Instruct: Given a question, retrieve relevant passages that answer the question.
Query: Can endometriosis effect fertility?
Endometriosis is a condition in which cells similar to those in the endometrium, the layer of tissue that normally covers the inside of the uterus, grow outside of it.[7][8] Most often this is on the ovaries, Fallopian tubes, and tissue around the uterus and ovaries; however, in rare cases it may also occur in other parts of the body.[2] The main symptoms are pelvic pain and infertility.[1] Nearly half of those affected have chronic pelvic pain, while in 70% pain occurs during menstruation.[1] Pain during sexual intercourse is also common.[1] Infertility occurs in up to half of women affected.[1] Less common symptoms include urinary or bowel symptoms.[1] About 25% of women have no symptoms.[1] Endometriosis can have both social and psychological effects.[9]
Complications of endometriosis include internal scarring, adhesions, pelvic cysts, chocolate cysts of ovaries, ruptured cysts, and bowel and ureter obstruction resulting from pelvic adhesions.[113] Endometriosis-associated infertility can be related to scar formation and anatomical distortions due to the endometriosis.[2]
The overall effectiveness of manual physical therapy to treat endometriosis has not yet been identified.[106] There is no evidence to support nutritional therapy as effective.
Dr. Abayomi Ajayi is the founder of the Fertility Treatment Support Foundation (FTSF) which provides free fertility treatment for financially restrained couples battling infertility. He is also the founder of Endometriosis Support Group Nigeria (ESGN) & Fertility Awareness Advocacy Initiative (FAAI).
In-vitro fertilization (IVF) procedures are effective in improving fertility in many women with endometriosis. IVF makes it possible to combine sperm and eggs in a laboratory and then place the resulting embryos into the woman's uterus. The decision when to apply IVF in endometriosis-associated infertility cases takes into account the age of the patient, the severity of the endometriosis, the presence of other infertility factors, and the results and duration of past treatments. In ovarian hyperstimulation as part of IVF in women with endometriosis, using a standard GnRH agonist protocol has been found to be equally effective in regard to using a GnRH antagonist protocol in terms of pregnancy rate. On the other hand, when using a GnRH agonist protocol, long-term (three to six months) pituitary down-regulation before IVF for women with endometriosis has been estimated to increase the odds of clinical pregnancy by fourfold.
A health history and a physical examination can lead the health care practitioner to suspect endometriosis. Although doctors can often feel the endometrial growths during a pelvic exam, and these symptoms may be signs of endometriosis, diagnosis cannot be confirmed by exam only.
The advantages of physical therapy techniques are decreased cost, absence of major side-effects, it does not interfere with fertility, and near-universal increase of sexual function.[107] Disadvantages are that there are no large or long-term studies of its use for treating pain or infertility related to endometriosis.[107]
In general, the diagnosis of endometriosis is confirmed during surgery, at which time ablative steps can be taken. Further steps depend on circumstances: a woman without infertility can be managed with hormonal medication that suppresses the natural cycle and pain medication, while an infertile woman may be treated expectantly after surgery, with fertility medication, or with IVF. As to the surgical procedure, ablation (or fulguration) of endometriosis (burning and vaporizing the lesions with an electric device) has shown a high rate of short-term recurrence after the procedure. The best surgical procedure with much lower rate of short-term recurrence is to excise (cut and remove) the lesions completely.
Surgery is more effective for infertility than medicinal intervention in endometriosis. One study has shown that surgical treatment of endometriosis approximately doubles the fecundity (pregnancy rate). The use of medical suppression after surgery for minimal/mild endometriosis has not shown benefits for patients with infertility. Use of fertility medication that stimulates ovulation (clomiphene citrate, gonadotropins) combined with intrauterine insemination (IUI) enhances fertility in these patients.
Surgery is more effective than medicinal intervention for addressing infertility associated with endometriosis.[85] Surgery attempts to remove endometrial tissue and preserve the ovaries without damaging normal tissue.[85] In-vitro fertilization (IVF) procedures are effective in improving fertility in many women with endometriosis.
A hysterectomy (removal of the uterus) can be used to treat endometriosis in women who do not wish to conceive. However, this should only be done when combined with removal of the endometriosis by excision, as if endometriosis is not also removed at the time of hysterectomy, pain may persist.[93]
Laparoscopy is used to examine the interior of the abdomen. It can be used to establish patency of the fallopian tubes, and is especially suitable for the diagnosis of endometriosis.
Excess estrogen, such as from birth control pills, appears to increase cholesterol levels in bile and decrease gallbladder movement, which can lead to gallstones.[85] Progestins found in certain formulations of oral contraceptive pills can limit the effectiveness of weight training to increase muscle mass.[86][87] This effect is caused by the ability of some progestins to inhibit androgen receptors. One study claims that the pill may affect what male body odors a woman prefers, which may in turn influence her selection of partner.[88][89][90] Use of combined oral contraceptives is associated with a reduced risk of endometriosis, giving a relative risk of endometriosis of 0.63 during active use, yet with limited quality of evidence according to a systematic review.[91]
Smoking increases the risk of symptoms associated with Crohn's disease (a dose-dependent effect with use of greater than 15 cigarettes per day). There is some evidence for decreased rates of endometriosis in infertile smoking women, although other studies have found that smoking increases the risk in infertile women. There is little or no evidence of a protective effect in fertile women. Some preliminary data from 1996 suggested a reduced incidence of uterine fibroids, but overall the evidence is unconvincing.
