Fertility treatment for endometriosis – ask the experts

Diagnosed with endometriosis, or suspect you might have it?

This Endometriosis Awareness Month, we caught up with Dr Marco Gaudoin, Medical Director at TFP GCRM Fertility, to chat through treatment options, fertility care possibilities, and to get your questions answered.

Lifting the lid on fertility treatment for endometriosis

Get notes and insight on:

• Treating and supporting endometriosis
• Stages of endometriosis and how they can each impact fertility
• Timelines, age and when to begin fertility treatment

We also cover the process of fertility treatment for endo, including:

• Fertility treatment for endometriosis risks and success stories
• Tailoring treatment with co-occurring conditions like PCOS and fibroids
• And much more

Whether it’s with Dr Marco Gaudoin in Glasgow or another of their world-leading team from across the UK, find out more about endometriosis with expert fertility support.

Connect with TFP Fertility to book a consultation today.

Transcript

Eloise Edington 

Hello, good evening, and welcome to those who are joining. I’m Eloise, the founder and CEO of The Ribbon Box, and we are delighted to be speaking this evening with Marco Gaudoin, Medical Director at TFP Fertility. 

Welcome, and thank you so much for joining myself and our registrants today to talk about treatment options for endometriosis. We’ve had some great questions come in, and since March is Endometriosis Awareness Month, this discussion is especially timely. We very much appreciate your expertise this evening. Please do introduce yourself.

Marco Gaudoin

Good evening, ladies and gentlemen. As Eloise introduced me, I’m Marco Gaudoin, the Medical Director at TFP GCRM in Glasgow, but we have clinics throughout the UK. I’m an obstetrician and gynecologist. I set up GCRM in 2006 with Professor Richard Fleming, who is a world-renowned IVF scientist. Richard developed the original long protocol back in 1982, at the very inception of IVF, but he then moved on to develop IVF further. GCRM pioneered what has been adopted globally as individualized stimulation protocols, aimed at minimizing the risk of OHSS and maximizing pregnancy rates. That approach has been adopted globally.

I’m not going to talk about that today because we are talking about endometriosis. Just a background about me, really. The definition of endometriosis is endometrial tissue, the lining of the womb, occurring in sites other than the uterine cavity. This is what’s called ectopic endometrium. It’s occurring somewhere it shouldn’t, but that endometrium still responds to the same hormonal changes that happen throughout the menstrual cycle. When you have a menstrual bleed, that ectopic endometriosis bleeds as well. Blood that’s meant to be in a blood vessel is no longer in a blood vessel, causing pain and scarring.

Scarring can occur anywhere, and if it occurs on the fallopian tubes, it affects their function. Endometriosis also affects egg quality and the chemicals it produces can impair sperm motility, preventing them from swimming well. It also affects the function of the fallopian tubes and the cilia that help move the egg.

How does endometriosis happen? Pathogenesis is the term for how something happens pathologically. There are three theories. The first is the implantation theory, where the endometrium from the lining of the womb flows backward along the fallopian tube and implants in the pelvis. The second is the theory of coelomic metaplasia, which explains why endometriosis can occur in other areas beyond the pelvis, such as the lungs or throughout the body. 

Rarely, even men can get endometriosis. Men don’t have a uterus, but coelomic metaplasia explains this occurrence. The third theory is lymphatic and vascular dissemination, where endometrial cells spread through blood or lymphatic vessels. However, this theory doesn’t explain endometriosis in men. Personally, I favor the coelomic metaplasia theory.

Endometriosis can manifest as minimal disease with few symptoms or minimal staging with profound pain. Symptoms can include secondary dysmenorrhea (painful periods caused by endometriosis), chronic pain, backache, dyspareunia (painful intercourse), rectal pain, rectal bleeding, and heavy, painful periods. The impact on fertility is significant. 

Endometriosis is graded from stage one to stage four using the Revised American Fertility Society (RAFS) scoring system. Stage one involves minimal disease, such as in the pouch of Douglas. Stage four involves severe disease affecting the ovaries, fallopian tubes, and bowel.

Another scoring system is the Endometriosis Fertility Index (EFI), developed in 2010, which predicts natural conception chances after surgery. However, it’s not widely used due to limited research.

Here are some pictures showing endometriosis. Stage one disease shows small spots of endometriosis. More extensive disease includes flame-like vesicles, increased vascularity, and bleeding in the pelvis. An endometrioma, or an endometriotic cyst in the ovary, can progress to stage three disease.

