Endometriosis and Conception: Clinical Practice Facts and Myths

Genital endometriosis is a fairly common disease present in 10% of women of reproductive age and in 50% of patients suffering from infertility. At the same time, we should note that the precise diagnosis of endometriosis presents certain difficulties, and we often encounter cases of hyperdiagnosis. Endometriosis undoubtedly affects the ability to conceive as well as the efficacy of assisted reproduction programmes but the exact mechanisms of such influence are unclear and are not evidence-based.

Since one of the primary symptoms of endometriosis is infertility, gynecologists often assume the existence of genital endometriosis in patients who have trouble conceiving; moreover, they consider this pathology to be the principal cause of infertility. However, it is not true in a whole range of cases, and a doctor and a patient end up going through ineffective treatment. Let us take a look at some practical aspects of the issue and try to draw conclusions that will be useful for us.

As often as not, one can hear the following point of view (myth number one): endometriosis hinders conception irrespective of the degree of its expansion. It follows that any reproductive technology will be ineffective unless all possible methods for treatment of endometriosis have been employed. Yet minor or asymptomatic forms of the disease rarely prove to be isolated causes of infertility and do not influence the efficacy of ART, whereas the attempts at their treatment lead to a waste of time as well as of reproductive age.

If the matter of conception is not pressing as yet, patients with symptoms of endometriosis make it to gynecologists and start treatment. As it is known, the treatment of endometriosis includes surgical interventions and hormonal therapy carried out together (or independently). Both are quite critical for the possibility of conception and childbearing in the future. At relapse, these methods are reapplied, sometimes in a larger extent. As a rule, patients turn to specialists in infertility treatment and assisted reproduction (fertility specialists) when the matter of conception becomes relevant and (or) if the conducted treatment for endometriosis does not lead to the desired pregnancy. Now it is time to talk about the second unfortunate myth: endometriosis should first be treated by all doctors except for fertility specialists. Yet modern Fertility Science is based on protocols sparing the reproductive system and is capable of preserving fertility by way of oocyte and ovarian tissue cryopreservation prior to surgery, massive hormonal therapy, anti-tumour treatment et cetera. Patients with endometriosis should be consulted by a fertility specialist as soon as possible after the establishment of the diagnosis regardless of whether conception is relevant for them at the moment or not, because they will then have more chances of giving birth to a child in the future.

The third and, unfortunately, not the last myth is that IVF furthers the progression of endometriosis.
This point of view actually existed, but it has not been evidentially proven in controlled randomized studies of the recent years. Over many years, the so-called long and super-long IVF protocols were considered to be a perfect choice for patients with endometriosis because of the long-term administration of GnRH agonists. Today, when short and low-dose protocols as well as GnRH antagonists are used widely, it is possible to retrieve oocytes and obtain high-quality embryos in patients with endometriosis without inducing deep pituitary depression or achieving apparent ovarian hyperstimulation accompanied by high levels of estradiol and being critical for the progression of estrogen-dependent diseases (endometriosis, myoma, hyperplastic processes of the endometrium etc.).

Another controversial issue is the necessity of endometriosis treatment with GnRH agonists over 3-6 months. Separate risk groups in this case are made up by patients of middle and late reproductive age (after 30) who had ovarian surgery, especially, repeat ovarian surgery. The results of such treatment often include premature and pathological menopause, the impossibility of retrieving a patient's own egg cells, psychosomatic disorders, family breakdown and social adaptation disorders. The achievement of pregnancy by means of assisted reproduction is then possible only with the help of donor and surrogacy programmes.

The next myth is very dangerous: surgery as a means of endometriosis treatment should always precede assisted reproduction. Incidentally, in all fairness, we should note that there is a similar "radical" point of view as regards the treatment of another estrogen-dependent disease – uterine myoma. In endometriosis, the problem is that ovarian surgery leads to the reduction in their volume and in the reserve of follicles that can potentially release an egg cell. In cases when external endometriosis is misdiagnosed, the ovaries often suffer for nothing going through an irreplaceable loss of tissues with follicles.

A special place in this issue is reserved for endometriotic cysts whose conservative treatment holds little promise. After surgical interventions, relapses of endometriomas often necessitate a repeat surgery. As a result, we face ovarian depletion and "a closed door" for assisted reproduction. At present, dosed superovulation stimulation aimed at retrieving oocytes in patients with endometriomas of small size (up to 3-4 cm) is considered to be safe and quite effective. Any extent of assisted reproduction is also possible in patients with minor and asymptomatic forms of endometriosis without any prior preparatory surgery.

The efficacy of alternative methods for endometriosis treatment is also exaggerated quite often. Today, there are unequivocally no evidential data in favor of an increased probability of natural conception or increased success of assisted reproduction programmes after non-drug and non-surgical treatment of endometriosis. In fertility practice, we largely deal with cases when women spend the entire period of their effective reproductive age trying to treat endometriosis, both traditionally and non-traditionally, over many years.

A very common myth with late effects is a complete and irrevocable cure of endometriosis due to pregnancy. However, in talking about such a possibility, doctors and patients fail to mention the issue of progression of all estrogen-dependent diseases (myoma, endometriosis) in the first trimester of pregnancy, which is observed during the routine monitoring of such patients. Surely, further development of pregnancy and progesterone dominance have a favourable effect on these diseases but the complete cure is rarely achieved, and the pathological condition begins to progress as soon as the menstrual cycle is back. Consequently, such patients may have trouble conceiving again with underlying reasons similar to the reasons behind the difficulties they had before the pregnancy.

It is important that a patient with diagnosed endometriosis should be properly consulted and informed about the possibilities of modern treatment and fertility preservation before any active therapeutic intervention is started. She needs to know about the possible side effects and consequences of treatment including the permanent ones so that she could make an informed decision.