Many people with endometriosis worry about whether they will be able to get pregnant.
Endometriosis is a condition where tissue that's similar to the lining of the womb begins to grow in other places, commonly in the ovaries or the fallopian tubes. Over the years, both campaigners and medical experts have called for more attention to be given to the disease as it's famously slow to diagnose, but it's predicted that 1.5 million women (opens in new tab) in the UK have endometriosis and it can have serious health consequences in the long run if it's left undiscovered.
Our expert consultant gynaecologists, Mr Denis Tsepov and Mr Shaheen Khazali say that many women find out they have endometriosis after struggling to get pregnant (opens in new tab) as this is one side effect of the condition.
- How does endometriosis affect pregnancy?
- How does endometriosis affect fertility?
- What are your chances of getting pregnant with endometriosis?
- How can I get pregnant with endometriosis?
- Ectopic pregnancy and endometriosis
- Endometriosis stages and infertility
- Seeking help for endometriosis and pregnancy
How does endometriosis affect pregnancy?
Endometriosis may increase particular risks during pregnancy and may cause complications during the child's birth. This could be linked to inflammation caused by endometriosis, damage to the muscle of uterus or hormonal influences.
Mr Denis Tsepov, consultant gynaecologist, laparoscopic surgeon and clinical lead at from The Harley Street Endometriosis Centre (opens in new tab), says, “Endometriosis can also affect the muscle of the uterus – myometrium and this is associated with higher risk of early miscarriage. This condition is called Adenomyosis.
“Presence of endometriosis increases the risk of ectopic pregnancy and risk of early miscarriage. It can also complicate pregnancy during later stages."
Mr Shaheen Khazali says other risks include "preterm birth, the need for caesarean section (opens in new tab) and low-lying placenta".
It is important to note, however, that the overall risk is thought to be low. "It should not be a cause for concern," Mr Khazali, consultant gynaecologists at The Lister Hospital (opens in new tab), says. “Pregnancy affects women in different ways; most women find that their endometriosis symptoms lessen when they fall pregnant, due to raised levels of progesterone and because they are no longer having periods (opens in new tab).”
However, this reduces the painful symptoms of endometriosis in the short term - rather than cures the condition permanently. Research published in the Human Reproduction Update in 2018 (opens in new tab) suggests that there's "fewer beneficial effects than previously reported" and little evidence that getting pregnant definitely reduces or gets rid of endometriosis symptoms in the long term.
Although some do discover that their symptoms are less severe (opens in new tab) than they were before, many women find that the condition comes back after their pregnancy and after they stop breastfeeding (opens in new tab).
How does endometriosis affect fertility?
As Mr Denis Tsepov says, "For example, endometriosis can cause scarring and inflammation which can block fallopian tubes. It can also affect the ovaries with endometriotic cysts. This can decrease the reserve of the ovary – in other words, the number of eggs available for fertilisation.
"Alongside this, endometriosis can create a rather hostile biochemical environment in the pelvis, which can make natural conception difficult."
However because of a lack on the subject, the connection between fertility problems and endometriosis isn't completely clear. Advanced stages of endometriosis that affect the ovaries or the fallopian tubes are likely to have an impact on fertility. Other types won't affect the ability to conceive all that much.
And importantly, not all women with endometriosis experience fertility problems. Some will be able to get pregnant without any medical intervention. Despite the risk of endometriosis to the reproductive system in more advanced stages, research from endometriosis experts Professor Andrew Horne and Carol Pearson (opens in new tab) suggests that 60 to 70% of women with the condition are still able to get pregnant "naturally and without a problem”.
What are your chances of getting pregnant with endometriosis?
It's estimated that anywhere between 30% to 50% of women with endometriosis have issues getting pregnant, according to various sources.
The leading charity for the condition in the country, Endometriosis UK, says that 60% to 70% of women (opens in new tab) with endometriosis will be able to get pregnant without any medical intervention or difficulty. The main determining factor for pregnancy, according to the organisation, is age.
"A woman is born with a lifetime supply of eggs that undergo maturation monthly once she has reached puberty," they say. "Fertility rapidly declines after the age of 38 both due to the rate at which the egg sacs disappear from the ovaries accelerating and due to increased rates for miscarriage and chromosomal abnormalities."
In the earlier research, doctors studied 197 women who had been diagnosed with infertility. Out of the almost 200 people, 68 were diagnosed with endometriosis. 59% had primary infertility, where pregnancy has never been achieved. 41% had secondary infertility, the inability to become pregnant or carry a baby after previously giving birth.
How can I get pregnant with endometriosis?
Up to 50% of infertile women have endometriosis and it can affect fertility in many ways. So those with endometriosis who are looking to get pregnant may need more help to do so.
"I would strongly recommend that women who have endometriosis discuss their desire to get pregnant with their specialist earlier rather than later," says Mr Denis Tsepov. "A lot can be done before pregnancy to try and improve the outcome."
