An endometriosis diagnosis doesn't necessarily mean infertility. Gynaecologist and specialist Dr. med. Roland Braneti explains how the condition can affect pregnancy and birth, and what complications may arise.
The term comes from "endometrium", the medical name for the lining of the uterus. It's a chronic condition characterised by abnormal growth of the uterine lining. This lining grows outside the uterine cavity, causing pain and potentially reducing fertility.
Diagnosis begins with a consultation, followed by a physical and ultrasound examination. Further tests such as MRI scans or laparoscopy may be considered depending on the case.
Pregnancy can still occur naturally, without medical assistance, even with endometriosis. However, success depends on several factors, including the severity of the condition, the woman's age and her ovarian reserve.
It can, but this isn't always the case. When it does, these are known as "chocolate cysts".
Possible symptoms include recurring, severe menstrual pain, pain during intercourse, and bladder or bowel problems. Some women may also have difficulty becoming pregnant.
First things first: Endometriosis doesn't automatically mean a woman is infertile. The condition has many different forms. Whether fertility is affected depends on which organs are impacted and to what extent.
If endometriosis spreads to the fallopian tubes, for example, they may become blocked. These are the channels where the egg and sperm meet and fertilisation takes place. The embryo then implants in the uterus, leading to pregnancy. If endometriosis blocks the tubes, fertilisation becomes more difficult or may not happen at all.
A specific form of the condition is known as adenomyosis. Here, endometriosis occurs within the uterus itself, triggering an inflammatory response. This can interfere with embryo implantation and increase the risk of miscarriage.
Many women can conceive naturally despite endometriosis.
Another aspect is the potential impact of endometriosis on sexuality. If the condition causes pain during intercourse, it can understandably reduce the chances of conception.
In endometriosis, tissue similar to the lining of the uterus grows outside the uterine cavity. It most commonly affects the pelvic area, but in rare cases it can spread as far as the lungs.
A normal menstrual cycle runs as follows: The uterine lining thickens and later bleeds away. The endometriosis lesions outside the uterus behave in exactly the same way. However, the resulting blood cannot drain via the vagina and remains trapped in the body. This leads to an inflammatory reaction and pain. If the lesions are located near nerves, the pain can intensify and may even become chronic.
If the fallopian tubes are affected, they may become blocked, which can impair fertility. Small endometrial lesions, ranging from a millimetre to several centimetres in size, can also form on the peritoneum. In other forms of the condition, nodules develop that grow in the bladder or bowel, or endometrial tissue is found in the deeper muscular layers of the uterus.
Despite its potential effects, endometriosis doesn't automatically mean infertility. Many women can still conceive naturally, without medical intervention. What matters most is the severity of the condition and, above all, where it's located.
A personal assessment is therefore essential. In this case, a gynaecologist will examine the patient carefully and outline suitable treatment options. Even if a woman can't conceive naturally because of her endometriosis, in vitro fertilisation (IVF) offers a promising alternative. In IVF, fertilisation takes place outside the body, and thanks to modern methods, success rates continue to improve.
Early detection is also crucial in cases of endometriosis.
As a general rule, the earlier endometriosis is diagnosed and treated, the less damage it can cause. Whether pregnancy is realistic depends directly on the stage of the condition. If medication can slow its progression, or if surgery can remove endometrial lesions, this creates favourable conditions for a pregnancy. However, if the fallopian tubes are already blocked, the chances decrease.
Previous efforts to conceive also play a role in the gynaecological assessment:
The anti-Müllerian hormone level also provides valuable insight. It indicates the size of a woman's remaining egg reserve. This measure is relevant for all fertility treatments, regardless of whether insemination or assisted reproduction such as IVF is performed. It also helps doctors assess the likelihood of natural conception more accurately.
In general, pregnancy progresses much the same as it does in women without the condition. Due to hormonal changes during pregnancy, it's often been observed that symptoms of endometriosis improve afterwards. This doesn't mean, however, that the condition or the symptoms it causes will automatically disappear afterwards.
Many women with the condition often face greater emotional challenges, especially if they've already gone through several unsuccessful attempts to conceive. Doctors therefore provide not only medical expertise but also the necessary empathy and can be of vital support during this uncertain time.
The risks during pregnancy depend largely on the severity and type of endometriosis.
Women with endometriosis aren't alone in their concerns and uncertainties. Complications during pregnancy or childbirth can also occur in women without the condition. In those with endometriosis, the level of risk depends largely on the severity and type of the disease. For example, severe tissue adhesions raise the likelihood of an ectopic pregnancy. In such cases, the embryo can't reach the uterus due to impaired function of the fallopian tube and instead implants in the tube itself, where it's unable to develop further. This leads to complications and requires treatment, either with medication or surgery.
If a woman has adenomyosis, the risk of miscarriage may be increased. In this form of the condition, tissue that normally lines the uterus is found within the uterine muscular wall, which can cause symptoms such as pain. Placenta praevia is also somewhat more common in this type of endometriosis; this is where the placenta grows low in the uterus and covers the birth canal. If the birth canal is completely blocked, delivery can only take place via Caesarean section. Other less common complications include rupture of ovarian cysts, ovarian torsion, or a uterine rupture.
Increased blood loss is possible. In cases of very advanced endometriosis with extensive adhesions, performing a Caesarean section can be more challenging. However, it's important not to generalise. As mentioned earlier, the condition has many different forms, and those affected should not assume they will automatically face a high-risk birth.
Ultrasound is often enough to produce a reliable endometriosis diagnosis. In some cases, an MRI scan is still needed, and more rarely, surgery.
Routine assessments include hormone analysis and a gynaecological ultrasound. This can show, for example, whether ovarian cysts are present. It's also essential for the gynaecologist to check whether the fallopian tubes are open or blocked. As these tubes are very thin organs, they're not usually visible on standard ultrasound. To assess them, a contrast fluid is introduced into the uterus. Ultrasound can then show whether the fluid passes through the tubes, indicating that they are open.
Patients often ask: When is laparoscopy used in endometriosis? This minimally invasive procedure is performed when symptoms are severe or when there is uncertainty about the condition of the fallopian tubes. Laparoscopy serves not only as another diagnostic tool but also allows endometrial lesions to be removed at the same time.
As long as the fallopian tubes are open and the results of further tests (including those of the partner) allow, intrauterine insemination (IUI) can be performed. In this procedure, ovulation is triggered by injection and a prepared sperm sample is then introduced directly into the uterus.
A distinction is made between insemination and assisted reproduction. The latter includes 2 main methods:
If the fallopian tubes are blocked, IVF or ICSI is used.
The decision as to whether endometriosis surgery is advisable must be assessed on a case-by-case basis.
Deciding whether surgery is advisable requires an individual assessment. It's usually recommended when symptoms are severe and drug treatments have had little or no success. If adhesions have impaired the function of the fallopian tubes, endometriosis surgery may help to restore them by releasing these adhesions.
There are various hormonal therapies, and the key distinction is whether the patient wishes to conceive. If pregnancy is not desired, options include specific medication for endometriosis, the contraceptive pill or a hormonal intrauterine device. It's important to assess any risks that might rule out hormonal treatment.
When trying to conceive, treatment with progesterone (luteal hormones) may be used. These can help reduce the inflammatory processes associated with endometriosis.
Medicine has made significant progress in helping women with endometriosis achieve pregnancy and several options are now available: medication, endometriosis surgery to remove lesions or assisted reproduction. Depending on the type and severity of the condition, doctors may also consider a combined approach. This can create favourable conditions, and in many cases, natural conception is possible.
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