A two-day campus course explored the latest research on the effect of endometriosis, adenomyosis, fibroids and polyps on the journey from conception to birth.
The meeting, which was organised by the Endometriosis and Endometrial Disorders and the Nursing and Midwives SIGs, also looked at how best to support women and highlighted the importance of patient communication and interdisciplinary care.
Some of the presentations, including one by Baris Ata, gave hope to women with endometriosis who wish to become mothers.
Dr Ata, of Koc University in Istanbul, began by questioning whether endometriosis affects fertility, other than through tubal dysfunction – which is overcome by IVF.
He explained that although endometriosis is typically thought to affect oocyte quality and endometrial receptivity, both of which are key in IVF, studies show otherwise (1).
Moreover, routine surgical treatment of endometriosis or endometriomas does not necessarily improve IVF outcomes in the absence of other indications (2).
Finally, studies show that women with endometriosis have a similar chance of success with IVF as other women (3).
He acknowledged that some studies do find reductions in live birth rates but said that this can largely be explained by adenomyosis, which often co-exists with endometriosis.
Speaking to Focus on Reproduction after his presentation, Dr Ata said: ‘The vast majority of IVF data shows oocytes from patients with endometriosis are similarly likely to fertilise, to grow into blastocysts, be chromosomally normal and implant at a similar rate when transferred. So, endometriosis doesn’t seem to affect IVF outcomes, except for oocyte count if there are endometriomas.’
However, a sub-group of women with endometriosis may be missing out on the chance to become mothers. Edgardo Somigliana told the meeting that research indicates that the endometriosis patients with the most severe dyspareunia do not go for fertility treatment.
Dr Somigliana, of the University of Milan, speculated that this is because they are too exhausted to socialise and find a partner. It is also possible that they are in too much pain to think about motherhood.
Nicola Pluchino used his keynote lecture to explore the impact of endometriosis and dyspareunia on sexual function – a topic he believes is overlooked.
He said that women with endometriosis are nine times more likely to have dyspareunia. They are also
more likely to have less interest in sex, have sex less often and find it less satisfying when they do.
Those who have sexual dysfunction may feel guilty about it, he said.
Male partners can experience frustration, helplessness, anger and worry, relationships can break up and couples can divorce.
And, although sexual function can improve after surgery, it typically does not return to normal levels.
Dr Pluchino, of University Hospital Lausanne, called for endometriosis to be treated holistically. For example, by offering physiotherapy, relaxation techniques and sexual counselling alongside surgery and hormone therapy.
He told Focus on Reproduction afterwards that the gynaecology training in many countries does not adequately address the management of chronic pain conditions or the biopsychosocial model of care – the influence of biological, psychological and social factors.
This gap, he said, ‘may represent one of the major barriers to effective communication and understanding between clinicians and patients’.
Siobhan Quenby, of the University of Warwick, presented new research on why Black women are at higher risk of miscarriage.
She said that many Black communities in the UK distrust the medical profession and this could make it difficult to recruit sufficient numbers of Black women for the study. To get round this, the study was advertised on social media channels popular with Black women.
More than 73,000 women were recruited and self-reported their ethnicity, age, BMI and medical history, including number of miscarriages.
As expected, Black participants reported more miscarriages than white or Asian participants.
Her team then carried out mathematical modelling and matching to explain why this might be. The results showed the higher rate of social deprivation among the Black participants to be the most important factor, followed by their slightly higher age. Third most important was the higher prevalence of fibroids in this group.
The same pattern was seen in the Asian participants. Dr Quenby told the campus attendees that this surprised her because she hadn’t thought that ‘fibroids were that important’.
Some previous studies have found that women with fibroids are less likely to miscarry and others have failed to find any association at all.
Nevertheless, there are a lot of potential biological mechanisms. For instance, fibroids might affect the uterus’s blood supply or disrupt its extra-cellular matrix. Learning more could lead to new treatments for miscarriage, said Dr Quenby, who is yet to publish her results.
