Endometriosis and Infertility

Endometriosis is the presence of endometrium, the tissue of the inner lining of the uterus, in a place other than the uterus. Endometrioma, or chocolate cysts, is a condition in which the endometrium tissue is inside the ovaries. The most common symptom of endometriosis is chronic abdominal and groin pain or infertility. Endometriosis and endometrioma may not give any symptoms and may be diagnosed incidentally during ultrasound or surgery for other purposes.

Apart from the ovaries (chocolate cysts), endometriosis can most commonly be found in the tubes, intestines or bladder and can give symptoms of disease in these organs. Endometriosis (chocolate cysts) is an important cause of infertility and low ovarian reserve and can cause infertility in 20-40% of women.

Endometriosis can be treated in different ways, so there is no single correct treatment method and individualised endometriosis treatment should be applied. Endometriosis treatment can usually include managing symptoms with medication, surgical intervention or both. Women withendometriosis and infertility problems are offered in vitro fertilisation treatment options.

What is a chocolate cyst (endometrioma)?

Theendometrium is a tissue that lines the lining of the uterus and thickens and sheds during the menstrual cycle. At the end of the menstrual cycle it is thin, but if pregnancy occurs, it thickens to allow the fertilised egg to implant and supports the embryo to implant and grow. If pregnancy does not occur, the upper layers of this tissue are expelled from the body during menstruation.

Endometriosis is a condition in which the lining of the uterus is located in areas other than the intrauterine tissue where it should normally be located. In this case, cells such as endometrium can grow and shed in areas outside the lining of the uterus, causing symptoms such as pain, inflammation and sometimes infertility.

Endometrioma is a type of endometriosis and usually occurs in the ovaries. The endometrial tissue in the ovary is normally located where the fertilised egg implants. In the case of endometriosis , however, this tissue is located in the ovary and forms cysts there. These cysts are called endometriomas .

What are the Causes of Endometrioma?

Endometrioma (chocolate cyst) occurs due to endometriosis. Although the exact cause of endometriosis is not known exactly, some factors are thought to contribute to this condition.

Factors such as genetic predisposition, hormonal imbalances, immune system problems, which is a defence mechanism that helps the body fight against diseases, injuries in the pelvic area, early menstrual onset, long menstrual period, not giving birth, some health problems can also increase the risk of endometriosis.

What are the Symptoms of Chocolate Cyst?

The examination of your physician who has experience inendometriosis , ultrasound and MRI are important in diagnosis. Ultrasound is relative and therefore the experience of the physician is very important. Endometrioma (chocolate cyst) symptoms are similar to other ovarian cysts. Symptoms may include:

• Abdominal and groin pain,
• Low back pain
• Pain in the legs,
• Painful menstrual bleeding,
• Excessive and prolonged menstrual bleeding,
• Nosebleeds during menstruation,
• Pain during sexual intercourse,
• Blood coming from urine, burning sensation during urination,
• Blood in the stool,
• Constipation or diarrhoea,
• Bruises on the body,
• It may give symptoms in the form of infertility problem.
• Endometriosis can cause pain in thepelvic area and this pain is usually associated with the menstrual cycle.
• Endometriosis can cause pain duringmenstruation and this pain can be more severe than normal menstrual pain.
• It can cause pain during sexual intercourse.
• It may cause changes in the amount or duration of menstrual bleeding.
• Endometriosis can cause pain duringurination or pain during bowel movements.
• Endometrioma can cause swelling in the abdomen.
• Endometrioma can cause infertility or increase the risk of infertility.

Symptoms of endometrioma may vary from woman to woman and some women may have no symptoms at all. A doctor should be consulted when symptoms are seen.

How is Endometrioma (Chocolate Cyst) Diagnosed?

Endometrioma (chocolate cyst) can be diagnosed using physical examination, imaging tests as well as symptoms and medical history. Your doctor can perform a pelvic examination to see if you have a cyst in your pelvic area. Ultrasound is an imaging test that helps visualise the pelvic area. Ultrasound can help determine the size and location of the cyst. MRI can determine the size and location of the cyst in more detail.

Does Chocolate Cyst Cause Infertility?

One of the most frequently asked questions is ‘how does endometriosis cause infertility?

Chocolate cysts can cause infertility and it is possible to prevent this. However, not all patients withchocolate cysts are infertile.

Cysts that develop in the ovaries due toendometriosis are called endometrioma or chocolate cysts. Endometrioma can cause infertility with low ovarian reserve or severe abdominal pain. Surgery is not the first option in its treatment. Unlike other ovarian cysts, in endometrioma surgeries, while removing the cyst in the ovary, intact ovarian tissue may be damaged and the ovarian reserve may decrease slightly after surgery. In order to minimise this decrease, it is important that surgery is performed by an experienced physician.

How Does Endometrioma Cause Infertility?

Endometriosis and endometrioma can cause infertility and are difficult to treat. However, the relationship between endometriosis and infertility is not always clear. Endometriosis does not prevent ovulation and patients usually have regular menstruation.

• It may decrease ovarian reserve. Especially in the presence of endometrioma , ovarian reserve is lower and may cause early ovarian failure.
• Endometriosis may cause bilateral tubal obstruction by adhesion in the intra-abdominal organs
• It can cause an inflammatory reaction in the abdomen, causing abnormal uterine lining structure, impaired egg and embryo quality.

Endometriosis treatment is performed according to the complaint. Women withendometriosis are less likely to become pregnant naturally and therefore options such as in vitro fertilisation or egg freezing may be offered to patients.

