FAQ Infertility and Endometriosis

an alt.med.endometriosis FAQ

revised April 28, 2000



Copyright © 1998, 2000 Susan Strandskov



The purpose of this FAQ is not to discourage questions and

discussion, but to provide a basic overview.  Information

provided here is intended only as a quick briefing, not the

definitive answer, and should not be substituted for competent

medical advice.







Although endometriosis doesn't always cause infertility (and

is certainly cause for concern aside from fertility), fertility

issues are often a major concern of endometriosis patients.

Endometriosis should be taken seriously during infertility treatment.



Those who are concerned about infertility are encouraged to

participate in the infertility newsgroups (such as alt.infertility),

as well as this newsgroup.  The very helpful FAQs for the

infertility newsgroups can be seen at:

http://www.fertilityplus.org/faq/infertility.html

If you are preparing for a particular procedure, you may find

many people who can share first-hand experience about that procedure

on the infertility newsgroups.  However, those on the infertility

newsgroups may or may not be familiar with endometriosis issues.

It is our hope that you will benefit from participation in both

groups.



RESOLVE is an organization for infertile couples, and provides

support much the same as the Endometriosis Association provides

support for women with endometriosis.  Resolve can be very helpful

if you are dealing with infertility.  They have a web site:

http://www.resolve.org





>Does endometriosis always cause infertility?



No, it doesn't.  Probably fewer than 40% of women with endometriosis

are infertile.  However, women with endometriosis make up a large

percentage of infertility patients.





>How does endometriosis cause infertility?



Because it doesn't always cause infertility, there are no easy

answers to this question.  Because endometriosis often causes

painful intercourse, couples may fail to have intercourse during

the woman's most fertile time.  If endometriosis or the resulting

adhesions have caused blockage in the path that an egg travels, this

may provide a simple explanation of the reason pregnancy is not

occurring.  Inflammation caused by endometriosis may be another

factor.  Prostaglandin activity may be yet another.  Research by

Dr. Bruce Lessey indicates that many women who have endometriosis

lack the beta-3 integrin which is important to the implantation of

an embryo in the uterus.  Another interesting area of investigation

involves immune system factors, and the concern that endometriosis

may activate natural killer cells.  Dr. Alan Beer is a leading

researcher in that area.





>If I know I have endometriosis, where should I start with

>infertility treatment?



A simple and inexpensive aid to infertility treatment is keeping

a temperature chart.  Chart your basal body temperature (BBT),

this is your temperature on awakening and before you get out of

bed.  There are special BBT thermometers available for this

purpose.  There is an excellent book:

Taking Charge of your Fertility by Toni Weschler

which explains how a BBT chart can help to identify both the most

fertile time and possible fertility problems.  This kind of charting

(as well as ovulation predictor kits) can be especially helpful to

women who are experiencing painful intercourse, so that they can

time intercourse appropriately and avoid painful activity during

less fertile times.



Women who don't know why they are infertile would probably start

with simple procedures, but endometriosis is a recognized

infertility problem calling for aggressive measures.  Your doctor,

of course, should be your guide, but if a woman already knows she

has endometriosis it may make sense to go to the more serious issues

of the infertility evaluation first.  After a basic exam, an HSG

(hysterosalpingogram, an x-ray of the uterus and fallopian tubes)

is a logical starting point for a woman who has endometriosis.

This test will tell whether the tubes are open and may reveal

abnormalities in the uterus.  If the fallopian tubes are blocked,

fertility drugs alone will not produce a pregnancy!



If the woman has already been diagnosed with endometriosis, a

laparoscopy will probably be scheduled early in the infertility

evaluation.  This is the only way the doctor can get a good look at

the endometriosis.  During the laparoscopy, he can remove the

endometriosis lesions and adhesions which may be interfering

with conception.  Many doctors feel that for a woman who has

endometriosis, the best chances of pregnancy occur during the

six to nine month period following a laparoscopy.



You can read more about endometriosis surgery on Dr. David

Redwine's web site:

http://www.scmc.org/endo.shtml





>Should women who have endometriosis use fertility drugs?



Fertility drugs can make endometriosis symptoms worse.  So, it's

a good idea to have a thorough infertility evaluation first, so

that all problems are identified.  If the woman seems to be ovulating

well despite her endometriosis, but her husband has a low sperm count,

simply giving fertility drugs to HER may not be the best course of

action.  Be sure you understand what the problem is and how it is to

be treated.  Doctors should not simply throw fertility drugs at every

infertility problem.