A talk by Henriette Svarre Nielsen, of the University of Copenhagen, also focused on early pregnancy. Dr Svarre Neilsen presented two unpublished studies on why women with adenomyosis are more likely to miscarry.
The first was a meta-analysis and systematic review of 25 studies involving 15,363 women with infertility, including 5,959 with adenomyosis. This looked at whether any specific features of adenomyosis are particularly detrimental to pregnancy.
It found that adenomyosis that is diffuse or located near the endometrium was associated with poorer outcomes. In addition, a large uterine volume in adenomyosis trended towards a poorer chance of live birth and greater risk of pregnancy loss.
The second piece of research explored whether any particular signs of adenomyosis, as defined by the revised MUSA criteria (4), were associated with the ploidy of pregnancy loss.
This study involved 338 women with adenomyosis and miscarriage at around nine weeks and known ploidy of the pregnancy loss.
To the researchers’ surprise, myometrial cysts, irregular junction zones, fan-shaped shadowing and other MUSA features were just as common in the women with euploid losses as they were in those with aneuploid losses.
Further analysis showed that two of the MUSA criteria, irregular junctional zone and interrupted junctional zone, were more prevalent in women with two or more miscarriages. In addition, women with severe menstrual pain were more likely to have a euploid loss.
Of course, patient care doesn’t end with pregnancy, and Anneke Schreurs, of Amsterdam UMC, discussed how to prevent endometriosis returning after pregnancy.
Her take-home message was that women with endometriosis should be educated during pregnancy about the importance of breastfeeding.
She explained how breastfeeding hormonally suppresses the menstrual cycle and outlined research that found that breastfeeding, particularly if exclusive, may lead to an improvement in endometriosis-associated pain proportional to the duration of breastfeeding, as well as a reduction in the size of ovarian endometriomas (5).
Dr Schreurs acknowledged that breastfeeding can be hard. She said that it is important that women are given advice on how to sustain breastfeeding and are not made to feel guilty if they stop.
She also recommended prescribing hormonal treatment to fall back on.
The mode of delivery may also be important. Some small studies have found that endometriosis is more likely to recur in women who have C-sections (6) and so Dr Schreurs advised avoiding doing a C-section, where possible.
References
1. Ata B, Somigliana E. Endometriosis, staging, infertility and assisted reproductive technology: time for a rethink. Reprod Biomed Online. 2024 Jul;49(1):103943. https://doi.org/10.1016/j.rbmo.2024.103943
2. Nickkho-Amiry, M., Savant, R., Majumder, K. et al. The effect of surgical management of endometrioma on the IVF/ICSI outcomes when compared with no treatment? A systematic review and meta-analysis. Arch Gynecol Obstet 297, 1043–1057 (2018). https://doi.org/10.1007/s00404-017-4640-1
3. Endometriosis does not impact live-birth rates in frozen embryo transfers of euploid blastocysts
Bishop, Lauren A. et al. Fertility and Sterility, Volume 115, Issue 2, 416 – 422 https://doi.org/10.1016/j.fertnstert.2020.07.050
4. Harmsen MJ, Van den Bosch T, de Leeuw RA, Dueholm M, Exacoustos C et al. Consensus on revised definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: results of modified Delphi procedure. Ultrasound Obstet Gynecol. 2022 Jul;60(1):118-131. DOI: 10.1002/uog.24786
5. Prosperi Porta R, Sangiuliano C, Cavalli A, Hirose Marques Pereira LC, Masciullo L et al. Effects of Breastfeeding on Endometriosis-Related Pain: A Prospective Observational Study. International Journal of Environmental Research and Public Health. 2021; 18(20):10602. https://doi.org/10.3390/ijerph182010602
6. Delli Carpini G, Giannella L, Di Giuseppe J, Montanari M, Fichera M et al. Effect of the mode of delivery on the risk of endometriosis recurrence: a retrospective cohort study. Fertil Steril. 2022 Dec;118(6):1080-1087. DOIL10.1016/j.fertnstert.2022.08.849
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