Endometriosis

What is endometriosis?

Endometriosis is a long-term condition in which tissue similar to the lining of the womb (endometrium) grows outside the uterus, most often on the ovaries, fallopian tubes, the lining of the pelvis and the bowel. This tissue responds to monthly hormone changes, causing inflammation, scarring and adhesions. It affects around 1 in 10 women of reproductive age and is found in a significant proportion of women having difficulty conceiving.

Symptoms and signs

• Painful periods that worsen over time or stop you from daily activities
• Chronic pelvic or lower back pain
• Pain during or after intercourse
• Pain with bowel movements or passing urine, especially during periods
• Heavy or irregular bleeding
• Fatigue
• Difficulty getting pregnant

Some women have few or no symptoms, and the amount of pain does not always match the extent of the disease.

Causes and risk factors

The exact cause is unknown. Theories include menstrual blood flowing backwards through the tubes into the pelvis (retrograde menstruation), immune system factors and genetic tendency. Risk is higher if a mother or sister has endometriosis, with early first periods, short cycles and heavy periods. Endometriosis can affect fertility by distorting the tubes and ovaries, creating an inflammatory environment that affects eggs, sperm and embryos, and by reducing ovarian reserve when cysts (endometriomas) are present.

How endometriosis is diagnosed

• Detailed history and pelvic examination
• Transvaginal ultrasound to detect ovarian endometriomas and some deep disease
• MRI in selected cases to map deep endometriosis
• AMH and antral follicle count to assess ovarian reserve
• Laparoscopy, which allows direct viewing and biopsy, and can treat disease at the same time

Endometriosis is often staged from I (minimal) to IV (severe), although the stage does not always predict pain or fertility.

Treatment options

Pain relief and hormonal treatment

Pain medicines and hormonal treatments such as progestogens or the combined pill can control pain, but they prevent pregnancy while being taken and do not improve fertility on their own.

Surgery

Laparoscopic removal or destruction of endometriosis can relieve pain and may improve natural conception in minimal to mild disease. Surgery on ovarian endometriomas needs careful planning because it can lower ovarian reserve, so the decision is individualised, especially when AMH is already low.

IUI and IVF

For minimal to mild endometriosis with open tubes, ovarian stimulation with IUI may be offered. IVF is recommended for moderate to severe disease, damaged tubes, low ovarian reserve, older age, additional male factor, or when other treatments have not worked. In some cases embryos are frozen and transferred in a later cycle.

Chances of pregnancy

Many women with endometriosis conceive, either naturally or with treatment. The chances depend on age, ovarian reserve, the extent of disease, tubal health and partner factors. Iswarya Fertility reports IVF success of about 75 percent for women under 35, though results vary from person to person and cannot be guaranteed.

When to see a fertility specialist

See a specialist if you have painful periods and have been trying for 6 to 12 months, if an endometrioma has been found on a scan, or if you are 35 or older. Early assessment of ovarian reserve helps plan the right timing for treatment. Iswarya Fertility has 91+ centres for consultation and testing.