Management depends on individual needs. Pain relief is crucial for functioning day-to-day. Analgesics like ibuprofen or mefenamic acid can help without affecting fertility. Hormonal suppression is effective for controlling pain but is contraceptive, so it’s not suitable for those trying to conceive. Treating endometriosis is complex. Surgical options include burning away superficial disease with diathermy or laser or excising deeper disease. Removing an endometriotic cyst (cystectomy) may remove good ovarian tissue, impacting fertility. In severe cases, pelvic clearance may be necessary.

The risks associated with cystectomy include removing good ovarian tissue while trying to remove the endometrioma. This presents a dilemma: you want to maximize fertility while minimizing the removal of healthy ovarian tissue. At the same time, you want to address symptoms, but doing so often requires removing some good ovarian tissue. This creates a challenging balance. In severe cases, the entire ovary might need to be removed (oophorectomy), and in extremely severe cases, pelvic clearance is required. This involves removing the ovaries, womb, and as much endometriosis as possible.

When it comes to infertility treatment, options include medical suppression of endometriosis, surgical treatment, ovulation induction, and IVF or ICSI if the sperm count is low. I will cover each of these.

First, for medical suppression, you can use the pill, progestogens like dienogest, or GnRH analogues. These are very effective at suppressing endometriosis. However, GnRH analogues, while effective, have significant menopausal-like side effects. The issue with all of these treatments is that they are contraceptive and, therefore, unsuitable for those trying to conceive. These treatments are great for managing pain but not helpful for achieving pregnancy.

Some people have suggested using the pill for six months and then trying naturally, but studies have shown this is not beneficial. It only delays trying to conceive, which is counterproductive since age significantly impacts fertility. The longer you wait, the lower your chances of success.

The European Society of Human Reproduction and Endocrinology (ESHRE) advises against using these medical treatments for subfertile patients. These treatments are suitable if you’re trying to manage pain or suppress the disease but not if you’re actively trying to conceive. Post-surgery, if you’re not trying to conceive immediately, medical treatments can suppress the disease. 

For early-stage disease (stage I or II), surgery using diathermy or a laser can destroy superficial endometriosis. If the fallopian tubes are unaffected, couples may try to conceive naturally, assuming the male partner has a normal sperm count. In selected cases, this approach may be effective.

If there is an endometriotic cyst, it can be drained laparoscopically. However, drainage does not treat the endometriosis; it simply empties the cyst, which often recurs. Endometriotic cysts are also known as chocolate cysts because the contents resemble melted chocolate. Stripping the endometrial lining from the ovarian capsule can be attempted, but this often removes healthy ovarian tissue, which negatively impacts fertility.

A newer approach is sclerotherapy, which involves using alcohol to destroy the endometriosis. Alcohol is injected into the endometrioma via a catheter to destroy the tissue. Sclerotherapy has been used in other surgeries, such as for varicose veins. Endometriosis is vascular, so destroying its blood vessels can be effective. However, sclerotherapy is not widely used and lacks extensive data on subsequent natural conception. Despite this, it appears to preserve ovarian tissue better than excision.

These treatments, whether performed in the NHS or privately, aim to provide symptomatic relief. Unfortunately, there is little data to suggest they improve natural conception rates. Waiting lists for NHS treatments in some areas, such as Glasgow, are extremely long, often taking up to two years for an outpatient appointment, let alone surgery. As a result, many patients turn to private care.

In my practice, I do not advocate for drainage because it tends to recur. Excision is preferable but should be as conservative as possible to minimize the removal of healthy ovarian tissue. Removing too much ovarian tissue reduces anti-Müllerian hormone (AMH) production, which negatively affects IVF outcomes.

Sclerotherapy, while not widely used in the UK, holds promise and should be explored further. It provides symptomatic relief, but its impact on natural conception remains unclear. For patients experiencing significant pain from endometriomas, surgery may be necessary, but the risks to fertility must be carefully considered.

When it comes to fertility treatments, if the disease is mild (stage I or II) and the fallopian tubes are open, intrauterine insemination (IUI) may be an option, particularly for single women or same-sex couples using donor sperm. For heterosexual couples with open tubes, IUI has not been shown to be more effective than trying naturally.

For moderate to severe disease (stage III or IV), IVF or ICSI is often the best course of action. IVF involves daily hormone injections for approximately ten days to stimulate the ovaries, followed by egg retrieval. The eggs are then fertilized in the lab and developed into embryos, ideally reaching the blastocyst stage on day five before transfer to the uterus.

