There is absolutely nothing enjoyable about period pain. The cramps, the discomfort, and that sore feeling that seems to crawl its way upwards from the abdomen—all this can leave you cursing mother menstruation, even though you know you need it to become a parent. But when that pain becomes unbearable and despite the monthly ordeal your fecundity is at an all-time low, you could be looking at a case of endometriosis.
Believe it or not, roughly 25 million women in the country could be suffering from this debilitating condition, according to the Endometriosis Society of India. Endometriosis is not only painful, but it can also make conceiving naturally difficult. That’s why we got Dr. Radhika Sheth, a fertility specialist who consults at Cloudnine Fertility Clinic in Malad & Vashi (Mumbai) to answer the most frequently asked questions about endometriosis and fertility. Dr Sheth is trained in reproductive endocrinology and ART from UK and Germany,—and this is what she has to say.
What is endometriosis?
Often recognised by severe menstrual pain, endometriosis is a disease where the tissue that forms the lining of the uterus—called the endometrium—grows outside of it. “It causes pain and/or infertility, and most commonly involves the ovaries, fallopian tubes, and the tissue lining the pelvis. Rarely, endometrium-like tissue may be found in areas beyond the location of the pelvic organs,” explains Dr. Sheth.
Every month as the endometrium inside the uterus thickens, sheds and bleeds so does the tissue that’s growing outside of it—thus giving rise to pelvic pain, extreme menstrual cramping and pain, and heavy bleeding.
The main symptom of endometriosis is pelvic pain, often associated with menstrual periods. Menstrual cramping is a common symptom seen in many, however, those with endometriosis often experience menstrual pain that is far worse than usual. Pain during or after intercourse is also common in women with endometriosis—so are painful bowel movements and/or urination during periods.
“The severity of pain may not be a reliable indicator of the extent to which a woman is suffering from the disorder. Women with mild endometriosis could present with severe pain and those with advanced endometriosis with minimal or no pain,” adds Dr Sheth.
So, how is endometriosis diagnosed?
“A detailed history of menstrual symptoms and chronic pelvic pain is usually the basis for suspecting endometriosis,” says Dr Sheth. If your doctor suspects you might be suffering from the disorder, s/he may use the following tests to confirm a diagnosis:
*Pelvic examination: During a pelvic exam, the doctor manually examines areas in the pelvis to check for abnormalities, such as cysts, tenderness or scarring in and around the reproductive organs. “However, small endometrial cysts and mild endometriosis often may not be picked up in pelvic examinations,” she explains.
*Ultrasonography: This uses high-frequency sound waves to create images of the structures inside the body. “While a standard ultrasound imaging test does not give a definitive diagnosis, it can identify cysts associated with endometriosis,” says Dr Sheth.
*MRI: “An MRI can often help by giving the doctor more details about the location and size of endometrial implants, involvement of the surrounding vital structures such as intestines and ureter and presence of deeply infiltrating endometriosis. This information is of great benefit for surgical planning,” she says.
*Laparoscopy: A laparoscopy can provide the most precise information about the site, extent, and size of the endometrial implants. Under anaesthesia, the doctor makes a tiny incision near the belly button and inserts a thin viewing instrument called a laparoscope to look for signs of endometriosis. “A tissue sample may also be taken during the laparoscopy for further testing under the microscope. Endometriosis can be treated to a large extent during laparoscopy,” suggests Dr. Sheth.
How does endometriosis affect fertility?
While not all women with endometriosis are likely to experience infertility, research suggests that about 30% to 50% of women suffering from the disorder may not be able to conceive naturally. But how does endometriosis cause infertility?
Well, according to Dr. Sheth, endometriosis can affect fertility in several ways by causing: distorted pelvic anatomy, adhesions, scarred fallopian tubes, inflammation of the pelvic structures, altered immune system functioning, changes in the hormonal environment of the eggs, impaired implantation of a pregnancy, and altered egg quality.
“Women with severe endometriosis—which is associated with significant scarring, blocked fallopian tubes, and damaged ovaries—experience problems while trying to conceive, and often require advanced fertility treatment,” she adds.
How can IVF help women with endometriosis conceive?
“In-vitro fertilization or IVF provides the best odds for pregnancy in women with severe (stage 3 or 4) endometriosis and in those where there is associated tubal blockage or severe scarring as observed during the laparoscopy,” explains Dr Sheth. But that’s not the only benefit IVF has to offer.
Women with endometriosis who also have multiple infertility risk factors—including male infertility, age above 35 years, or low ovarian reserve—can conceive with IVF successfully.
Are there any other fertility treatments for women with endometriosis?
“Studies have shown that fertility can be enhanced in women with minimal or mild endometriosis using controlled ovarian stimulation (COS) with intrauterine insemination (IUI),” says Dr Sheth. This fertility treatment is also called superovulation with IUI, and women are administered medicines after their menses to produce two to three eggs.
“After these eggs are released, the husband’s semen sample is processed to remove debris and immotile sperms. The washed semen sample containing good quality motile sperm is then transferred into the wife’s uterus using a gentle, atraumatic procedure,” she adds.
If you have endometriosis, this is Dr. Sheth’s advice to you
“Treatment for endometriosis-associated infertility needs to be individualized for every woman. And some cases can be tricky with no easy answers,” says Dr. Sheth. “Treatment decisions depend on factors such as the site of the endometrial growth, the extent of endometrial lesions, duration of infertility, age of the patient, and other coexisting factors if any,” she adds.
While in some cases, natural conception can be expected with a “wait and watch” policy, in other cases fertility treatments can help in reducing the time to conceive. “A brief consultation with a fertility expert can help you draw a road map and avoid delays in treatment. Timely treatment is a key to higher pregnancy rates,” Dr. Sheth concludes.