Gynaecology

Endometriosis

Endometriosis is a condition where abnormal tissue outside of the uterine cavity reacts to the hormonal changes of the menstrual cycle. Endometriosis lesions are structurally similar to the endometrium in your womb. Active endometriosis is associated with inflammation and scarring. Lesions, nodules and endometriomas (endometriosis lined ovarian cysts, known as chocolate cysts) can cause anatomical damage to important pelvic organs, leading to impaired fertility. Inflammatory mediators of endometriosis in a woman’s pelvic environment can have toxic effects on eggs and embryos.

Endometriosis can cause a spectrum of pelvic pain syndromes, which are cyclical in nature. Pain tends to be worst in the days leading up to and during your menstrual period. Endometriosis can also cause pain associated with your bowel and bladder function and “deep“ pain with sexual intercourse.

The gold standard treatment for endometriosis is surgical removal of abnormal tissue. It is SO important that in women seeking fertility, a conservative surgical approach is taken. Extensive surgery to a woman’s ovaries can destroy normal surrounding ovarian cortex (the tissue containing her eggs). As a Fertility Specialist, Dr Raelia Lew is highly trained in minimally invasive laparoscopic gynaecological surgery. Her treatment goal is to simultaneously eradicate your endometriosis symptoms and to maximize your fertility.

FAQs

How common is endometriosis?

Endometriosis is extremely common. It affects 1 in 10 Australian women and is even more common in women suffering infertility.

Doesn’t endometriosis always cause really bad period pain, so I would know if I had it?

Some women with endometriosis suffer crippling pain with their periods, but in others it can be silent. Nobody yet understands why this is the case, not even the experts. For some women, the presenting symptom of endometriosis can be infertility.

I’ve had one baby naturally. Can I still have endometriosis?

Yes. Not all women with endometriosis suffer primary infertility. Endometriosis is a condition that worsens over time and can be a cause of secondary infertility (inability to conceive a child naturally after having had a baby before).

What is endometriosis?

Endometriosis is an inflammatory condition where abnormal tissue that looks and behaves like the endometrium (lining of the womb) grows inappropriately elsewhere around the body.

Where does endometriosis occur?

Endometriosis most commonly affects the peritoneum (inner soft lining of the internal pelvis) but can also cause surface disease and chocolate cysts on the ovaries (endometriomas) and hard scar-like nodules on the bladder, rectum and bowel, pelvic ligaments and even on distant tissues like the diaphragm muscle and pleura (lining of the lungs).

That’s why some women with endometriosis can suffer chest pain when they have their period!

Can surgical management of endometriosis help with natural fertility?

Yes. Recognising and gently treating endometriosis through her fertility focused and delicate approach to keyhole (laparoscopic) surgery not only allows Dr Raelia Lew to achieve improved IVF treatment outcomes but critically allows many of her patients to go on to conceive naturally. At the same procedure to excise endometriosis, fallopian tubal flushing is performed to optimise a woman’s chance of achieving natural fertility.

Why does endometriosis happen?

The short answer is – we don’t really know. Experts have studied endometriosis for a long time and have come up with several theories but ultimately we still don’t know why it happens.

Does a family history of endometriosis increase my risk of having it?

Yes. Having a relative with endometriosis is a strong risk factor. In fact if your mother or sister had endometriosis, your risk is seven times greater than the average woman. This fact indicates that our genes play an important role.

What are other risk factors for endometriosis?

Having your first baby later in life increases your risk of developing endometriosis. Having menstrual cycles over and over is a risk factor that can stir up endometriosis and allow disease to progress. That’s why if you have proven endometriosis (found at laparoscopy), or your doctor suspects it (based on your symptoms, the oral contraceptive pill might be suggested if you are not trying to conceive.

Does it matter what kind of doctor treats your endometriosis?

