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How does endometriosis affect IVF success rates and what can be done with it? #IVFWEBINARS

Endometriosis is a serious condition which can severely impact fertility. It affects a significant percentage of women of childbearing age. Although modern medicine hasn’t yet established the precise cause of endometriosis, the link between the condition and lowered fertility has been clearly demonstrated. The problem with gauging the disorder’s precise impact is that it manifests itself differently in each patient – some experience severe pain and have significant difficulty conceiving, while others are asymptomatic and aren’t aware they’re affected.

For those afflicted with endometriosis, IVF is often presented as a potential way of achieving pregnancy. Why, though? Is the IVF process different for affected patients? Are success rates affected by the disorder?

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To help us answer all of these questions – and more – we invited Dr Ruth Sánchez, a gynaecologist at Pregen, the reproduction unit at Clinica Vistahermosa.

Endometriosis is a chronic and benign disease – simply put, it is the presence of endometrial tissue outside of the uterus. It affects between 6 to 10% of all women of reproductive age. Between 25 and 50% of women with fertility problems are affected by endometriosis, while around half of patients with endometriosis present infertility.

The endometrial tissue most commonly ends up on the ovaries – as cysts – or inside the fallopian tubes, although implants on the uterine wall, bladder, abdomen – endometriosis sometimes makes it as far as the lungs! Depending on the location of the endometriosis, afflicted patients can experience painful menstruation or localised pain in case of the endometriosis making it all the way to the chest.

Endometriosis is different in each patient. To help sort it out, a four-stage classification system was devised – each stage corresponds to a certain level of severity, from stage I (minimal) to IV (severe).  Minimal and mild endometriosis – the first two stages – are the most common occurrences of the disorder, and often present either minimal and sporadic symptoms, or are asymptomatic altogether.

Almost half of all cases of endometriosis don’t manifest any symptoms. For the other half, symptoms include:

  • Pain – abdominal pain, painful menstrual cramps, pain during intercourse
  • Infertility
  • Location dependant:
    • Painful urination or the presence of blood in the urine
    • Pain when defecating, rectal bleeding
    • Chest pains, bloody coughs

These symptoms often intensify during menstruation and often go away following menopause or during pregnancy.

Endometriosis can cause infertility in many different ways. Implants on the ovaries reduce the ovarian reserve and negatively influence the development of the oocytes. They can also lead to abnormal ovulations. Implants in the fallopian tubes can cause difficulties in transport or adhesions, while those in the endometrium often result in alterations of the immune system or abnormal endometrial receptivity. Endometrial implants also release toxic substances which can prove lethal to an embryo.

Properly diagnosing endometriosis often requires a clinical history in order to determine risk factors the patient may have been exposed to. Such risk factors include nulliparity, early first menstruation, heavy bleeding during short cycles, low BMI, alcohol use, history of gynaecological or obstetric surgery. Family history is also important, as those with first-degree relatives afflicted by the disorder are seven to ten times more likely to be affected themselves.

Physical examinations are also important, but endometriosis likes to hide itself; most affected patients present completely normal during normal testing. Despite this, some procedures, such as a transvaginal ultrasound, can reveal endometriosis – in this case, by helping doctors detect cysts on the ovaries. In selected cases, an MRI scan needs to be employed.

Ultimately, however, it’s the laparoscopy which confirms the diagnosis. It’s a surgery in which small incisions are used to allow a small surgical camera to examine a cavity for endometriosis. In some milder cases, endometrial implants can be removed during the laparoscopy, without having to schedule a completely different surgery.

There is no cure for endometriosis. It is a chronic disease for which the therapeutic approach depends on the patient’s priorities – treating either the pain, or the infertility.

For pain management, hormone therapy is the first and most common option – simply prescribing common contraceptives prevents heavy menstruation and relieves pain. Radical surgery is also an option, although it isn’t a cure-all: despite symptoms dissipating and life quality being improved, in 50% of cases the disorder can reoccur within five years. It can also permanently diminish the ovarian reserve.

If the patient wants to preserve her fertility, surgical removal of lesions larger than 4 centimetres is possible, which improves spontaneous conception rates. In the case of IVF, it makes no difference – for patients considering IVF, the current trend is to not perform surgery and continue with early fertility treatments. However, surgery may still be indicated for IVF patients in specific circumstances; namely, if their ovarian reserve has been preserved, if they haven’t undergone surgery previously, if their disease is unilateral, and/or if they are experiencing rapid growth or lesions larger than five centimetres.

In patients with decreased ovarian reserve, or those in whom endometriosis reoccurred (following a surgery), or those whose disease is bilateral, it is recommended to go straight to IVF, as other surgical attempts may do more harm than good.

For patients affected by endometriosis, the first choice of treatment is usually IVF. It provides the best chances of success for such patients, even though the treatment’s effectiveness is lower than in patients not affected by the disorder. This difference becomes larger the more severe the disorder. Fertilisation rates, implantation rates and the number of recovered eggs are all lower across the board in patients with endometriosis. In order to increase the pregnancy rates, patients can undergo hormone therapy lasting three to six months.

Other treatments include intrauterine insemination (IUI), which is usually attempted in cases of minimal or mild endometriosis, although pregnancy rates are usually low. Patients who have diminished ovarian reserves as a result of surgery, or those with multiple adhesions can opt for egg donation. Patients who are in the early stages of endometriosis can also consider freezing their eggs before the disorder progresses.

