Endometriosis and pregnancy

Among the medical problems of women's reproductive health, endometriosis and pregnancy occupy a special place. That is, the probability of pregnancy with endometriosis - a gynecological pathology that appears in the abnormal spread of cells of the glandular inner layer of the uterus (endometrium) beyond its cavity.

This problem is relevant, since endometriosis is considered not only one of the main reasons for gynecological operations, but also the leading cause of female infertility and chronic pelvic pain.

But, despite the fact that up to 30-35% of women with endometriosis have problems with conception, gynecologists give an affirmative answer to the question – is pregnancy possible with endometriosis?

Why does pregnancy not occur with endometriosis?

Experts do not recommend equating endometriosis with infertility: in women with this disease, a pregnancy test for endometriosis may be positive, because the ability to get pregnant depends on the type and localization of dyshormonal endometrioid heteropia, as well as on the degree of the cicatricial adhesive process characteristic of endometriosis. However, the negative impact of this disease on fertility should not be ignored either.

It should be noted that the types of pathology in the form of genital and extragenital endometriosis differ in localization: either on the organs of the reproductive system, or on the structures and organs of the pelvis and abdominal cavity. But in any case, their displacement relative to the normal position occurs with various functional disorders. Clinical varieties of genital endometriosis are damage to the ovaries, fallopian tubes, uterine ligaments, and then a problem arises - external endometriosis and pregnancy, with a level of secondary infertility up to 25% of cases.

In case of endometrioid heteropia of the cervix, cervical canal and myometrium (muscular membrane), the problem is formulated as internal endometriosis of the uterus and pregnancy. Since endometriosis of the myometrium – adenomyosis of the uterus – can occur in parallel with uterine myoma, women face such a double problem as pregnancy with myoma and endometriosis, when the chances of motherhood are minimal. In addition, if pregnancy does occur, the myoma nodes begin to grow, which increases the risk of its interruption.

With extragenital spread of tissues similar to the internal lining of the uterine cavity, the urinary bladder and urethra, the umbilical region and the anterior abdominal wall are mostly affected, especially in the presence of postoperative scars.

But why does pregnancy not occur with endometriosis? Here are some examples.

Endometriosis of the cervix and pregnancy: problems with conception arise due to the formation of a cyst (one or more) in the cervical canal, which leads to its deformation and narrowing.

Retrocervical endometriosis and pregnancy: in this rather rare type of pathology, endometrial tissue is found on the back of the cervix with spread to the posterior vaginal fornix, the septum between the vagina and rectum, intestines, urinary tract, and also to the muscular walls of the uterus. And, according to experts, this complicates conception, and treatment of this clinical problem can be used to solve it in isolated cases.

Ovarian endometriosis and pregnancy: due to the proximity of the ovaries to the uterus, this is one of the most common places for endometriosis to develop. As a result of the appearance of endometrioid ovarian cysts, there are disturbances in the functions of their follicular apparatus, that is, the ability to form eggs and synthesize hormones. See more - Endometrioid cyst. Ovarian endometriosis is the most likely cause of infertility.

Endometriosis of the fallopian tubes and pregnancy: the formation of external (peritubal) adhesions can lead to stenosis or complete obstruction of the fallopian tubes. In such cases, the fertilized egg simply cannot enter the uterine cavity, and with this localization of the pathology, an ectopic (extrauterine) pregnancy often occurs.

Epidemiology

The number of women with this pathology is estimated by experts of the American Journal of Obstetrics & Gynecology at 6-10% (i.e. up to 145-180 million) – regardless of age and presence of children. First of all, this is a disease of reproductive age: the typical age at diagnosis is from 25 to 29 years. Endometriosis is more common in women with infertility and chronic pelvic pain (35-50%). The racial trend is a higher level of endometriosis in white women.

According to some studies, endometriosis is the cause of 27-45% of infertility cases in women of childbearing age. In terms of species, patients with genital endometriosis account for slightly more than 90% of clinical diagnoses, and diagnosed extragenital endometriosis accounts for no more than 7-8%.

The probability of restoring the ability to conceive and bear a child after comprehensive treatment of endometriosis depends on the characteristics of the woman’s body and the severity of the disease and can be up to 50% in mild cases, and within 10% in severe cases.