It can. Aggressive surgical management of endometriosis involving the ovary can seriously diminish a woman’s ovarian reserve. If fertility is a current or future priority for you and you think you may have endometriosis, seeking out a CREI subspecialist surgeon like Dr Raelia Lew is likely to give you your best outcome.

I’m worried about future fertility but I’m not ready to have a baby. How can my endometriosis be managed?

If you are not trying to have a baby now, “turning off” your menstrual cycle using hormonal medications may be the best way to ensure your endometriosis does not get worse with time. You may also consider freezing your eggs. If you have serious endometriosis that puts your future fertility at risk, you may be eligible for medicare subsidised treatment to freeze your eggs.

Freezing eggs with endometriosis: Does the process of egg freezing treatment make endometriosis worse?

The hormones used in ovarian stimulation for egg freezing ( otherwise known as oocyte cryopreservation) can stir up your endometriosis. However, if individualised care is provided by a CREI subspecialist, they know how to manage the situation both in the short and longterm to optimise your fertility outcomes.

After surgical treatment of endometriosis at laparoscopy, should I move directly on to IVF?

It depends. Where a woman’s anatomy has been surgically normalised and fallopian tubes are working well, Dr Lew generally advises women to continue to try to conceive naturally following laparoscopic excision of endometriosis.

If your fallopian tubes are blocked, if you are older (above 35 years), If you have a very low egg count (ovarian reserve) or if there is also a serious and irreversible sperm problem, proceeding directly to IVF may be your best option.

 

How many women suffering infertility have endometriosis?

If you have been trying to conceive for 12 months without success, have open (clear) fallopian tubes, normal hormonal blood tests and your partner has a normal sperm test, there is over an 80% chance of diagnosing (and being able to helpfully treat) endometriosis at a laparoscopy assessment.

My pelvic ultrasound was reported as normal. Does this mean I don’t have endometriosis?

Having a normal pelvic ultrasound means you probably don’t have stage 3 or 4 endometriosis (very severe disease causing scarring, nodules, cysts and associated distortion of normal pelvic anatomy).

Unfortunately stage 1 and stage 2 endometriosis are unable to be diagnosed by ultrasound but can still cause infertility.

My periods are only mildly painful. Does this mean I don’t have endometriosis?

Endometriosis is a spectrum and symptoms can often be fairly subjective. A challenge to doctors is that some women with endometriosis have a lot of pain with their periods, sex, ovulation and even with normal bladder and bowel function during a period. Other women carry the burden of endometriosis silently and first present for help when they suffer infertility.

If I have bad period pain, does that mean I will definitely need IVF?

Women whose endometriosis causes pain paradoxically may have better fertility outcomes as they are more likely to seek help at an earlier stage of their disease.

My period pain got worse when I stopped the pill – why has this happened?

Many women with endometriosis have been managed on the oral contraceptive pill for a long time but cease this treatment to try to have a baby.

Period pain that worsens progressively over several months of trying is highly suspicious for active endometriosis.

How does endometriosis cause infertility?

Endometriosis can cause infertility in multiple ways:

  • Causing scarring/blockage of the fallopian tubes
  • Causing pelvic adhesions which prevent normal ovarian and fallopian tube interaction
  • Causing inflammation in the pelvis which can be toxic to eggs, sperm and embryos
  • Causing sex to be painful
I’m trying to conceive but my periods are getting really painful. What can I use for period pain relief?

It is ok to use ibuprofen and paracetamol during your period, but after ovulation, non steroidal anti-inflammatory pain killers should be avoided. This is because they may increase your risk of having a miscarriage.

Is regular IVF ok if I have endometriosis?

Maybe not. Studies have showed that specific techniques of ovarian stimulation and embryo transfer achieve best outcomes for women with endometriosis. Surgical management of endometriosis before IVF and techniques of ultra-long central GnRH agonist down regulation therapy before ovarian stimulation and before embryo transfer may achieve your best chance of success. These techniques require individualisation of care, and are best performed with the involved oversight of your care by a CREI fertility expert like Dr Raelia Lew.