How does endometriosis affect IVF success rates and what can be done with it? – Questions & Answers

Question:

I have an adenomyosis. What can be done? Should I take corticosteroids before the transfer? Are there any other pharmaceuticals that can help the embryo implantation process?

Answer:

Adenomyosis is a form of endometriosis affecting the walls of the uterus. We don’t have good results with patients affected by it, so we advise our patients to take analogues before the treatment. This helps to improve the pregnancy and implantation rates

Question:

What exactly do you mean by “analogues”?

Answer:

The term “analogues” refers to a medication which is analogical to gonadotropins. We put patients on three-month courses of analogues in order to induce an artificial menopause.

Question:

I have severe endometriosis. I went through seven IVF cycles, had four miscarriages and three implantation failures. Once I tried egg donation, my first transfer resulted in a miscarriage, while the second resulted in a healthy child. I would love to try with my own eggs again. What’s your medical opinion?

Answer:

If you already had seven IVF cycles with your own eggs without success, I would not advise you to try that route again. The probability of success is very slim.

Question:

I’m 47. I had three failed IVF treatments in the UK. I had a hysteroscopy to determine if I have endometriosis. Despite having good quality blastocysts, they did not implant. What can I do to get pregnant now?

Answer:

If the IVF treatment was conducted using your own eggs, it’s amazing that you had a good blastocyst at your age. However, their morphological quality is one thing – their genetic health is another. At your age, the probability of having embryos with genetic defects is very high, which is probably the reason for the implantation failure. I’d recommend egg donation or using PGT-A to ensure that your embryos are genetically healthy.

Question:

I have two children and I’m not planning to have any more for now. According to my doctor, my endometriosis is non-operable, but I am in pain. Is there any alternative treatment?

Answer:

There are several treatments for dealing with pain. The most common option is taking contraceptives; other options include inserting an IUD, such as the Mirena coil. You can ask your doctor for more information.

Question:

Is endometriosis an immunological disease?

Answer:

The exact causes of endometriosis aren’t clear, and there’s much debate as to the origins of the condition.

Question:

I have low AMH and I underwent surgery in January to remove my stage 3 endometriosis. Is there any chance my AMH levels could improve? Will my chance of implantation improve as well?

Answer:

Actually, the opposite will likely happen. Depending on the severity of your condition, some healthy tissue could have been destroyed alongside the endometriosis – your AMH may stay the same or drop, but never increase. While it does improve pregnancy rates, this refers to spontaneous pregnancies – the surgery has no bearing in IVF.

Question:

About success rates – I have endometriosis and I’m thinking about egg donation. Compared to patients without endometriosis, how are the overall success rates affected?

Answer:

Endometriosis affects all stages of fertility. Success rates are lower across the boards in patients with endometriosis because the condition releases toxins that can affect the embryo and the endometrial receptivity. It varies from patient to patient – endometriosis is a complicated disease which can manifest in a myriad of ways, so the precise degree to which you’re going to be affected by it depends on the severity of your condition.

Question:

Is there a link between endometriosis and a high NK cells count? I have both conditions and I’m wondering if there’s a link between the two.

Answer:

There is a possibility that a link exist, but it hasn’t been demonstrated yet. We know endometriosis has an impact on the immune system, but so far no research has demonstrated the true extent of this relationship.

Question:

Would you recommend a Mediterranean diet or other foods to lower the pain?

Answer:

I do believe in the Mediterranean diet and I do believe we are what we eat. I think the diet is important, but we need more research to prove that it is effective for pain management and improving fertility.

Question:

I had surgery to remove stage 3 endometriosis. Does this reduce the toxicity level and improve the chances of implantation with egg donation?

Answer:

Yes, although it is better to perform the donation cycle as soon after the surgery as possible in order to minimise the chances of the endometriosis coming back.

Question:

Can endometriosis happen at any age?

Answer:

Yes, but it most frequently appears between the ages of twenty and thirty years old.

Question:

I have a problem with my ovulation. Can it be because of endometriosis?

Answer:

It’s difficult to answer a question like that if you don’t say what kind of problem you have.

Question:

I had an endometrial scratch done. Will that improve my implantation chances?

Answer:

Yes; endometrial scratches improve implantation rates, as it increases the receptivity of the endometrium. It has nothing to do with endometriosis, though; this procedure is performed in cases of implantation failure.

Question:

Will an endometrial scratch help with adenomyosis if I’m on warfarin?

Answer:

The scratch has nothing to do with adenomyosis. It simply improves the endometrial receptivity, regardless of endometriosis. We only perform it in cases of implantation failure. Warfarin should not be taken during pregnancy, as it increases the chances of thrombosis. I recommend switching to Eparin.

Question:

Would you recommend assisted hatching?

Answer:

This has nothing to do with endometriosis. The decision whether or not assisted hatching should be used lies with the embryologist.

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About the Author

Ruth Sánchez

Ruth Sánchez

Dr. Ruth Sánchez has been working as a gynecologist at Clinica Vistahermosa since 2000. She has been an attending physician in the Gynecology & Obstetrics Dept. at the General Hospital of Elda (Alicante) and has been treating patients as a Doctor of Medicine and Surgery, at the hospital since 2015. Dr. Sánchez obtained her medical degree from the University of Alicante in 1995.She has published many articles, publications, and delivered many talks at various Congresses on Assisted Reproduction and Gynecology. She is also a member of scientific associations such as the Spanish Association of Gynecology and Obstetrics, Ultrasound Section of the Spanish Society of Gynecology, Valencian Community Association of Gynecology and Obstetrics and Obstetrics and Spanish Fertility Society.

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