Endometriosis is a chronic inflammatory condition affecting up to 10% of women of reproductive age. It can significantly reduce fertility, sometimes lowering natural conception rates to as little as 2–10% per month. IVF is often the recommended treatment, especially when other fertility methods fail.
What Is Endometriosis and How Does It Affect Fertility?
Endometriosis occurs when tissue similar to the uterine lining grows outside the uterus, often on the ovaries, fallopian tubes, or other pelvic organs. It may cause pain, inflammation, adhesions, and structural changes in the reproductive system.
- Symptoms vary but commonly include:
- Painful periods (dysmenorrhea)
- Chronic pelvic pain
- Pain during intercourse
- Fatigue
- Infertility
- Digestive issues such as painful bowel movements or blood in stools
The severity is classified into four stages, from minimal to severe, based on lesion size, depth, location, and adhesions. Diagnosis is typically confirmed via laparoscopy, which can also allow for surgical treatment during the procedure.
Case 1: Secondary Infertility After First Child
A 34-year-old woman with prior mild endometriosis had given birth but experienced two years of secondary infertility. All hormonal and imaging tests appeared normal, and several IUIs and stimulation protocols failed.
IVF led to the retrieval of 12 eggs, 10 of which were fertilized, resulting in 5 blastocysts. Two embryos were transferred, and a twin pregnancy was achieved.
Key insight: A second laparoscopy early on may have prevented prolonged treatment. IVF was more effective than IUI due to the patient’s age and endometriosis history.
Case 2: Severe Endometriosis with Multiple Failed IVF Cycles
A 35-year-old woman with rectovaginal endometriosis (stage 3–4) and a frozen pelvis had undergone four unsuccessful IVF cycles. Despite normal hormone levels and good ovarian reserve, two ovarian endometriomas were found.
Surgical removal of the endometriomas followed by IVF resulted in two good-quality blastocysts and a successful pregnancy.
Key insight: Even small endometriomas can significantly affect embryo quality. Surgical intervention can restore fertility potential, even in complex cases.
Case 3: Single Woman, Advanced Age, Donor Sperm
A 39-year-old woman with a history of stage 3 endometriosis experienced recurrence after previous surgery. Despite low AMH and a failed IVF attempt, she underwent an optimized IVF protocol without another surgery.
With adjusted hormone doses and supportive medication (aspirin, steroids, intralipids), five eggs were retrieved, resulting in three embryos, two of which were transferred successfully, leading to a twin pregnancy.
Key insight: In asymptomatic patients with low ovarian reserve, avoiding surgery may be the better option. Adjusted stimulation and supportive treatments can make a significant difference.
Clinical Considerations
- Frozen pelvis: A severe condition where pelvic organs are fused together, often requiring complex surgery.
- AMH levels post-surgery: AMH may decrease temporarily after surgery but may return to baseline levels. A significant increase is rare.
- Donor IVF and endometriosis: Advanced stages can reduce success rates due to a compromised uterine environment. Pre-treatment or surgery may help in specific cases.
- Diagnosis: CA 125 markers and ultrasounds are not sufficient for a definitive diagnosis. Laparoscopy remains the gold standard.
- Treatment decisions: Whether or not to operate on endometriomas depends on symptoms, ovarian reserve, age, and prior surgeries.
Differences Between Endometriosis and Adenomyosis
- Endometriosis affects external pelvic structures and often causes pain and infertility.
- Adenomyosis thickens the uterine wall, potentially impacting implantation if the endometrium is involved. Both can influence IVF outcomes, especially in severe cases or when coexisting.
Final Takeaways
- Every case of endometriosis is unique; personalized treatment is essential.
- Surgery may improve IVF success, but must be carefully weighed against the potential impact on ovarian reserve.
- In cases with diminished ovarian reserve or asymptomatic endometriomas, a non-surgical IVF strategy may be more appropriate.
- Collaboration between fertility and endometriosis specialists is crucial for optimal outcomes.
