Endometriosis is one of the most confusing conditions that can impact fertility. The symptoms of endometriosis, according to The Mayo Clinic, include painful periods, pelvic pain during intercourse or bowel movements, and very heavy periods. The truth is, endometriosis can present as all the above symptoms, one of them, or none of them. Many women with endometriosis have zero symptoms. Some only have gastrointestinal symptoms like bloating, nausea, constipation or loose stools/diarrhea that gets misdiagnosed as IBS. Still others may present with bladder issues like interstitial cystitis as the only symptom. Recently, Mayo Clinic added “infertility” as a symptom of endometriosis on their website, much to our relief, as sometimes it is only considered once a woman is struggling to conceive. It can be confusing, challenging and frustrating and since it can present so differently in women, it is also difficult to consider as a diagnosis and to properly GET diagnosed. We have seen patients consult with 10 different doctors before getting a proper diagnosis of endometriosis.
Johns Hopkins Medicine estimates anywhere from 24-50% of infertility cases might be due to underlying endometriosis. Luckily, there are things you can do with or without a diagnosis if you suspect you might have it contributing to your fertility struggles.
What IS endometriosis how do you get it?
This condition occurs when endometrial cells, which typically grow INSIDE the uterus to build and shed the uterine lining each month (shedding would be a “period bleed”) become embedded onto tissue OUTSIDE the uterus in the abdominal cavity…on the outside of the uterus, fallopian tubes, ovaries, bladder, large or small intestines, or peritoneum (the membrane encasing our inner organs). One theory of how this condition forms is through endometrial cells migrating out of the uterus. Think of them like coral polyps in the ocean…they become little mobile units that escape their home by floating away (through the fallopian tubes, likely during a period bleed) and find a new place to implant and set up shop. Another way is through trauma (like the removal of a fibroid or a C-section) or in some cases, it might form in-utero and be present from birth as there is sometimes a hereditary component. Regardless of how endometriosis forms, it is difficult to get rid of, but with the right support, it can be managed, and fertility can improve.
The key factor of endometriosis that influences fertility? Inflammation.
When these little cell bundles set up shop in their new locations outside the uterus, they create a network of blood flow to support them and grow and shed in response to fluctuating hormones, bleeding a little each month during the period. But because the bleed is inside the abdominal cavity instead of being contained safely in the uterus, and even though these cells are YOUR cells, they are in a place where they shouldn’t be, so the body gets irritated and mounts an immune response against them. This response creates inflammation and can sometimes confuse the immune system and lead to autoimmune conditions. Over time this can also create pain and the formation of scar tissue, and can negatively impact ovarian function, egg quality, hormone balance, and the ability of an embryo to implant inside the uterus and grow to term.
One confusing feature of endometriosis is that it doesn’t always impact fertility. Sometimes women with severe known cases conceive easily. While others with mild undiagnosed cases experience repeat miscarriage, premature diminished ovarian reserve, poor egg quality, or repeat lack of implantation for no apparent reason. The other confusing thing is that endometriosis is difficult to diagnose. A doctor might suspect endometriosis based on symptoms, but the only definitive way to receive an official diagnosis is through an exploratory laparoscopic surgery, which often then becomes the treatment through surgically excising the tissue or lasering (ablation) them off. If you have a mass of endometrial cells on your ovary creating a cyst, your doctor may diagnose you with an endometrioma during a transvaginal ultrasound, which is another way to diagnose it. Sometimes, webbing from scar tissue forming around the fallopian tubes can also be seen on an ultrasound. MRI or CT scans can also be diagnostic tools, but they don’t always pickup smaller lesions, so they are not as thorough or dependable as a laparoscopic diagnosis. Recently, Reproductive Endocrinologists started using a uterine biopsy test called Receptiva, which looks for an inflammatory marker from tissue inside the uterus that has a high correlation with endometriosis present elsewhere.
So, what can you do if you suspect you might have endometriosis?
Here are some tips to help you navigate trying to conceive with this condition potentially or definitely in the mix.
1. Talk to your doctor (or several doctors) about the possibility of endometriosis in your case and how it might change your treatment approach.
2. Switch to an anti-inflammatory diet asap. Do this right away, as the impacts of diet take time to influence fertility, but it can really help. Women with endometriosis are more likely to have food sensitivities, especially to gluten and dairy, so eliminating these are a good start. Read our Lily + Horn blog about the ideal diet for endometriosis and fertility. Eating an anti-inflammatory diet is always a good idea, so even if you don’t have endometriosis, this modification is risk free!
3. Find a local acupuncturist who knows how to treat endometriosis. Acupuncture and Chinese herbs have been improving endometriosis-related infertility for centuries. Several herbal formulas have even been shown to shrink endometrial lesions in studies. Chinese herbal formulas are best when taken as customized formulas, which is why working with an experienced acupuncturist who can prescribe them is ideal. Try to work with an acupuncturist 6-12 weeks before an IVF if possible, to really reap the benefits. These tools help your body calm inflammation, improving body chemistry, so the eggs in subsequent cycles can be their healthiest and not as damaged by the impacts of inflammation.
4. Explore targeted supplements like N-Acetyl Cysteine, Alpha Lipoic Acid, and Pycnogenol, all of which are anti-inflammatory/antioxidants that have been shown in studies to improve endometriosis.
5. Talk to your doctor to see if you are a candidate for a laparoscopic surgery, which can improve ovarian function, egg quality and implantation rates in subsequent cycles. Surgery can help reduce symptoms for years, but it is likely that endometriosis will return as it is almost impossible to remove all cells surgically. It can, however, improve fertility in the months or years after.
6. If you are experiencing repeat miscarriages, your doctor may test you for autoimmune markers or blood clotting issues, which could help them choose medications to prevent future miscarriages. You can also consult a Reproductive Immunologist in your area for more in-depth testing and more aggressive treatments.
7. If you tested positive on a Receptiva biopsy, your doctor may do a specific protocol to try and reduce estrogen (which feeds the endometrial cells) exposure leading up to an embryo transfer cycle. This is another excellent time to work with an acupuncturist to help your body clean up inflammation and maximize your chances of implantation and a healthy pregnancy.