Some doctors have even prescribed fertility drugs before conducting

an HSG, only to find later that the woman's tubes were blocked, so

she endured the discomfort and expense of fertility drugs for nothing!

Because endometriosis and fertility drugs are not a happy combination,

insist on a thorough evaluation, and don't settle for trying a little

of this, a little of that.



At the conclusion of the infertility evaluation, when all problems

can be addressed simultaneously, it may make good sense to use

fertility drugs, even though the fertility drugs may create extra

endometriosis pain.



Recent research still in the investigative phase may indicate that

the fertility drug clomid might cause implantation problems in the

lining of the uterus of a woman who has endometriosis.  It may be

many years before we know the outcome of this research, but in the

meantime it's probably best to consider other treatment options

rather than continue clomid for an extended period of time.





>Isn't it simpler to go straight to IVF?



Some doctors urge their endometriosis patients to move directly

to IVF (in vitro fertilization), saying, "don’t waste time."  If

the woman's tubes are blocked, IVF is certainly the best option

for her and many other issues become insignificant.  Some doctors

say that if any treatment at all is going to work, IVF is going to

work so it's easier for all concerned to go straight to IVF.



However, IVF is extremely expensive, does not eliminate the need for

fertility drugs, and for all the trouble and expense the success

rates are not admirable -- around 20% for a single cycle.  Many

couples have gone deeply into debt to pay for IVF and still not

become pregnant.  In addition, IVF alone does not override all

possible problems; it still makes sense to determine the cause

of infertility before moving to IVF.



If there is no problem with tubal blockage many couples prefer to

start with less expensive treatment.  IUI (intrauterine insemination)

with progesterone treatment, for instance, makes sense for many couples

when endometriosis is involved, and the cost is only a small fraction

of the cost of IVF.





>What problems are there which IVF won't override?



If a woman lacks sufficient beta-3 integrin receptors, an embryo

might not stick to the uterine lining.  Some doctors are giving

high doses of progesterone to try to override this problem.  There

is no approved treatment for lack of beta-3, at present.



Immune problems can also be a significant problem.  Women who have

endometriosis are much more likely than the general population to

have immune problems which interfere with conception.  Many doctors

do not want to test for immune problems until after the couple has

had several failed IVF cycles, or several miscarriages.  Endometriosis

itself, however, is a significant risk factor for reproductive immune

problems, and testing for immune problems is less expensive than an IVF

cycle.  (Remember, it's your money!)  If endometriosis has in fact

caused your immune system to have strange antibody reactions or has

activated your natural killer cells, even IVF is likely to fail without

immune treatment.  Proper treatment for immune problems can mean the

difference of whether an IVF cycle succeeds or fails, and it can mean

the life or death of an unborn baby.  Much of immune treatment is

experimental, so it's important to gain an understanding of the issues

involved.





>How are immune problems treated?



The cutting-edge experimental treatment is IVIG.  LIT is another

treatment, which has been in use for several years.  These

treatments are started before conception is attempted.  You can

read more about these treatments on Dr. Beer's web site:

http://repro-med.net/index.html



Some doctors who feel that these treatments are too experimental

are still using aspirin and heparin or prednisone therapy to try

to suppress immune problems.  These therapies are sufficient for

some immune problems.  As with most treatments, there are risks

involved.





>If I have lupron treatment for my endometriosis, will that

>help me get pregnant?



Probably not.  Some studies have indicated increased pregnancy

rates after endometriosis surgery, but there have been no studies

which indicate that endometriosis treatment with lupron or any of

the other suppressive medications increases pregnancy rates.  Women

in their late 30's or their 40's, especially, should consider

whether lupron treatment might just waste valuable time.



Lupron is sometimes used in a very brief pre-treatment (treatment

lasts only a matter of days) before IVF to assist in regulating

hormone levels, and that kind of treatment does seem to be helpful.

But this is a different protocol from using lupron for several months

in an attempt to suppress the endometriosis.  It should be noted

that although such use is common, lupron is not labeled for use

in infertility treatment.





>Some basics of the infertility evaluation:



For the man:

Semen analysis



For the woman:

Physical exam

Cervical cultures

HSG (hysterosalpingogram)

Sonograms

Laparoscopy

Hormone screening (blood tests)

Cervical mucus test

Endometrial biopsy

Immune testing



For both:

Post-coital test

Sperm antibody tests







FAQ is for general information purposes

and does not constitute medical advice.



An alt.med.endometriosis FAQ

Copyright © 1998, 2000 Susan Strandskov

All Rights Reserved.

Please do not copy this material for use elsewhere

without express permission.