Endometriosis can raise a lot of questions, especially when it comes to fertility. Recently, Carla Cressy of The Endometriosis Foundation sat down with Aria Fertility’s Ms Srividya Seshadri to discuss the link between endometriosis and fertility.

Carla: We’re sitting down with gynaecologist and fertility specialist, Ms Srividya Seshadri at Aria, where we’ll be talking openly and honestly about what endometriosis really means for reproductive health. We’ll cover everything from lifestyle and early testing to fertility preservation treatments and planning a pregnancy so that you can feel informed, supported and empowered to make decisions that are right for you at the right time. Before we talk about medical treatments or fertility preservation. I wanted to start with something a little more fundamental, like the everyday things that people can do to support their fertility.

How do nutrition, stress and sleep play a role in long -term fertility, especially for those with endometriosis?

Vidya: You’ve highlighted two very important factors that could affect fertility. Recently, there has been a focus on PFAS, or forever chemicals, and their potential effects on egg and even sperm quality.

I’m a big believer that nutrition should be in pristine health, at least before any fertility treatment is contemplated. This can range from diet, what triggers to avoid, or curbing excessive caffeine or alcohol intake

Vitamins are also important for fertility, especially folic acid. Folic acid is paramount for egg quality and early pregnancy development, especially the central nervous system development of the baby. Vitamin D also plays a powerful anti-inflammatory role, and we should really be taking it year-round.

One of our government’s guidelines is that all of us who live in the UK must take a daily dose of 10 micrograms of vitamin D. It’s not only helpful during the Winter, but it’s also very good for symptoms of endometriosis and improving egg quality.

However, anything taken in excess is also not great for egg quality. Vitamin E is thought to be good for the eyes and the skin. But it’s a fat-soluble vitamin and so is stored in our fat deposits for a considerable length of time.  Also, taking too much vitamin A in early pregnancy is not conducive to embryonic growth and could be quite toxic for early embryo development. So, I would say avoid vitamin A if you’re trying to conceive.

Sleep is also very important, and we often underestimate its effect on egg quality. There have been some observational studies in the US that looked at how sleep quality affects egg quality, and I’m a firm believer that we need everything in balance to achieve an optimum outcome.

Carla: What fertility tests are available for someone with endometriosis, even if they’re not trying to conceive yet?

Vidya: The fertility investigations would include a blood test that checks our Anti-Mullerian Hormone level. It’s a hormone secreted by small cells lining the follicle, or fluid bubble, that contains our eggs.

It gives us a rough indication of our egg reserve at a given point in time compared to that of a woman of our age. But it does not often predict your future fertility.

So, if you’re an individual wanting to exercise your reproductive choice or even have underlying endometriosis and considering fertility preservation, then doing that test may be valuable because then you can ascertain if you want to do an IVF cycle for egg freezing before embarking on endometriosis treatment.

The test is not dependent on your cycle, so it can be done at any point in your menstrual cycle. The second test is a transvaginal or internal scan.

For individuals with endometriosis, this scan will be very important because endometriosis often causes scarring due to inflammatory deposits or adhesions. A transvaginal scan will also ascertain the position of the ovaries and the number of follicles.

As I alluded to earlier, follicles are the bubbles that contain eggs, so they represent the number of eggs recruited from the federal egg bank reserve each month.

Those are the two tests I would initially offer. But doing tests just for the sake of checking things without wanting to do anything about them is not advisable. But I tell any patient, it is valuable to ensure that our diet, exercise, nutrition, and supplements are in order. Those are the parameters I would look for or try to optimise before we start thinking about reproduction.

Carla: When should someone with endometriosis consider having fertility preservation?

Vidya: If they have been diagnosed with stage 3 to stage 4 endometriosis, and they’ve done their AMH level, and it is borderline.

I feel strongly that the number doesn’t always matter because I have seen individuals with severe endometriosis with a very good AMH value, but I still would encourage them to consider egg or embryo freezing because of the nature of the condition.

The reason for that is that endometriosis is a very difficult condition to predict. Unfortunately, we cannot map out the reproductive cycle and tell an individual how many months they have before their AMH or egg reserve drops. And with endometriosis, that drop could be quite sudden, from a very good egg reserve to negligible.

So, a blood test should not explicitly dictate what an individual should do.

Carla: At what point should someone with endometriosis who is actively trying to get pregnant seek help?

Vidya: I believe that after three to six months of trying naturally, if there is no natural conception, they should seek medical investigations and further intervention.

Now, saying that, not all women with endometriosis have difficulty conceiving. There have been many anecdotal cases where women have had severe endometriosis and have fallen pregnant naturally and have had a wonderful pregnancy and child delivery.

So, I don’t think we need to sort of compartmentalise based on the severity of the diagnosis, but it would depend on the individual’s symptoms, what stage they are at in their life, and their individual circumstances before they make that decision.

Carla: How do you help patients to understand results without any unnecessary fear or anxiety?

Vidya: That is a very important question because, as a clinician, conveying a test result without causing undue anxiety for the patient is paramount. And often it’s difficult because what they take home from the discussion about the results may be completely different from what the clinician discussed with them.

I discuss their results with them, give them time to reflect on the discussion and, if they want, have a follow-up appointment so they can ask any questions that have been left unanswered or help with any ambiguity in their decision-making.

Carla: One of the most common and often kind of frightening beliefs around endometriosis is that it automatically means infertility. What is the real link between endometriosis and infertility?

Vidya: Very good question. The link between endometriosis and infertility is not clearly defined, but up to nearly 50 % of women with endometriosis have problems conceiving. It is a lot, but again, we must bear in mind the other side of the coin that the majority have no problem conceiving.

But endometriosis is an inflammatory condition; those deposits, as they travel through the tubes, can cause scarring and therefore tubal blockage, preventing the egg from fertilising the sperm. Or it could mean that these deposits sit in the ovaries and are akin to rust on metal.

And this inflammation of the ovaries can mean that egg numbers and egg quality can rapidly deteriorate.

Carla: And what do the actual statistics tell us versus the myths that we often hear?

Vidya: The myth we often hear is that if you’ve got endometriosis, you can’t conceive, and you’re doomed for infertility, or you can only conceive through IVF treatment, and the answer is no, because most women with endometriosis have no problem conceiving.

Another myth is that if you get pregnant, be it through natural conception or IVF, your endometriosis will improve. That is a myth that’s been busted. Some women can have a smooth pregnancy, but quite often symptoms will return shortly after birth; for others, their pain just exacerbates during pregnancy.

What I don’t want is for everyone to panic about being diagnosed with endometriosis, because number one, we have so much more information compared to 25 years ago.

For more advice on how we treat patients with endometriosis, please arrange an initial consultation with one of our fertility experts.