According to the World Health Organisation, endometriosis affects approximately 10% of women of reproductive age globally. Among the adverse effects experienced by those suffering from endometriosis, fertility issues stand out as one of the most distressing symptoms. However, equipped with accurate information on how to manage symptoms as well as the treatment options available, women can reduce the impact that the disease has on their lives and their dreams of starting a family.
This is the message of hope that gynaecologist, Dr Abri de Bruin, wishes to share with South Africans in honour of International Endometriosis Awareness Month. Dr de Bruin is the Senior Medical Director of Genesis Reproductive Center, and heads up Mediclinic Kloof’s dedicated multidisciplinary endometriosis unit, which currently has the most modern theatre in the southern hemisphere.
In his opinion, awareness campaigns that highlight the prevalence of endometriosis and the importance of reproductive health are vital in curbing the effects of this “21st century disease.”
As he elaborates: “Endometriosis is definitely more prevalent today than it was 20 years ago and is becoming increasingly prevalent in younger women. Experts attribute this rise to factors such as increasing stress levels as well as the kinds of hormones contained in the foods we eat.
Furthermore, studies have shown that in South Africa – and Africa at large – the prevalence of endometriosis has been largely understated, due to high diagnostic costs, lack of information and underdeveloped healthcare infrastructure. While the medical community has not yet pinpointed the exact reason why endometriosis grows in certain individuals, we are now infinitely more knowledgeable on how it presents in different women and how to treat it in the least invasive way.”
Endometriosis and the causes of fertility issues
Endometriosis is a condition where the cells that form the lining of the uterus grow outside the uterus. Symptoms of endometriosis vary from person to person but commonly results in painful periods, chronic pelvic pain and pain during intercourse. In many cases, the impact of the disease on reproductive health is often the most pronounced, given that issues such as infertility, difficulty with conceiving and the impact on one’s quality of life can be emotionally and mentally devastating.
According to Dr de Bruin, endometriosis can cause infertility if it results in adhesions (scar tissue) that cause the ovaries and fallopian tubes to get stuck together or the ovaries to get stuck to the pelvic sidewall. This prevents fertilisation from taking place. In instances where the endometriosis occurs inside an ovary, it can prevent or decrease the chances of ovulation or the production of eggs, which in turn, makes it more difficult to conceive. Furthermore, if endometriosis grows inside the uterus and penetrates the uterine wall, this results in a condition called adenomyosis, which adversely impacts the implantation of the embryo in the uterus. Lastly, if endometriosis forms inside the pelvis, it creates what’s known as a hostile environment that reduces the quality of the egg that gets formed. This in turn, impacts the function of the fallopian tube to pick up the egg, affecting fertilisation, the development of the embryo and implantation.
However, as Dr de Bruin asserts: “Having endometriosis doesn’t automatically mean that you can’t fall pregnant or that you must have in vitro fertilisation (IVF). This is because endometriosis occurs in four stages, ranging from minimal to severe. Each stage has a different impact on infertility, yet even patients with stage four endometriosis can conceive without medical intervention. The encouraging news is that there are various treatments and strategies that can help sufferers of endometriosis to increases their chances of falling pregnant.”
Effective treatment options
Elaborating on this, Dr de Bruin explains that treatment is tailored to patients based on whether they present with only pain, only infertility or both pain and infertility. “This is a very important differentiation to make. For example, if a patient doesn’t have any symptoms except infertility, and endometriosis is found by means of an ultrasound, then fertility treatment can be initiated without performing surgery.
However, if a patient presents with both infertility and pain, then we need to perform surgery to treat the endometriosis. This is because even if a patient manages to conceive, her quality of life can still be diminished by the disease. And if she cannot conceive, surgery to remove the endometriosis can boost her chances of falling pregnant,” he says.
Explaining how surgery addresses infertility, Dr de Bruin says that no open surgery is ever indicated for endometriosis. Instead, the procedure is laparoscopic; or minimally invasive, and excisional, involving the removal of the diseases tissue from the body. For example, if the patient’s endometriosis causes adhesions, surgery can remove this tissue to restore a normal relationship between the fallopian tube and the ovary, which increases the chance of falling pregnant. Likewise, if the endometriosis is removed from inside the ovary, it will have no more impact on the quality of the egg. Furthermore, removing endometriosis in the pelvis, also takes away the hostile environment it creates.
Based on his experience, Dr de Bruin concludes with these encouraging statistics. “Even in patients with stage four endometriosis, the chance of falling pregnant are more than 60% either following surgery, or IVF, or a combination of the two.”
