PMA and endometriosis: which route to take?

Written with Samantha Load

For women with endometriosis, the uterine lining develops in places where it shouldn't, i.e. in the genitals, vagina, rectum, bladder, etc. It's usually at periods that the pain occurs, as the body is unable to eliminate these lesions, leading to inflammation and lesions.

Why can endometriosis cause infertility?

It is estimated that 35-55% of people with fertility problems suffer from endometriosis, and 30-40% of people with endometriosis will have infertility problems. Not all women with endometriosis are affected by it. 

What is the link between endometriosis and infertility? 

Endometriosis can be responsible for infertility, since it gives rise to many mechanisms such as :

• reduced follicular reserve, notably due to the presence of endometriosis cysts, which invade the ovary and destroy the eggs inside.

• ovulation disorders ldue to hormonal abnormalities or cysts in the ovaries

• impaired embryonic implantation due to increased IgC and IgA antibodies and lymphocytes in the endometrium

• fertilization abnormalities

• oocyte uptake disorders

• gamete transport disorders

The main causes of infertility are related to anatomical lesions that create an inflammatory climate harmful to fertilization, and to altered 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 experience dyspareunia, which makes intercourse more difficult, and therefore increases the chances of pregnancy.

How is endometriosis treated if you want to become pregnant?

When a couple encounters difficulties in conceiving a child, the first step is to carry out a battery of tests to determine the cause of the infertility. Infertility can come from either the woman or the man, and depending on its origin, the solutions for supporting the pregnancy project will not be the same. A woman with endometriosis is not necessarily infertile. Consult a doctor who will be able to guide you.

Women suffering from endometriosis have a number of options to help them achieve pregnancy if it does not occur naturally. Surgery or medically-assisted procreation can be proposed to the patient, depending on her personal choices, symptoms, etc...

Which surgery for endometriosis?

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

The benefits of this operation are being studied in cases where endometriosis is painful, and 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. There are several ways of proceeding:

• by eliminating lesions, either using laser techniques, laser vaporization or coagulation  

• removing lesions by excision 

The presence of small lesions can complicate the operation, as can lesions in other areas such as functional organs like the bladder, rectum or colon. Surgical intervention becomes 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. opening the abdominal wall. 

Following this operation, some patients succeed in becoming pregnant naturally. For others, it's more complicated, and recourse to PMA may be considered.

How does a PMA course work?

There are several types of medically assisted reproduction techniques. Firstly, there is artificial insemination. Artificial insemination, the simplest and least expensive technique, involves injecting sperm into the woman's uterus during ovulation.

Another MAP technique is IVF (in vitro fertilization). This is a much more invasive technique, in which sperm and egg are brought together directly in the laboratory. Mature follicles, whose production is stimulated by hormones, are harvested, 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, i.e. In Vitro Fertilization with microinjection. This technique is suitable for male infertility, as it selects 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 severe pain she felt during her periods, that her gynecologist told her she had 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 is the cause of her infertility. Her endometriosis manifests itself in multiple small lesions.

Following this diagnosis, Samantha was given a choice of two solutions to deal with her infertility. The first was surgery. This involved the destruction of all endometriotic lesions, enabling 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 PMA program, including conventional IVF, or In Vitro Fertilization. Samantha explains that each pathway is different, but in her case, she had her first hormone injection on the first day of periods, followed by an injection every morning and evening for around 20 days. 

The aim of the injections is to enlarge the follicles. Regular checks are carried out to ensure that the follicles are developing correctly, are the right size and are harvested at the right time. Two days before the puncture, Samantha had a final injection of hormones to trigger ovulation.

For Samantha, the puncture took place under local anaesthetic, but it is also possible to do it under general anaesthetic. All the follicles were removed, and sperm donated at the same time. The harvested follicles are then brought into contact with the sperm to create embryos.

Finally, you have to wait until a follicle is of good quality before you can implant it. In Samantha's case, the most resistant follicle is implanted 2 days after the puncture, at which point the viability of the embryo must be checked regularly. You have to wait between the moment of implantation and the level of the beta HCG test, the pregnancy hormone. Pregnancy tests are forbidden during this time, as the hormone injections can distort the results. After the blood test, beta HCG levels should be checked every 48 hours. The pregnancy can then proceed as normal!