PMA and endometriosis: which path?

Women with endometriosis have the uterine lining develop in places where it is not supposed to develop, i.e. in the genitals, in the vagina, rectum, bladder etc. It is mostly during menstruation that the pain appears, since the body cannot eliminate these lesions, which causes inflammation and lesions.

Why can endometriosis cause infertility?

It is estimated that 35 to 55% of people with fertility problems have endometriosis, and 30 to 40% of people with endometriosis will have infertility problems. Thus, not all women with endometriosis are affected by endometriosis.

What is the link between endometriosis and infertility?

Endometriosis can be responsible for infertility since it causes many mechanisms such as

• a reduction in the follicular reserve, particularly linked to the presence of endometriosis cysts, since these invade the ovary and destroy the eggs present inside.

• ovulation disorders linked to hormonal anomalies or to the presence of cysts in the ovaries

• disorders of embryo implantation linked to the increase of IgC and IgA antibodies and lymphocytes in the endometrium

• abnormalities in fertilization

• disorders of oocyte uptake

• gamete transport disorders

The main causes of infertility are related to anatomical lesions which create an inflammatory climate harmful to fertilization, and to an alteration in the ovarian reserve, particularly when the patient has had endometriosis cysts.

Certain surgical procedures can also have an impact on fertility. Women suffering from endometriosis also sometimes suffer from dyspareunia, which makes intercourse more complicated and therefore the chances of pregnancy.

What treatment for endometriosis in the desire to become pregnant?

When a couple encounters difficulties in conceiving a child, a battery of tests should first be performed to determine the cause of the infertility. It can come from the woman or the man, and depending on its origin, the solutions to accompany the pregnancy project will not be the same. A woman who has endometriosis is not necessarily infertile. Consult a doctor who will be able to guide you.

Women suffering from endometriosis have several solutions to support their desire to become pregnant if a pregnancy does not occur naturally. Surgery or medically assisted reproduction can be proposed to the patient, depending on her background, her personal choices, her symptoms, etc.

Which surgery for endometriosis?

When hormonal treatment is not sufficient to relieve endometriosis and/or when it continues to cause infertility, surgery may be useful.

The interest of this operation is studied in cases where the endometriosis is painful, in cases of infertility where there is a desire for pregnancy.

The first step is to determine the location and nature of the endometriosis lesions. Then the operation takes place. There are several ways to proceed:

• by eliminating the lesions, either with the laser technique, by laser vaporization, or by coagulation

• by removing the lesions by an exeresis

The presence of small lesions can complicate the operation, as well as if the lesions are implanted in other places such as functional organs like the bladder, the rectum, or the colon. The surgical procedure is made more complex.

Most of the time, this operation is performed under laparoscopy, but in the case of deeper endometriosis, it can be performed by laparotomy, i.e. an opening of the abdominal tract.

Following this operation, some patients are able to become pregnant naturally. For others, it is more complicated, and recourse to MAP may then be considered.

How does a PMA procedure work?

There are several types of medically assisted reproduction techniques. First of all, we have artificial insemination. Artificial insemination, which is the simplest and least expensive technique, consists of injecting sperm into the woman's uterus during ovulation.

Another MAP technique is IVF (in vitro fertilization). This is a much more invasive technique that consists of bringing sperm and an egg together directly in the laboratory. Mature follicles are harvested and their production is stimulated by hormones, and when the embryo is viable, it is implanted in the woman's uterus 2 to 5 days after the egg meets the sperm.

There is also IVF ICSI, that is to say, In Vitro Fertilization with micro injection. This technique is adapted to male infertility because it allows the selection of the most suitable spermatozoa.

Samantha: her endometriosis and infertility

Samantha explains that it was during an appointment with her gynecologist, when she described her symptoms and in particular the very strong pain she felt during her periods, that her gynecologist told her about endometriosis. She then prescribed further tests to confirm the diagnosis of endometriosis, with more extensive examinations. Once the tests were completed, the verdict was in: she had endometriosis.

Endometriosis was the cause of her infertility. Her endometriosis manifested itself in multiple small lesions.

Following her diagnosis, Samantha had two options for dealing with her infertility. The first was surgery. This operation consisted of the destruction of all endometriotic lesions, allowing the patient to become pregnant naturally. After 6 months of trying to get pregnant naturally, Samantha was offered the option of moving on to a MAP program, including conventional IVF, or In Vitro Fertilization. Samantha explains that each pathway is different, but for her, she had her first shot of hormones on the first day of her period, and then a shot every morning and evening for about 20 days.

The purpose of the shots is to make the follicles grow. Regular checks are made to ensure that the follicles are growing properly, that they are the right size, and that the time is right to harvest them. Two days before the puncture, Samantha had a final injection of hormones to trigger ovulation.

For Samantha, the puncture took place under local anesthesia, but it is also possible to do it under general anesthesia. It consists of removing all the follicles, with a parallel donation of spermatozoa. The removed follicles were put in contact with the spermatozoa to create embryos.

Finally, it is necessary to wait until a follicle is of good quality before it can be implanted. Then, the most resistant follicle is implanted 2 days after the puncture for Samantha, and from that moment on, the viability of the embryo must be regularly checked. It is necessary to wait between the moment of implantation and the level of the beta HCG test, the pregnancy hormone. During this time, it is forbidden to perform pregnancy tests because the hormone shots can falsify the results. After the blood test, the beta HCG level should be checked every 48 hours. Then the pregnancy can proceed as normal!