Endometriosis remains one of the most enigmatic diseases affecting fertility. Approximately 5-10% of reproductive age women experience this condition. Despite its prevalence, diagnosis remains difficult. Many women aren’t diagnosed with endometriosis until 4-11 years after their first evaluation. Part of the reason for the difficulty in diagnosing this condition is how variably it presents. Some women experience painful periods or even daily pelvic pain, others may have prolonged periods, and still others may have no symptoms at all. Another reason for this difficulty in diagnosis is that definitive diagnosis requires surgery (which is generally laparoscopy) and obtaining a biopsy of any lesion suspicious for endometriosis.
Compounding the difficulty in diagnosing this condition are the profound effects this has on a woman’s reproductive life. This ranges from painful menstrual periods to even daily debilitating pelvic pain which can drastically impact a quality of life. It can lead to scarring inside the belly which can affect neighboring organs including bowel and bladder. Additionally, it can also lead to infertility. Endometriosis is also associated with both prolonged menses and unpredictable intermenstrual bleeding which has substantial implications when factoring in a woman’s status as a niddah (more on this later).
Treatment of endometriosis is a goal-dependent endeavor. If a woman’s goal is pain control and better regulation of her cycle, then a whole spectrum of medical treatments are available. These include oral contraceptive pills, progestin pills, intrauterine devices, injectable and oral suppressive medications (e.g. Leuprolide, Elagolix, Relugolix, etc.). However, if the aim is to conceive, then these medications generally cannot be used. Surgery to reduce the amount of endometriosis lesions can be done and has been shown to improve fertility rates. Yet, if the patient is not planning to become pregnant shortly after the surgery, one of the above medical therapies needs to be started to prevent recurrence of the endometriosis.
When considering how to treat endometriosis, the issue of conception must be considered with careful incorporation of essential halacha. Since the pattern of menstrual bleeding will affect whether a woman is niddah, any irregular or prolonged bleeding due to endometriosis can drastically affect a couple’s chance to be together and try to conceive. If the niddah status and mikvah immersion are prolonged and delayed, respectively, due to an irregular bleeding pattern this could force the couple to miss being together during the optimal conception window, that is shortly before ovulation. Numerous treatments could address the issue. We can use low doses of estrogen at the start of the cycle to both shorten the bleeding time and delay ovulation. Ovulation can also be delayed using a short course of Clomiphene Citrate (aka Clomid).
It should also be noted that surgery could also play a beneficial role and increase the time span during which a couple could have relations and try to conceive. By excising any visible endometriosis and potentially reducing the level and duration of pain experienced prior to menses, or hargasha, this could reduce the time a couple should abstain while the woman is observing an onat perishah (period of separation). Surgery most often takes the form of a laparoscopy in which two-four small incisions are made and all visible endometriosis is either excised or destroyed and any scar tissue is removed to the safest extent possible. The vast majority of patients recover quickly and most experience some improvement in symptoms.
Now if a couple has been trying consistently to conceive for one year (or six months if the woman is 35 and over), this will require more aggressive therapy to address their infertility. Endometriosis has been observed in 30-50% of women with infertility and their treatment generally takes a more focused course. Many women with less extensive endometriosis will start with ovarian stimulation, often starting with Clomiphene, and intrauterine insemination (IUI).
However, for later stage endometriosis, in-vitro fertilization (IVF) will likely be the recommended course. It must be noted that patient age and medical history will also influence the choice of treatment. Numerous studies have recommended pre-treatment with agents like Leuprolide for a few months prior to the start of an IVF to maximize outcomes. These agents serve to reduce the level of estrogen which can help reduce the size and number of endometriosis lesions.
Additional medical therapies are on the horizon that could possibly help a woman with endometriosis conceive. Given the abundance of studies suggesting some degree of immune dysfunction and systemic inflammation in women with endometriosis, there is an increasing push to consider immune-modulating therapies. These include agents like hydroxychloroquine, which have been extensively used for other conditions and are safe in pregnancy. However, extensive clinical trials must still be done.
Nevertheless, while endometriosis remains one of the most challenging conditions in the field of fertility, current treatments provide concrete improvements. The improvements can both enhance a woman’s quality of life and aid in achieving the next step in building her mishpacha.
Alexander Kotlyar is director of resident education at Genesis Fertility and Reproductive Medicine, Brooklyn.