Outcomes for women with endometriosis are less favorable compared to those without the condition. Egg yields are often lower, and implantation rates are reduced. Even with donor eggs, implantation rates for women with endometriosis are often lower. Overall, live birth rates decline with increasing severity of endometriosis.

A common concern is whether infertility treatments worsen endometriosis. The answer is no. IVF stimulation is short-lived, and although estrogen levels rise, they do not worsen the disease. Pregnancy itself suppresses endometriosis due to high progesterone levels.

In summary, endometriosis is ectopic endometrial tissue, commonly found in the pelvis. Its cause remains debated, though celomic metaplasia is a leading theory. The disease is graded from stage I (mild) to stage IV (severe). Medical suppression has no place in fertility treatment as it only delays progress, and age is the greatest enemy of fertility.

Surgery can help with pain but is not a definitive solution for fertility. Insemination may be useful for mild disease in women using donor sperm but is not effective for more severe cases. For moderate to severe disease, IVF is the standard treatment.

Women who don’t have endometriosis, unfortunately, endometriosis is not good news for fertility. Having said that, millions of women with endometriosis have had babies, so if you have endometriosis, you shouldn’t despair because it can still happen for you. 

Eloise Edington 

Thank you very much, Marco. That was very thorough and useful, especially with the imagery provided.

Marie has asked how far we are from more modern treatments becoming routine in the UK and whether anywhere in Europe is offering this. 

Marco Gaudoin

If you’re referring to scar therapy, the answer is I don’t know. It’s not used in Glasgow, as far as I know. It originated in Germany and is spreading across Europe. Some places in London may offer it. If you have severe endometriosis, seek out a gynecologist with a proven track record in endometriosis surgery. There is an endometriosis service in Glasgow, but the waiting times are massive unless you go privately. Even then, waiting times are long because so many people are opting for private treatment.

Eloise Edington 

Why does it take so long to diagnose endometriosis? Many people report waiting eight to ten years or more. 

Marco Gaudoin

Traditionally, endometriosis was thought to be a disease of older women. There are predisposing factors like increasing age, fewer pregnancies, and genetic predisposition—if your mother or sister had it, you’re more likely to have it. However, risk factors are often unrecognized, and symptoms are dismissed as primary dysmenorrhea, which is common in young women. It’s often treated with nonsteroidal anti-inflammatory drugs or contraceptive pills without further investigation. Diagnosis requires a laparoscopy, which is a surgical procedure requiring general anesthesia, leading to delays in the NHS due to waiting times.

Eloise Edington 

Can you advise what women should tell GPs to access services more quickly? 

Marco Gaudoin

A good approach is to express concern about potentially having endometriosis, highlight its impact on fertility, and request a referral. Mentioning symptoms and the impact on fertility can help emphasize the need for a prompt diagnosis, as addressing it sooner prevents further decline in fertility.

Eloise Edington 

So, what is the relationship between AMH and endometriosis? 

Marco Gaudoin

Women with endometriosis tend to have lower AMH levels because endometriosis on or near the ovary damages ovarian tissue, destroying follicles that produce AMH. Endometriomas are even more destructive. Surgery can further reduce AMH levels if healthy ovarian tissue is removed.

Eloise Edington

Can severity of endometriosis only be determined through laparoscopy? 

Marco Gaudoin

Yes. While a large endometrioma may indicate stage 3 disease, a laparoscopy is required to see structures like the fallopian tubes, scarring, or the pouch of Douglas. It is the gold standard for diagnosis and staging.

Eloise Edington 

Would that be required prior to fertility treatment? 

Marco Gaudoin

No. For example, with an endometrioma, you may already know it’s stage 2 or 3 disease and proceed directly to IVF. Surgery may address pain or remove an endometrioma, but it doesn’t directly improve fertility.

Eloise Edington 

When people are having a cycle of IVF, would you predict that there may be fewer eggs retrieved and fewer embryos developing? 

Marco Gaudoin

The answer to that is yes, unfortunately. We know that women with endometriosis tend to have lower AMH levels for the reasons I’ve mentioned, so you get fewer eggs. But it’s not just that. The impact of endometriosis, particularly the chemicals it produces, has a detrimental effect on egg quality, which means that embryo development is compromised. So, you do tend to get fewer embryos, which in turn means that overall, you get fewer embryos and, ultimately, fewer babies.

Eloise Edington 

Does it affect implantation rates as well? 

