.
A number of theories exist to explain how endometriosis causes female infertility. One is that scarring from endometrial lesions makes it difficult for a woman to become pregnant by blocking the fallopian tubes, which prevents the egg from being picked up and transported to the uterus for fertilisation by the sperm. Fallopian tube scarring can also prevent the egg from being transferred to the uterus for implantation. The more scarring a woman has, the greater her risk of infertility.
Other ways endometriosis could prevent a woman from becoming pregnant include:
n A high number of scavenger cells in the lubricating peritoneal fluid between the layers of tissue that line the belly’s wall and abdominal organs; these can destroy sperm cells, thus decreasing a woman’s chance of getting pregnant.
n An adverse effect on the quality of eggs, which can reduce the pregnancy rate.
According to Dr. Banerjee, over-production of prostaglandin hormones can likewise impede fertility. These play an important role in the fertilisation and implantation of the embryo; an excess of them may interfere with those processes.
Endometriosis often makes intercourse painful. Dr. Banerjee believes couples might therefore avoid having sex during a woman’s most fertile time. This obviously rules out the possibility of conception.
As endometriosis implants grow and develop in the abdomen, the body tries to surround them with fibrous connective scar tissues known as abdominal adhesions. This is an attempt to isolate the implants and prevent them from causing harm. If the adhesions pinch the fallopian tube or block its opening, they will obstruct the merger of the egg and sperm and prevent fertilisation and conception.
Ectopic pregnancies (pregnancies outside the womb) are more common among endometriosis sufferers, because the embryo can’t travel to the womb. However, this type of obstruction can easily be diagnosed and remedied.

Treatment Options

Fertiloscopy – Assessing the Extent of Infertility
This procedure (see p.74 for further details) is a modified form of laparoscopy. It is performed by inserting a special instrument at the top end of the vagina, where there are very few nerves and which offers easy access to the upper reproductive tract. A local or a light general anaesthetic is used, and the procedure can be completed on an outpatient basis in under two hours. It is less dangerous and costly than laparoscopy, and it can be carried out at any ObGyn clinic.
“Fertiloscopy is a simple but highly accurate assessment of the pelvis,” says Dr. Law Wei Seng, an obstetrician, gynaecologist, and gynae-laparoscopist at Pacific Healthcare Specialist Centre in Singapore. “The camera used has a very high magnification level, and it can easily detect endometriosis in the ovary or pelvis.”
The fertiloscope is designed so that any mild endometriosis or minor adhesions that are found can be surgically treated as part of the diagnostic fertiloscopy procedure – and in as little as 20 minutes.

This is the most common surgical procedure, especially where the ability to procreate is high on the agenda. It removes pelvic adhesions surrounding the ovaries, tubes and uterus. The surgical removal of endometriotic implants (small endometriosis growths) and ovarian endometriomas (ovarian cysts) are also priorities during this treatment.
It consists of cauterising (burning), coagulation (blood clotting), and excision (removal by cutting) or vaporisation (liquefying). Excision is often the method of choice, since the disease can go far deeper than it first appears. As Dr. Law explains: “If the endometriosis is extensive, it is advisable to remove it by key-hole surgery or laparoscopy, which requires three to four small incisions, each measuring 0.5 to 1 cm, on the tummy. In less-complicated cases, it is possible to perform this via single-incision surgery, in which one incision measuring about 2 cm is made at the belly button.”

Both these options have been found to help women who are suffering from endometriosis, particularly when they are used in conjunction with fertility medications. Certain drugs also help to induce ovulation if it doesn’t occur naturally. Some women with endometriosis have difficulty ovulating, due to the presence of scar tissue or the abnormal secretion of certain hormones. Infertility drugs trigger ovulation, and the possibility of pregnancy rises.
“Infertility drugs cause multiple ovulation. Provided the tubes are open, that increases the chance of conception for those with endometriosis”, says Dr. Banerjee.
Dr. Hrishikesh Pai, consultant gynaecologist and infertility specialist at Fortis la Femme Hospital in New Delhi, India, says a few attempts at IUI (artificial insemination), which involves injecting sperm directly into the uterus, can help women with endometriosis to become pregnant. “Most patients achieve pregnancy within the first four to six attempts at IUI,” he explains.
With IVF, fertilisation takes place outside the body, thereby reducing the chances of endometrial tissue affecting the process. If necessary, ICSI (intracytoplasmic sperm injection) can also be used in conjunction with IVF to inject a single sperm directly into an egg.

Did you know?
The luteal phase defect is a commonly misunderstood condition that frequently affects fertility. It refers to the amount of time during the menstrual cycle between ovulation and the onset of the next menstrual period, normally about 10-14 days. If the luteal phase is less than 10 and more than 14 days, it is possible a woman is suffering from this condition. If the menstrual cycle is affected, as it often is when a woman has endometriosis, her ability to release eggs at the appropriate time in order for them to be fertilised will be affected.

Questions to Ask Your Doctor
It’s important to seek treatment if you suspect you may have endometriosis. Keeping a record of your symptoms can help your doctor make the diagnosis. Here are some questions worth asking:

1 How is endometriosis diagnosed?

2 What medications are available to treat it? Could a certain medication improve my symptoms?

3 What side effects should I expect from the medication?

4 Under what circumstances would you recommend surgery?

5 Will I take medication before or after surgery?

6 Will endometriosis affect my ability to become pregnant?

7 Can treatment of endometriosis improve my fertility?

8 Can you recommend any alternative treatments that I might try?

(Information courtesy of