What causes endometriosis? Am I at risk?
Endometrial cells grow abnormally fast in the presence of estrogen, which is great when the cells are in the uterus, but a problem when they escape the uterus. This can happen due to retrograde menstruation, endometrial cells that actually develop in the bone marrow and travel by blood to different locations in the body, or through metaplasia when healthy cells in the pelvis and abdomen change into harmful endometrial cells.
Women with first degree relatives diagnosed with endometriosis are six times as likely to develop it themselves. There is also evidence that women who have their first period at a young age, have short menstrual cycles, or have migraines all have a higher risk for endometriosis.
Can endometriosis impact fertility?
Endometriosis can impact a couple’s fertility in a number of ways. Recent studies suggest it can impact ovarian reserve. Surgery to remove endometriosis from the ovaries can also decrease ovarian reserve. The inflammation caused by endometriosis may also create an environment that worsens egg quality. This inflammation may also impair the uterus’s ability to allow an embryo to implant and receive nourishment. Finally, inflammation may impair sperm motility if the sperm swim near the sight of inflammation.
How do I get a diagnosis?
Endometriosis is quite common, affecting one in ten women, and twenty to seventy percent of women with infertility. On average, it takes ten years to diagnose. Why so long? Symptoms often come and go, and overlap with other common conditions like irritable bowel syndrome. Additionally, there are no methods for diagnosis that are both accessible and reliable. Warning signs of endometriosis are painful periods, pain with sex, non cyclical pelvic pain, infertility and fatigue.
Surgery is the only way to definitively diagnose endometriosis, but in current practice many patients are diagnosed and treated without surgical diagnosis. Diagnosis by history taking and physical exam is accurate if the endometriosis is on the ovaries, but low for other areas of the pelvis. Diagnosis by ultrasound is extremely accurate for ovarian endometriosis, but tends to over diagnosis in areas outside of the ovaries. It is generally better than diagnosis by physical exam.
If you are thinking of whether to have surgery to diagnosis endometriosis, consider your doctor’s background and whether a second opinion is warranted. Surgeons or gynecologists who perform surgeries are likely to recommend surgery. Reproductive endocrinologists may be more likely to recommend other treatments. Both perspectives are valid, but context and your goals are key factors in making the appropriate decision.
What are my best treatment options if I’m trying to conceive?
Appropriate treatment depends in part on the severity of endometriosis, and whether you are trying to conceive naturally or with IVF. The Endometrial Fertility Index can be a helpful tool for a patient and doctor to use to determine the likelihood that a woman will conceive naturally. (https://www.danmartinmd.com/efi_calc.html).
Most studies show that surgery before starting IVF is of no benefit. The one exception is if there is a hydrosalpinx. In that case, surgery after retrieval and before transfer is highly likely to improve IVF outcomes. There is some evidence that three to six months of ovarian suppression before an IVF cycle can be helpful, but many providers don’t feel the potential benefits outweigh the delay in treatment or side effects of the medications. Patients with endometriosis have lower fertilization rates. Recent data suggests that endometriosis patients are better off having their eggs fertilized with ICSI, and that they also benefit from freezing eggs and waiting at least a month before transfer.
Acupuncture and Chinese herbs for endometriosis
I’ve worked with many women who have endometriosis. Treatment varies depending on your goals. Many of the most effective herb and acupuncture protocols for severe symptoms of endometriosis are not appropriate if you are trying to conceive. However, I have seen that most of my patients see a lessening in their symptoms during menstruation. Typically, they continue to have moderate cramping, but it will usually last for only a day and be more manageable. Clotting in the menstrual flow improves as well.
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