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Risk factors

Endometriosis develops in women of different ages, and gynecologists and endocrinologists include the following factors that contribute to the development of the pathology:

• acute and chronic forms of gynecological inflammatory diseases;
• history of abortions, complicated births, or cesarean section;
• gynecological operations (laparoscopic and laparotomic), cauterization of the cervix, abdominal operations on abdominal organs;
• imbalance of endogenous sex hormones with increased levels of estriol and estradiol ( hyperestrogenism ), which is associated with changes in regulation in the hypothalamus-pituitary-ovarian system;
• immune disorders;
• genetic predisposition;
• congenital or acquired lesions of the hypothalamus, pituitary gland, adrenal cortex (leading to disruption of the synthesis of a number of hormones).

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Symptoms endometriosis in pregnancy

Endometriosis is a chronic disease accompanied by intense menstrual flow and severe pain, as well as certain anatomical changes in the pelvic area, although in 20-25% of women this pathology does not manifest itself in any way.

Pregnancy does not cure the disease, and symptoms of endometriosis during pregnancy can range from mild to severe. For most patients with endometriosis, pregnancy – especially after the first few weeks – is a period of relief from symptoms. This is mainly due to the increased levels of progesterone associated with pregnancy: while a healthy woman produces up to 20 mg of progesterone per day during her menstrual cycle, a pregnant woman can produce up to 400 mg of progesterone per day (due to the synthesis of this hormone by the placenta).

The first signs of pregnancy with endometriosis are the absence of menstruation, as progesterone prevents ovulation. In addition, this hormone prevents the lining of the uterus from shedding, slowing down the growth of its cells, so the absence of menstruation during pregnancy can also reduce the symptoms observed in endometriosis, as abnormally located areas of the endometrium stop bleeding.

However, as studies have shown, some women with endometriosis have a reduced or absent response to progesterone, which can be explained by the general low sensitivity of the receptors that interact with this hormone. It is in such cases that endometriosis during pregnancy and discharge (spotting, brown) can occur.

Symptoms of endometriosis may increase during gestation. These are mainly pains associated with the fact that the rapidly growing uterus stretches cystic formations and adhesions. And in the later stages of pregnancy, estrogen synthesis increases again (also due to its production by the placenta), which provokes increased growth of endometrial cells and more pronounced symptoms of the pathology.

How does pregnancy proceed with endometriosis?

So, firstly, how does endometriosis affect pregnancy? And secondly, does pregnancy cure endometriosis?

Let's start with the second. Previously, pregnancy was considered a "cure for endometriosis", but numerous studies have shown that this is not the case. Even if the symptoms of the disease subside during pregnancy (and the reasons for this were named in the previous section), then in most women after childbirth or after the end of lactation they return, sometimes with double force.

Pregnancy with endometriosis can proceed in different ways. Obstetricians-gynecologists call the first two months (8 weeks) the most difficult period: according to statistics, it is during these periods – while the placenta is being formed – that spontaneous abortion occurs.

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Forms

Also in gynecology, there are four degrees of endometriosis, which largely determines the possibility of pregnancy.

Stage 1 endometriosis and pregnancy "coexist peacefully" quite well: the foci of pathology are small and solitary, located shallowly; they affect, as is commonly believed, only the vaginal part of the cervix and the anatomical structures of the small pelvis. Experts estimate the chances of pregnancy at 75-80%.

Endometriosis stage 2 and pregnancy: there are more foci of endometrial growth, and they are located deeper in the pelvic tissues surrounding the bladder; in the recess of the parietal peritoneum there may be a bloody accumulation; there is an adhesive process in the area of the fallopian tubes (with their narrowing) and ovaries. The probability of pregnancy is about 50%.

Endometriosis stage 3 and pregnancy: heterotopia foci in the uterus and fallopian tubes are multiple and deep; presence of peritoneal adhesions and small unilateral or bilateral endometrioid ovarian cysts. The probability of pregnancy is no more than 30-40%.

Stage 4 endometriosis and pregnancy: multiple and deep foci of endometrial proliferation in the bladder and pelvic peritoneum; multiple dense adhesions of abdominal organs; bilateral endometrioid ovarian cysts of significant size. The chances of getting pregnant do not exceed 15%, since changes in the pelvic and uterine areas negatively affect the implantation of the egg and the development of the placenta.

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Complications and consequences

Additionally, the most likely consequences and complications include:

• bleeding after the 24th week of pregnancy, which usually occurs due to placenta previa or placental abruption;
• fetal death at around 20 weeks;
• preeclampsia in the second and third trimesters of pregnancy;
• premature birth;
• low birth weight;
• weakness of labor and delivery by caesarean section.

Complications of pregnancy in the presence of internal endometriosis, in particular, myometrial endometriosis, are associated with increased stress on the muscular lining of the uterus as the term increases, which is fraught with uterine rupture in the second half of gestation.