Marco Gaudoin

As I mentioned, endometriosis per se doesn’t if you’re using donor eggs. We know that women using donor eggs who have endometriosis have the same implantation rates as women using donor eggs who don’t have endometriosis. There’s great data from Spain—some of you may know that Spain has a huge egg donation program—so they have fantastic data sets on conditions like this. Because their data sets are so large, the data is really quite robust.

Endometriosis itself doesn’t affect implantation. It’s the impact it has on sperm function in natural conception and the impact it has on egg quality, whether with natural conception or IVF.

Eloise Edington 

After surgery, is there anything we should know in terms of risks, recovery time frame, conception after surgery, or assisted conception after surgery? 

Marco Gaudoin

It depends on the extent of the surgery, but really, what you want to do is have fertility treatment as soon as possible after the surgery. Sadly, endometriosis just marches on, and the longer you leave it, the more likely it is to recur. So, it depends on how much surgery you’ve had and the recovery thereafter, but the sooner you can have fertility treatment after the surgery, the better.

Eloise Edington 

That makes complete sense. Does this affect the chances of conception, like you just mentioned? If you leave it, is it going to come back? Could it potentially come back worse than it was before? 

Marco Gaudoin

It won’t come back worse; it’ll just come back as it was, as it marches on. As I said, just simply draining an endometrioma will mean that the endometrioma is going to come back again. You want to either ablate it using cautery or strip it out if you can, but certainly, stripping it out means you remove good ovarian tissue as well.

Eloise Edington 

Could endometriosis ever resolve itself and just stop? Or would something like pregnancy slow it down or stop it for the nine or ten months you’re pregnant? 

Marco Gaudoin

Certainly, pregnancy does suppress endometriosis because you’ve got high progesterone levels throughout the course of pregnancy. So, it does suppress the endometriosis. The only thing that ultimately stops endometriosis is menopause because then you don’t have the monthly hormonal stimulation from estrogen that causes the endometriosis to proliferate.

Eloise Edington 

That’s why people, I presume, get put on the pill or a progesterone pill to decrease the effects of endometriosis. 

Marco Gaudoin

Absolutely, yes. That’s why people get put on GnRH agonists as well because that essentially makes you menopausal—albeit temporarily—for the time you’re on the agonist. But you get all the flushes and sweats and things associated with menopause. However, agonists are the most effective treatment from a pain point of view. The problem is that they stop ovulation, so you can’t get pregnant while on them.

Eloise Edington 

Would you suggest that people who may think they have endometriosis or have been diagnosed look at freezing their eggs if they’re not ready to have a child at that moment? 

Marco Gaudoin

I would recommend all young women who want to have a child freeze their eggs. The average age of patients in my clinic is over 38, and I have so many patients who say, “I wish I’d frozen my eggs when I was younger because now my eggs aren’t as good.”

The problem is that egg freezing, while it’s a great technology, is expensive. When you’re young and your eggs are at their best quality, you often don’t have the money to freeze them. Egg freezing will never be offered on the NHS because it’s considered a kind of lifestyle choice. Previously, we used slow freezing for egg freezing. The problem with slow freezing is that the human egg, being the largest cell in the body at about 100 micrometers in diameter, is full of water. When you freeze it slowly, the water swells and damages the egg.

Now, with vitrification, a different method of freezing where you essentially remove the water from the egg, you can freeze eggs without damaging the organelles. When you thaw the eggs, you reverse that process, and the egg is much more viable. 

On average, it takes about 17 eggs to make a baby naturally. With vitrified eggs, it takes about 18 eggs, so it’s virtually the same. You want to freeze your eggs when you’re young and, if necessary, use them when you’re older. Vitrification has really changed the game with egg freezing.

The issue, again, is the expense. The ideal time to freeze eggs is in your mid to late 20s, but most women in that age group don’t have the money to do it.

Eloise Edington 

And as you just mentioned, you might need to do a couple of cycles to get that quantity of eggs? 

Marco Gaudoin

Yes, absolutely.

Eloise Edington 

Thank you, Marco. This has been so helpful. Is there anything you want people to know or consider now for Endometriosis Awareness Month, or just generally, day-to-day, with family planning and fertility treatment? Any parting thoughts in terms of people seeking help and making that first step? 

Marco Gaudoin

I keep coming back to it: age is the biggest factor in fertility treatment. So, sooner rather than later is always the mantra.

Eloise Edington 

Brilliant. Thank you, Marco, so much for this amazing advice you’ve given us this evening. Thank you, everyone, for joining. We look forward to speaking with you again soon. Thank you very much, everyone, for logging in.

Marco Gaudoin

All right, thanks a lot. Bye-bye. Cheers now. Bye.

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