For Your Patients: Fertility and Pregnancy in Endometriosis

If you suffer from endometriosis, you've been focusing on pain and symptom control – perhaps with birth control pills or other estrogen-suppressing drugs.

But now you want to have a baby, and you may fear your condition will prevent you from conceiving.

But be optimistic, because the majority of endometriosis patients will be able to conceive and have a safe pregnancy and a healthy baby – even though the process of conceiving may take longer. "A diagnosis of endometriosis is not a diagnosis of infertility," emphasized Kamaria Cherise Cayton Vaught, MD, a reproductive medicine specialist at Johns Hopkins School of Medicine in Baltimore.

While many may conceive spontaneously, others (about 30-50%) with endometriosis can be subfertile. They tend to have what is known as a reduced "fecundity index" – that is, the chance they will be able to become pregnant with unprotected sexual intercourse in a single monthly cycle is lowered.

Getting Started

First, advised Cayton Vaught, have a full fertility assessment by an obstetrician/gynecologist, including your egg reserve and other aspects of your reproductive health to make sure everything is in order.

If you're younger than 35 and have not been able to conceive in 6 months of unprotected, targeted trying, you should consult a fertility specialist, advised Mark Hornstein, MD, director of the Reproductive Endocrinology Division of Brigham and Women's Hospital and Harvard Medical School in Boston. "Cut that trying time in half to 3 months if you are over age 35."

What Happens When You Stop Estrogen Suppression?

When you go off estrogen-suppressing drugs in order to become pregnant, the return to fertility depends on factors such as your age and type of treatment. If you've been on birth control pills, egg production may be restored as soon as your next cycle. "But if you're on an injected drug such as Lupron, it may take 3 months or so from your last injection," said Cayton Vaught.

Your endometriosis symptoms will not usually return immediately after you stop suppressive therapy. But if you want to try for a spontaneous, unassisted pregnancy, which may take 9 to 12 months, your symptoms may reappear within that timeframe.

Assisting Fertility

If you've had extensive surgery for adhesions of endometriotic tissue on your ovaries, getting pregnant is likely going to be more challenging, and assistive fertility treatments may be required. These include:

• Stimulation of the ovaries with a drug such as clomiphene (Clomid) to increase egg production with/without intrauterine injection (IUI), in which semen is injected directly into the uterus so it bypasses the mucus in the cervix and brings the sperm closer to the egg

• In vitro fertilization (IVF), a process in which an egg (or eggs) is combined with sperm in a culture dish in the laboratory. Sometimes a sperm cell is injected directly into the interior of an egg in a procedure known as intracytoplasmic sperm injection (ICSI)

The fertilized egg – known as a zygote – is grown for a few days into an embryo and then implanted in the uterus, which has been specially prepared to be receptive to embryo implantation.

Endometriosis in Pregnancy

While pregnancy is not a cure for endometriosis, most women will feel much better in terms of their endometriosis-associated pain while they are pregnant, said Hornstein. Endometriosis is an estrogen-driven condition, and while levels of this hormone are high in pregnancy, they are counterbalanced by equally high levels of progesterone. Progesterone, alone or in combined oral contraceptives, is in fact a common first-line treatment for endometriosis-associated pain.

The return of endometriosis symptoms after giving birth depends on the individual and will reappear after varying lengths of time once the monthly cycle is re-established.

Complications

Some studies have suggested that endometriosis patients may be at a slightly increased risk of certain complications, but the evidence is not clear, and most pregnancies and deliveries will be safe and complication-free. You should discuss any potential increase in risks with your doctor.

While women with endometriosis are generally not considered high-risk pregnancy patients, said Hornstein, your doctor may nevertheless want to follow you a bit more closely than usual.

Breastfeeding

In addition to its well-known benefits to mother and baby, breastfeeding is a good way for endometriosis patients to prolong the symptom-free period. Lactation suppresses estrogen production, so your symptoms will likely remain in abeyance while you nurse your baby. Again, symptoms will typically return after varying intervals when breastfeeding stops.

Subsequent Pregnancy

If you've successfully given birth, you can likely do so again, but don't wait too long before seeking treatment. If you had difficulty conceiving the first time, your doctor will likely recommend fertility therapy or assisted reproduction.

The bottom line is that the majority of women with endometriosis will be able to conceive and give birth. The risk of complications during gestation and delivery is low, and most patients can look forward to a healthy pregnancy and a healthy baby.

Read previous installments in this series:

What Is Endometriosis?

How Will Your Doctor Diagnose Endometriosis?

What to Know About Endometriosis Treatment

"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this 12-part journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.