A rare but severe and life-threatening complication of endometriosis during pregnancy is intra-abdominal bleeding (hemoperitoneum), associated with either rupture of the uterine or ovarian vessels, or bleeding from areas of endometriotic heteropia.

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Diagnostics endometriosis in pregnancy

Doctors will not establish the causes of endometriosis during pregnancy, since there are several versions of the etiology of this disease, including: the embryonic theory of the development of pathology from the glandular elements of the Müllerian ducts and Wolffian bodies; retrograde menstruation; mutations of genes that regulate the estrogen-induced cell cycle of the endometrium in the proliferative and menstrual phases, etc. More information in the article - Endometriosis

Endometriosis is difficult to diagnose. The only definitive way to make an accurate diagnosis is to perform a laparoscopy and examine a tissue sample (biopsy) obtained during this examination. But endometriosis is not diagnosed in pregnancy in this way due to potential risks associated with uterine perforation, decreased uteroplacental blood flow and the development of fetal hypoxia, as well as the threat of intrauterine fetal injury.

Instrumental diagnostics in the form of hysteroscopy is also impossible. Therefore, a routine examination, ultrasound (which, as ultrasound diagnosticians claim, does not give a picture of endometrioid heteropia) are carried out, all necessary blood tests are taken, including hormone levels.

Anamnesis collection (with mandatory consideration of family history on the female side) plays a special diagnostic role. Based on the patient's complaints - pain during menstruation (its duration and intensity), pain during or after sex, bloody discharge outside of menstruation, chronic pain in the lower abdomen and in the pelvic and lumbar region not associated with menstruation, problems with the intestines - an experienced doctor can assume the presence of endometriosis.

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Treatment endometriosis in pregnancy

Endometriosis is not treated during pregnancy, but expectant mothers with endometriosis are under special observation in women's consultations - with increased attention to their condition, fetal development and additional monitoring of the pregnancy. At the same time, pregnant women with this pathology should be warned about the full scope of risks of such a pregnancy.

In non-pregnant women, the key component of conservative treatment of endometriosis is hormonal drugs. The hormonal drug Visanne used outside the gestation period is contraindicated for endometriosis during pregnancy.

The hormonal drug containing goserelin (analog of GnRH – gonadotropin-releasing hormone), Zoladex for endometriosis during pregnancy is also contraindicated due to embryotoxic effects and increased risk of miscarriage. For the same reason, similar drugs are prohibited during pregnancy: Triptorelin, Diphereline (Decapeptyl), Buselerin, Leuprorelin.

Pregnant women with endometriosis should not use the drug Danazol (Danol, Danoval, etc.), which inhibits the synthesis of pituitary hormones.

But the analogue of natural progesterone Duphaston for endometriosis during pregnancy (up to 12-20 weeks) can be prescribed by a gynecologist only in cases of habitual miscarriages or threatened abortion and only if the tests confirm progesterone deficiency. More details in the article - Duphaston during pregnancy

With endometriosis, pregnancy is associated with certain problems, for example, the risk of miscarriage with this disease increases by 76% (compared to healthy women), so neither folk remedies, nor herbal treatments, and especially homeopathy cannot be used!

Planning a pregnancy with endometriosis

Women in general have a much better chance of getting pregnant when they are in their 20s (i.e. 20-30 years old) than when they are in their 30s. So if you have been diagnosed with endometriosis, start planning your pregnancy with endometriosis early.

There is no cure for this disease, but there is treatment that can help women combat its symptoms and, in the case of problems with pregnancy, create the most favorable conditions for realizing the dream of becoming a mother.

Today, gynecologists use hormonal therapies, including oral contraceptives, progesterone medications, and GnRH analogs. But most of these medications can only be used for a limited period of time, and the side effects can cause problems for some women.

Experts say that the best way to plan a pregnancy with endometriosis is a complete examination and, if necessary, surgical treatment – removal of endometriosis lesions and excision of cysts, nodules and adhesions by laparoscopic or any other intervention.

If treatment fails, reproductive specialists offer in vitro fertilization (IVF). However, before resorting to this method, it is necessary to properly treat endometriosis, since preparation for IVF involves increasing the level of estrogen, which will stimulate the development of this pathology.

Prevention

Prevention of endometriosis has not been developed. However, timely medical help for women's health problems can help identify developing pathology and treat it.

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Forecast

The prognosis for the course of pregnancy and its outcome in the case of diagnosed endometriosis largely depends on the phenotypic characteristics of the endometrium, the type, location and degree of development of this pathology.

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