A major symptom of endometriosis is recurring pelvic pain. The pain can range from mild to severe cramping or stabbing pain that occurs on both sides of the pelvis, in the lower back and rectal area, and even down the legs. The amount of pain a woman feels correlates weakly with the extent or stage (1 through 4) of endometriosis, with some women having little or no pain despite having extensive endometriosis or endometriosis with scarring, while other women may have severe pain even though they have only a few small areas of endometriosis.[12] The most severe pain is typically associated with menstruation. Pain can also start a week before a menstrual period, during and even a week after a menstrual period, or it can be constant. The pain can be debilitating and result in emotional stress.[13] Symptoms of endometriosis-related pain may include:
Several cases of inguinal endometriosis, that infiltrates the round ligament of the uterus have been reported in fertile, non-pregnant women. In the majority of these cases, diagnosis was problematic. In some cases, definitive diagnosis of round ligament endometriosis was only possible during exploratory surgery.
Assisted reproductive technology (ART) is the use of reproductive technology to treat low fertility or infertility. ART is currently the only form of reproductive technology in clinical use, and is more effective in those suffering from ovulatory disorders or endometriosis (those without a functional uterus, for example, for the time being can only conceive through surrogacy methods). Examples of ART include "in vitro" fertilization and its possible expansions, including:
In rare cases, oophorectomy can be used to treat endometriosis by eliminating the menstrual cycle, which will reduce or eliminate the spread of existing endometriosis as well as reducing pain. Since endometriosis results from an overgrowth of the uterine lining, removal of the ovaries as a treatment for endometriosis is often done in conjunction with a hysterectomy to further reduce or eliminate recurrence.
The cause of thoracic endometriosis is unknown. Those with previous surgeries are more prone to developing thoracic endometriosis due to the surgical manipulation that can cause embolisation of the endometrial tissue into the thoracic cavity. Some thoracic endometriosis patients have been described as having a congenital defect in the diaphragm. There is also an association between thoracic and pelvic endometriosis.
Laser surgery and cauterization are considered to be far less effective and only burn the top layer of endometrial tissue, allowing for the endometrioma and endometriosis to grow back quickly. Likewise, endometrioma drainage or sclerotherapy are somewhat controversial technique for removing endometriomas with varied degrees of success. Conservative surgery can be performed to preserve fertility in younger patients but as earlier stated can have the effect of raising FSH values and making the ovaries less productive, especially if functional ovarian tissue is removed in the surgical process.
Hormonal birth control therapy: Birth control pills reduce the menstrual pain associated with endometriosis.[94] They may function by reducing or eliminating menstrual flow and providing estrogen support. Combined estrogen–progestogen birth control is the first-line treatment for most women with endometriosis due to its ability to be used over long periods of time, relative inexpensiveness and ease of use, and additional benefit of reducing ovarian/endometrial cancer risk.[95] Progestogens: Progesterone counteracts estrogen and inhibits the growth of the endometrium.[96] Such therapy can reduce or eliminate menstruation in a controlled and reversible fashion. Progestins are chemical variants of natural progesterone. An example of a progestin is dienogest (Visanne). Whilst progestogens are often given as part of a combined hormonal therapy with the addition of estrogen, progestogen-only therapy may be an acceptable alternative. Danazol (Danocrine) and gestrinone (Dimetrose, Nemestran) are suppressive steroids with some androgenic activity.[85] Both agents inhibit the growth of endometriosis but their use remains limited as they may cause masculinizing side effects such as excessive hair growth and voice changes. Gonadotropin-releasing hormone (GnRH) modulators: These drugs include GnRH agonists such as leuprorelin (Lupron) and GnRH antagonists such as elagolix (Orilissa) and are thought to work by decreasing estrogen levels.[97] A 2010 Cochrane review found that GnRH modulators were more effective for pain relief in endometriosis than no treatment or placebo, but were no more effective than danazol or intrauterine progestogen, and had more side effects than danazol.[97] A 2018 Swedish systematic review found that GnRH modulators had similar pain-relieving effects to gestagen, but also decreased bone density.[74] Aromatase inhibitors are medications that block the formation of estrogen and have become of interest for researchers who are treating endometriosis.[98] Examples of aromatase inhibitors include anastrozole and letrozole. Evidence for aromatase inhibitors is limited due to the limited number and quality of studies available, though show promising benefit in terms of pain control.[99]
Several studies have investigated the potential link between exposure to dioxins and endometriosis, but the evidence is equivocal and potential mechanisms are poorly understood.[36] A 2004 review of studies of dioxin and endometriosis concluded that "the human data supporting the dioxin-endometriosis association are scanty and conflicting",[37] and a 2009 follow-up review also found that there was "insufficient evidence" in support of a link between dioxin exposure and women developing endometriosis.[38] A 2008 review concluded that more work was needed, stating that "although preliminary work suggests a potential involvement of exposure to dioxins in the pathogenesis of endometriosis, much work remains to clearly define cause and effect and to understand the potential mechanism of toxicity".[39]
Less commonly lesions can be found on the diaphragm. Diaphragmatic endometriosis is rare, almost always on the right hemidiaphragm, and may inflict the cyclic pain of the right shoulder just before and during a menstrual period. Rarely, endometriosis can be extraperitoneal and is found in the lungs and CNS.[67]
It has been found that vaginal gestrinone shows fewer androgenic side effects and weight gain than oral gestrinone with equivalent effectiveness in endometriosis. Gestrinone appears to show similar effectiveness to danazol in the treatment of endometriosis but with fewer side effects, in particular androgenic side effects.
During fertility treatment, the ultralong pretreatment with GnRH-agonist has a higher chance of resulting in pregnancy for women with endometriosis, compared to the short pretreatment.[74]