Endometriosis and Infertility: Symptoms, Diagnosis, and Treatment

By Dr. Anshika Lekhi | MBBS, DGO, Fellowship in Reproductive Medicine, The Fertilife, Gurgaon

Endometriosis gets missed more often than almost any other cause of female infertility, and it gets undertreated just as often. At The Fertilife we see a lot of patients who spent years managing painful periods with no formal diagnosis, then found out once they started trying to conceive that endometriosis had been quietly working on their fertility the whole time. Endometriosis affects approximately 1 in 10 women of reproductive age, and among women with infertility the figure runs considerably higher. Between 25% and 40% of women who struggle to conceive have endometriosis.

What Is Endometriosis, and Why Does It Affect Fertility?

Endometriosis is what happens when tissue similar to the lining of the uterus, the endometrium, grows outside the uterine cavity, most often on the ovaries, the fallopian tubes and the peritoneum. That tissue answers to the monthly hormonal cycle exactly as the uterine lining does. It builds up and it bleeds. With no way out of the body, it sets off inflammation, scarring and, over time, adhesions.

Endometriosis works on fertility through several routes at once:

• Damage to the ovaries can pull down egg quality and ovarian reserve

• Scarring around the fallopian tubes can block egg transport or impair it

• Inflammatory changes in the pelvic environment get in the way of fertilisation

• Changes in the uterine lining can bring implantation success down

• Endometriomas, the ovarian cysts endometriosis causes, damage the surrounding ovarian tissue directly

What Are the Symptoms We Look For?

Endometriosis gets brushed off or put down to "normal" period pain all the time, which is why so many patients reach our Endometriosis Treatment service years into their symptoms. Signs that warrant investigation:

• Severe or worsening menstrual pain that disrupts daily activity

• Pelvic pain outside of menstruation

• Pain during intercourse (dyspareunia)

• Painful bowel movements or urination during menstruation

• Heavy or irregular menstrual bleeding

• Difficulty conceiving after 6 to 12 months of trying

Worth saying that some patients with endometriosis have minimal symptoms, or none at all. No pain does not rule the condition out.

How Is Endometriosis Diagnosed?

Female Fertility Assessment

A thorough Female Fertility Assessment is where it starts. That takes in a transvaginal ultrasound to look for ovarian endometriomas, an AMH test to read ovarian reserve, and a detailed run through the menstrual and pain history. Advanced imaging such as an MRI comes in where deep infiltrating endometriosis is suspected.

The definitive diagnosis comes off a laparoscopy, a keyhole surgical procedure that puts eyes directly on the lesions and allows a biopsy. In plenty of fertility cases, though, the clinical picture that imaging and history give you is enough to guide treatment decisions without going to surgery first.

What Does the Diagnostic Review Involve at The Fertilife?

• Detailed medical and menstrual history

• Transvaginal ultrasound for ovarian cysts and pelvic anatomy

• AMH and antral follicle count to assess ovarian reserve

• CA-125 blood test where appropriate

• Referral for laparoscopy where surgical confirmation or treatment is indicated

How Is Endometriosis-Associated Infertility Treated?

Treatment turns on the stage of the endometriosis, the patient's age, her ovarian reserve, and how long she has been trying to conceive.

Surgical Management

For patients with endometriomas or significant pelvic adhesions, taking lesions out through laparoscopy can improve both the ovarian environment and the pelvic anatomy. Surgery on ovarian endometriomas carries a risk of knocking ovarian reserve down, though, so the decision gets made carefully, and particularly carefully where AMH is already low.

IVF Treatment

IVF Treatment is what we recommend for patients with moderate to severe endometriosis, patients with low ovarian reserve, and anyone who has not conceived after less invasive interventions. IVF goes round the fallopian tubes and the pelvic environment altogether, dealing with the fertilisation barrier directly in the laboratory. At The Fertilife, IVF protocols for endometriosis patients get adjusted off their ovarian reserve and their response history rather than applied as a standard template.

Fertility Preservation

For younger patients newly diagnosed with endometriosis who are not ready to conceive yet, egg freezing is a sensible option, preserving their reproductive options before ovarian reserve takes any further hit.

Our Approach at The Fertilife

We treat endometriosis as the systemic condition it is rather than as a gynaecological inconvenience. Where painful periods, difficulty conceiving or pelvic pain are the concern, a structured Female Fertility Assessment is the right place to start. Early diagnosis and a clear treatment pathway, whether that runs through our Endometriosis Treatment program, through IVF Treatment, or through fertility preservation, makes a meaningful difference to outcomes. Visit thefertilife.in to arrange a consultation.

This article is for general educational purposes and is not a substitute for personalised medical advice from your fertility specialist or embryologist.