Endometriosis and Infertility Treatment

Endometriosis treatment is performed according to the location of endometriosis and the complaint. Early diagnosis and treatment of the disease is important. Endometrioma can cause a decrease in egg quality and a decrease in the number of eggs. Ifendometriosis causes infertility, IVF or egg freezing is recommended. In case of chronic abdominal pain, it may be necessary to open adhesions with closed surgery, and in the presence of masses in the intestine or other organs that may cause complaints, these masses may need to be removed. Endometriosis (chocolate cyst) surgery performed by an experienced physician prevents or minimises the adverse effects (bowel injury, bladder injury, etc.) that may occur during surgery.

How to Treat Infertility Due to Chocolate Cyst?

Treatmentof endometriosis or chocolate cysts should be personalised. The woman's complaint is very important. After investigating the age of the woman withchocolate cyst and infertility complaints and other causes such as male factor that may cause infertility, IVF treatment option should be offered. Since there is noovulation problem in endometriosis, egg growing and cracking treatments alone are not recommended. Vaccination treatment in endometriosis also has a low chance of success.

In the presence ofchocolate cyst and infertility, surgery is the last option. However, in case offluid accumulation in the tubes, surgery should be recommended before treatment to increase the success of IVF. If surgery is to be performed in chocolate cyst, our preference is closed (laparoscopic) surgery, but open surgery can also be performed. Before surgery, hormone therapy should be used to reduce complaints.

Women with chocolate cysts and low ovarian reserve or women over 35 years of age should be offered the option of egg freezing or embryo freezing with IVF before surgery if they want to have children.

Should Patients with Endometriosis undergo Surgery or IVF?

Even experienced physicians sometimes have difficulties when deciding on the treatment of this complex disease. There is no single treatment forendometriosis .

In patients who cannot use hormone treatments that suppress the disease or in patients whose complaints persist despite using hormone treatments, treatment may be surgical. Sinceendometriosis causes adhesions that disrupt the anatomy, the bowel or bladder may be damaged during endometrioma surgery. If the physician is experienced, the risk of organ injury is minimal.

When thechocolate cyst is removed bysurgery , some ovarian reserve may decrease. Therefore, the decision for surgery should be well considered. If there is severe pain in chocolate cysts, if there is suspicion of ovarian cancer, if there is swelling in the tubes called hydrosalpenx, surgery is recommended. In case of hydrosalpenx, the tubes should be ligated or functionalised before IVF.

In cases of recurrent IVF failures, the burden of disease can be reduced with diagnostic and operative laparoscopy.

Even if intra-abdominal adhesions are removed by surgery, the adhesions may recur. Therefore, surgery is not the first choice due to surgical risks. Patients who will undergo surgery should be offered the option of egg freezing or embryo freezing with in vitro fertilisation before surgery.

Egg reserve can be checked with tests such as AMH test before chocolate cyst and AMH can be monitored for postoperative evaluation.

What is the Chance of Getting Pregnant After Chocolate Cyst Treatment?

After chocolate cyst surgery, the ovarian reserve may decrease to some extent, but if an experienced physician performs the surgery, this decrease will not be too much. Factors such as the woman's age, preoperative ovarian reserve, duration of infertility, size and location of the cyst, other effects of endometriosis and the general health status of the person affect this process.

The aim of chocolate cyst treatment is to control the complaints, to stop the growth of the cyst and, if possible, to remove the cyst completely. Treatment is usually with medication (for example, hormonal therapies), surgery or a combination of both. In some cases, fertility potential may increase after surgical removal of a chocolate cyst.

However, the chances of pregnancy after chocolate cyst treatment depend on a number of factors in the period following treatment:

• Success of treatment: It is important whether the cyst is successfully treated and whether the symptoms of endometriosis are controlled.
• The condition of the uterus and ovaries: Whether the uterus and ovaries are damaged during surgery can affect the chances of pregnancy.
• Ovarian reserve: A woman's ovarian reserve is a critical factor in determining her chances of pregnancy. The ovaries may have been damaged during or aftertreatment for endometriosis , which can have an impact on fertility.
• The partner's sperm quality: The quality of the partner's sperm can also affect the chances of pregnancy. If there are any problems with sperm quality, the chances of pregnancy may be reduced.
• Other medical factors: Other medical factors such as a person's general health, age, weight, hormonal balance can also affect the chances of pregnancy.

If pregnancy does not occur naturally within 1 year afterendometrioma surgery, IVF treatment is recommended.

Can IVF be performed in advanced endometrioma treatment?

Ifpregnancy has not occurred naturallyafter chocolate cyst treatment, IVF should be recommended. If there is permanent damage to the tubes due to adhesions, IVF should be recommended because conception cannot be achieved naturally. If there is fluid accumulation in the tubes, the tubes should be ligated before IVF to increase the success of IVF.

It is difficult to make a precise prediction aboutthe chance of pregnancy after chocolate cyst treatment . However, it is important to keep in regular contact with your health care provider after treatment and to share your concerns about fertility. Your experienced doctor can recommend the most appropriate treatment plan and help you take the appropriate steps.

Istanbul Endometriosis Prices

Endometrioma treatment may vary according to the patient's condition, severity of the disease and treatment options. Endometriosis treatment methods include drug therapy, surgical intervention and supportive treatments. Endometriosis treatment is usually managed by an experienced gynaecologist.

In vitro fertilisation (IVF) treatment is also a method used when couples cannot conceive naturally. The costs of IVF treatment can vary from clinic to clinic, depending on the technology used and the procedures involved in the treatment. These prices usually include services such as medical counselling, medical tests, medications, surgical procedures and embryo transfer.

Çiğdem Yayla Abide and her team offer counselling and treatment services for endometriosis treatment and IVF in our clinic in Ataşehir, Istanbul. However, it would be the most appropriate way to contact our clinic directly to get precise information about prices. The treatment plan and costs for each patient may differ, so it is important to have a personalised assessment.

Frequently Asked Questions About Endometriosis and Infertility