LUNA Explains: Endometriosis And Infertility

Infertility is defined as the inability of a couple to conceive and carry a pregnancy to term after a year or more of regular unprotected sexual intercourse for women under 35 years of age and after six months for women over 35 years of age.

Infertility is said to be:

Primary if the woman has never been pregnant;

Secondary, if the woman has already experienced the onset of a pregnancy, at least once in her life, and this regardless of its evolution (miscarriage, early or late, ectopic pregnancy, full-term or premature delivery).

Infertility allocates approximately 1 in 7 or 8 couples (between 12 and 15%).

LUNA helps you to understand how endometriosis can cause fertility problems.

There are several mechanisms that explain the impact of endometriosis on fertility:

• Pelvic inflammation: during menstruation, under the effect of uterine contractions, a little blood is “flushed” through the fallopian tubes and into the abdominal-pelvic cavity (the belly). This menstrual reflux creates an inflammation that will “pollute” the peritoneal fluid, with a solid impact on the interaction between the male (spermatozoa) and female (egg) gametes, reducing the chances of fertilization.
• So-called mechanical factors: pelvic inflammation, caused by menstruation, favors the occurrence of adhesions (coupling of organs: ovaries, fallopian tubes, intestine), fibrous retractions and obstruction of the fallopian tubes. These changes in the pelvic anatomy will hinder the meeting between the gametes. And therefore reduce the chances of fertilization and/or disrupt tubal transport (fertilization takes place in the distal part of the tube and the embryo progressively travels from the tube to the uterine cavity, where it’s implanted).
• Qualitative and quantitative alterations in ovarian function: reduction in the number and quality of oocytes can also be caused by endometriosis:
• An alteration in endometrial receptivity can also be observed. This is caused by progesterone resistance and/or uterine adenomyosis associated with endometriosis, contributing to a lower rate of embryo implantation.
• Immune dysfunctions, with autoantibodies (i.e., antibodies against the patient’s own antigens), against the ovaries or the endometrium.
• Dyspareunia, pain triggered during sexual intercourse, which can be responsible for a decrease in sexual activity within the couple.

LUNA presents you with the therapeutic options available for treating endometriosis causing infertility.

Medical hormonal treatments, which are effective for pain, have no indication in this context because, by blocking ovulation, they’re all contraceptive.

Two therapeutic options are possible. They offer comparable chances of pregnancy.

It consists of:

• destroying superficial endometriosis lesions (by coagulation or laser)
• releasing the adhesions to restore normal pelvic anatomy
• removal of endometriosis ovarian cysts (cystectomy)
• And resection of deep endometriosis nodules implanted in the organs near the uterus (utero-sacral ligament[s], vagina, bladder, intestines, ureters).

Surgery offers the advantage, while optimizing the chances of spontaneous pregnancy, of treating the pain associated with endometriosis at the same time. Surgery for deep endometriosis may require extensive procedures requiring experienced surgeons, and in some situations, multidisciplinary surgical teams (e.g., a gynecological surgeon and a digestive surgeon).

• either by ovarian stimulation and intrauterine insemination;
• or by medically assisted reproduction (MAP): in vitro fertilization (IVF) or intra-cytoplasmic sperm injection (ICSI).

The advantage of MAP is that it can be carried out without prior surgical removal of endometriomas or deep endometriosis nodules, while offering good pregnancy rates.

LUNA shows you the criteria for choosing the best treatment option for endometriosis causing infertility.

The choice between surgery and MPA depends on many parameters:

• The first one to consider is the quality of the ovarian reserve (hormone levels and antral follicle count). If it’s diminished, surgery isn’t recommended and MPA must be proposed as a first option.
• The second, vital and too often neglected by practitioners, is the patient’s priorities, choices and intentions, as well as her preferences regarding the different therapeutic options (surgery or MPA). Today, patients are increasingly seeking pregnancy at a later age (the majority of patients want their first child after the age of 30) and the diagnosis of endometriosis should no longer be synonymous with immediate surgery.
• The other parameters, apart from the patient’s age, are linked to the endometritis disease: the duration of the infertility, the existence of other infertility factors, a history of surgery for endometriosis, the intensity of the pain, the phenotype of the disease (endometrium, uni or bilateral, deep endometriosis with or without digestive infiltration), the association with adenomyosis

Finally, modern management of endometriosis must offer the patient the possibility of benefiting from fertility preservation techniques (after ovarian stimulation, collection of oocytes by puncture under the control of a vaginal ultrasound scan then cryopreservation of the gametes).

There are two situations:

• In the case of an immediate desire for pregnancy: if the surgical option is chosen, this preservation can be proposed before the operation (particularly in the case of ovarian endometriomas: risk of alteration of the ovarian reserve) to be able to propose, lacking a spontaneous pregnancy after the operation, to carry out an MPA with oocytes collected in advance
• In the event of a delayed desire for pregnancy: offer to preserve the oocytes during diagnosis of endometriosis, which can be used for a few years later by the patient to carry out MAP if she doesn’t manage to become pregnant spontaneously.

Co-authored and scientifically validated by Pr Charles Chapron,

Head of the Department of Obstetrics and Gynaecology II and Reproductive Medicine at the Cochin Hospital in Paris