Visit your endometriosis specialist before trying to get pregnant
"It would be extremely useful to know the severity and location of endometriosis and state of the fallopian tubes. Possible involvement of the overies and uterine muscle before pregnancy is considered. Sometimes only fertility treatment - sparing excisional surgery for endometriosis before pregnancy - can make either natural conception or assisted fertility possible," Mr Tsepov says.
In vitro fertilisation (IVF)
Our expert says that "very often women with endometriosis require IVF to get pregnant."
"Therefore, fertility options discussed with an endometriosis or fertility specialist before pregnancy will allow couples to understand how they can optimise their chances of conceiving. Furthermore, this will often save time, money, and minimise stress."
However, studies (opens in new tab) have shown that women with moderate to severe endometriosis struggle to conceive with IVF and they have a lower chance of being successful.
“If you suffer with endometriosis and you have been trying to conceive for 12 months and you have been unsuccessful, you should speak to your doctor to discuss your options,” Mr Khazali suggests.
Take folic acid
This is essential while trying to get pregnant and during early pregnancy, Mr Tsepov says.
"There is also some promising scientific data suggesting that the use of low dose Aspirin - and possibly Progestagens - in early pregnancy will help minimise the risk of miscarriage."
But he adds, "These options are not universally suitable for everyone. They have to be individually discussed with an endometriosis specialist."
Get an early ultrasound scan
“Additionally, women with endometriosis who become pregnant can benefit from an early ultrasound scan and early antenatal care with increased level of foetal wellbeing monitoring during all three trimesters of their pregnancy," Mr Tsepov says.
“These patients are best looked after in “high risk antenatal clinics” by experienced obstetric consultants and midwives. The decision where to deliver the baby – either on a midwifery led unit or on high-risk delivery suite – should be discussed individually with an obstetric consultant with risks balanced versus benefits.”
Ectopic pregnancy and endometriosis
Mr Tsepov says, "Presence of endometriosis increases the risk of ectopic pregnancy and risk of early miscarriage and can complicate pregnancy during later stages."
An ectopic pregnancy is when a fertilised egg implants itself outside of the womb, often in the fallopian tubes. These tubes connect the ovaries to the womb. So when an egg gets stuck in them, it can't develop into a baby.
"According to data analysed and presented by ESHRE (opens in new tab) - European Society of Human Reproduction and Embryology, the risk of an ectopic pregnancy is increased from 0.6% normally to 1.6% with endometriosis," he says.
The risk of ectopic pregnancy is relatively low in the general population, with 1 in 90 pregnancies in the UK becoming ectopic. However, as consultant gynaecologist and laparoscopic surgeon, Mr Tsepov, says, this risk is more than doubled in women who have been diagnosed with endometriosis. This is because the condition can produce tissue and even adhesions. These interfere with the journey of the fertilised egg to the uterus.
Unfortunately, the NHS says, it's not possible to save a pregnancy that's ectopic. Doctors use medicine or an operation to remove it.
Endometriosis stages and infertility
The American Society of Reproductive Medicine has classified the stages of endometriosis to better understand the condition. These are:
- Minimal - Stage One
- Mild - Stage Two
- Moderate - Stage Three
- Severe - Stage Four
What stage of endometriosis someone is at depends on the location, depth, size and amount of endometrial issue they have. This specifically includes how far the tissue has spread. As well as what involved pelvic structures and the extent of any pelvic adhesions. Plus, any blockage of the fallopian tubes.
However, according to Johns Hopkins Medicine (opens in new tab), these stages of endometriosis may not reflect the level of pain that someone is experiencing - or their fertility. They say that it's entirely possible for a woman with stage one endometriosis to be in enormous amounts of pain. And someone in stage four may be completely asymptomatic.
Medical studies suggest that it's only when the person with endometriosis undergoes surgery that their risks of infertility change.
For example, there is research (opens in new tab) that shows pregnancy rates may improve in people with stage one or two endometriosis if the tissue is removed via laparoscopic surgery. While a wider review (opens in new tab) on the subject has concluded that pregnancy rates are higher after surgery for those who have stage three or four endometriosis.
In all cases, speak to your endometriosis specialist if you have any concerns about the condition and getting pregnant.
Seeking help for endometriosis and pregnancy
All our experts say the best place to seek help with pregnancy if you have endometriosis is an endometriosis specialist.
Visit your GP who will be able to refer you to a specialist as part of the NHS. Alternatively, you can visit a private specialist, such as those at HCA Healthcare UK (opens in new tab) - of which The Harley Street Endometriosis Centre and The Lister Hospital are a part of.
As well as medical support, you might find that help through a support group is useful. Endometriosis UK (opens in new tab) offers general information and advice for those with the condition, along with a directory of local support groups.
They also have a helpline (0808 808 2227) and an online community for women who have the condition.