Endometriosis and pregnancy: what you need to know

Alongside the pain, theendobelly fatigue and infertility are among the main symptoms of endometriosis. Between 30 and 40% of women with endometriosis will face this in their journey to have a child.

It is often when experiencing difficulties conceiving and during a fertility assessment, with no apparent symptoms, that endometriosis is discovered. It is the leading cause of female infertility.

It is, however, extremely important to emphasise that endometriosis is not inevitable. With effective management, many women are still able to conceive naturally or with medical assistance. Do not hesitate to consult your healthcare professional (doctor, gynaecologist, etc.) if you are affected. For more advice, you can find our article endometriosis and fatigue. 

The difficulties in starting a pregnancy can be explained by several causes related to endometriosis.

Adhesions

They correspond to scar tissue resulting from repeated bleeding and the adhesion of organs present in the pelvis. This scar tissue can alter the shape and position of the organs. This can impair the normal mobility of the Fallopian tubes, thereby reducing the chances of conception.

Inflammation

The fluid contained in the pelvis (or peritoneal fluid) contains more inflammatory molecules (cytokines and prostaglandins). These molecules create a toxic environment for cells and can damage the egg, sperm, and embryo.

Ovarian cysts

They can reduce fertility by diminishing the production of oocytes by the ovaries.

Endocrine and ovulatory abnormalities

Oocyte maturation and the ovulation process appear to be altered in women with endometriosis. Statistics show that 17% of them do not ovulate[1].

Reduced endometrial receptivity

The endometrium produces proteins called integrins between day 20 and day 24 of the female cycle. These enable embryo adhesion. However, in some women with endometriosis, endometrial receptivity is compromised. They do not produce the alpha v beta 3 integrin that is essential for implantation. This uterine dysfunction can reduce female fertility rates. Nevertheless, more research is needed to determine the appropriate treatment[2].

It is worth knowing that the difficulties are not proportional to the extent of the lesions or the severity of the condition. The pregnancy prognosis is not necessarily better for a woman with a few painless foci than for one where it is more painful and widespread.

To find out more about this topic, you can read our article: Getting pregnant with endometriosis. In addition, a fertility supplement, such as Ovo+, that is compatible with endometriosis, may help. 

The first-line treatment recommended by the French National College of Gynaecologists and Obstetricians (CNGOF) for relieving endometriosis pain is based on hormonal treatments [3].

Taking the pill as a treatment to relieve pain over many months or even years can also be a source of difficulties in conceiving, for several reasons.

Suppression of the menstrual cycle

The woman finds herself in a state of artificial menopause. It can take a significant amount of time for the cycle to re-establish itself, which may delay the possibility of pregnancy.

Nutritional deficiencies

Taking the pill can in particular create significant nutritional deficiencies (magnesium, zinc, selenium, vitamin B6, B2, B9, B12, C, E). Among these nutrients, some are essential for healthy fertility. Pill-based treatments may therefore have the secondary effect of reducing the chances of conception. Taking a women's food supplement can be an option, alongside a healthy diet. 

Thyroid disruption

The pill also affects thyroid function: the thyroid is an endocrine gland that secretes hormones essential for the onset and maintenance of pregnancy.

To find out more, you can read the blog article on The pill and endometriosis.

Laparoscopy

The first option recommended by conventional medicine is surgical intervention. This procedure, performed by laparoscopy, allows the removal of lesions and the reduction of adhesions.

The doctor then allows women who have undergone surgery 6 to 9 months to conceive naturally.

According to the latest statistics, this laparoscopy can increase the chances of spontaneous pregnancy by 60%[4].

In vitro fertilisation (IVF)

The second option offered by conventional medicine is medically assisted reproduction. This includes in particular ovarian stimulation and in vitro fertilisation (IVF). It is worth noting that in cases of endometriosis, the number of oocytes retrieved during ovarian stimulation appears to be lower, particularly in cases of severe endometriosis. Furthermore, studies on ovarian stimulation for IVF show no worsening of symptoms related to endometriosis lesions, nor any acceleration of its progression or increase in the recurrence rate [5]. 

There are also other assisted conception techniques, such as artificial insemination. Everything depends on each patient. Do not hesitate to consult your healthcare professional (doctor, gynaecologist, etc.) to find out which techniques are right for you. 

There are many complementary and natural therapeutic options. These include naturopathy, osteopathy, physiotherapy, micronutrition, nutritherapy, fascial therapy, psychotherapy, acupuncture, Ayurveda, kinesiology, and more.

They may have an effect on inflammation, oxidative stress, immunity, adhesions, and endocrine abnormalities, as well as on emotional wellbeing, transgenerational memories, and more.

Certain products can also help. A food supplement premenstrual syndrome or a food supplement painful periods may in particular help to relieve pain. 

All of this should of course only be considered alongside ongoing care with your medical team.

Endometriosis affects female physiology in many ways and can therefore interfere with pregnancy. By causing inflammation of the endometrium or by resisting the action of progesterone during implantation and throughout pregnancy, endometriosis can disrupt the normal course of pregnancy in various ways.

Pregnant women who suffer from endometriosis need to be monitored more closely than others during their pregnancy. It is also important that they take the best pregnancy food supplement that is suitable for their situation, and which provides omega-3s in particular, which are anti-inflammatory. 

The impact of endometriosis on pregnancy

Having endometriosis can have certain consequences during pregnancy:

- Miscarriage rates are higher,

- A higher likelihood of having a caesarean section,

- Premature births (before 37 weeks of pregnancy) are more frequent,

- There is a higher risk of placenta praevia or low-lying placenta (placenta situated over the cervix, preventing a vaginal birth),

- Babies have a smaller size at birth[6].

Endometriosis has no impact on certain pregnancy outcomes

- The gestational diabetes [7],

- The fact that the baby has a lower birth weight,

- Placental abruption.

The unknown consequences of endometriosis on pregnancy

Based on scientific studies, there are differing views on certain points:

- The risk of ectopic pregnancy (the same or higher),

- Pre-eclampsia (pre-eclampsia is characterised by elevated blood pressure and elevated levels of protein in the urine).

In pregnant women with endometriosis, having diffuse adenomyosis is associated with delivering a low-birthweight baby. It is therefore recommended that pregnancies with adenomyosis be managed as high-risk for placental dysfunction and be closely monitored[8].

To date, there is no study or concrete evidence that pregnancy has any impact on endometriosis, whether in terms of reduction, stabilisation or progression.

The impact of pregnancy on endometriosis lesions

It is important to know that the growth and structural changes of endometriosis lesions during pregnancy may occur due to decidualisation [9]. Decidualisation is a process by which one type of endometrial cell — stromal cells — undergoes a series of changes and becomes decidual cells. Throughout pregnancy, the endometrium undergoes multiple changes that are essential to female reproductive function. The new decidual cells will interact directly with the embryo: an adequate interaction between decidual cells and the embryo is notably necessary for the proper development of the latter.

A similar hormonal response can also be detected in ectopic endometrium (present outside the uterus). As such, ovarian endometriomas and deep endometriosis implants may undergo this process of decidualisation.

Overall, the progestogenic state of pregnancy tends to improve endometriosis. However, decidualisation may lead to an increase in the size of endometriomas and deep endometriosis implants, changes in appearance on imaging, or even complications such as the presence of blood in the peritoneum during pregnancy.

Awareness of this process can help prevent a misdiagnosis of decidualised endometriomas as malignant ovarian tumours, and help recognise the typical imaging findings of the hormonal effects of pregnancy on endometriosis.

The impact of pregnancy on endometriosis symptoms

In most cases, these symptoms are put on hold during pregnancy due to the strong progesterone saturation of the body; however, some women report specific pain linked to endometriosis. 

These pains may be identical to those felt before pregnancy, but they may also be exacerbated or different: pulling sensations or stabbing pains in the lower abdomen, in the thighs, Lacomme syndrome, neuropathic pain, etc.

This can be explained in part by the fact that the uterus grows in volume and displaces the organs in the pelvis. This change affects the adhesions created by endometriosis and also impacts the stretching of the ligaments that support the organs. These ligament pains occur in a large number of women without endometriosis but can be far more intense in those with endometriosis due to the lesions present on the ligaments.

The impact of endometriosis on childbirth

Regarding childbirth, the risks for women with endometriosis do not stem from the condition itself, but from any surgery they may have undergone prior to pregnancy.

If surgery has affected the terminal part of the rectum or the vagina, a caesarean section may be preferred, as a vaginal birth could lead to perineal tearing and complications such as anal and urinary incontinence.

Pregnancy does not cure endometriosis

For a long time, it was believed that pregnancy had a positive impact on endometriosis and its symptoms, due to both:

- The blocking of ovulation, preventing endometriotic tissue from bleeding

- The induction of various metabolic, hormonal, immune and angiogenic changes (development of blood vessels).

Many women with a diagnosis of endometriosis have been prescribed pregnancy as a remedy for the progression of the condition and the various symptoms they experienced, and therefore expect pregnancy to bring genuine improvement.

In reality, studies show that the effects of pregnancy on the progression of endometriosis and on symptoms (particularly during periods) are highly variable, and there is no evidence that pregnancy is necessarily a way to reduce the size and number of endometriosis lesions[10].

Endometriosis can develop on a caesarean section or episiotomy scar

It is also worth knowing that the caesarean section scar can, in some women, be a site for the development of endometriosis lesions — known as parietal scar endometriosis[11]. This is one of the rarest locations of endometriosis.

This is also the case with episiotomy scars.

Indeed, during surgery, endometrial cells attach to the scar and their development is promoted by oestrogens, which leads to the formation of an endometrioma[12].

What are the effects of breastfeeding on endometriosis?

Breastfeeding (and the lactational amenorrhoea that accompanies it) may protect women from endometriosis and may also have an effect on pain as well as on its spread[13].