Fertility & Subfertility

2020, Responses from: Dr VP Singh, Roberta Mek, Hannah Blakely, Dr Lakshmi Ravikanti, Dr Phill McChesney and Prof Neil Johnson.

I’m in my late 20s and have mild stage I endometriosis. I am worried this will affect my fertility. Can ESIG give me some guidance please.

Dr VP Singh

It’s natural to be worried about fertility after the diagnosis of endometriosis. Most women will have normal fertility as long as they don’t leave it too late. It’s ideal to look at having a family between 20-30 yrs as the egg quality is the best but obviously this depends on one’s social circumstances. One option is to get an AMH test for checking ovarian reserve which a key concern for many patients with endometriosis. It is a simple blood test obtained through fertility clinic and offers accurate assessment of egg reserves. There is now a reliable option of freezing eggs for future to mitigate risk of loss of egg supply and quality with age.

I am trying to get pregnant and want to know the things I can do to improve my fertility without having to go to a fertility clinic yet?

Dr VP Singh

1. Know the correlation between age and chance of getting pregnant  or ‘biological clock’ e.g. chance of getting pregnant per month at 25 yrs is 25% versus 5% at 40.

2. Healthy lifestyle- BMI 20-25, avoid smoking, alcohol drugs, take folic acid, Mediterranean diet, reduce coffee intake

3. Know your egg reserves through a simple test called AMH test, if AMH low then consider freezing eggs or embryos for fertility preservation

4. Consider pre-pregnancy bloods through GP e.g. Rubella Immunity, Hep B, HepC, HIV, Blood group, Chicken pox immunity and VDRL screen

5. know your partners health and if delay consider a semen test, 30% sub fertility is caused by male factor, male lifestyle matters too, he needs to avoid smoke, alcohol, drugs, hot spa baths, tight briefs, take foods rich in antioxidants

6. Know your fertile window, 2-4 days before ovulation is ideal time to try, for someone with 28 days regular cycles the day of ovulation is generally day 14

Seek help through fertility clinic if not pregnant within 12 months

Roberta Mek

  • Know your fertile window; When you are trying to conceive it’s crucial to learn when and if you are ovulating. I know that it doesn’t sound like a fertility-boosting tip. But actually, it’s one! This of the most overlooked factors trying for a baby. In fact, over 80% of women don’t know when is the best time to have intercourse for conception.
  • Period tracking apps; If you are using a period tracking app, be careful, many of them may mislead you. I had many patients who used apps and their fertile window was a way off. Most of us have unique menstrual cycles. Unfortunately, period tracking apps don’t know that. They calculate your fertile window like we all would be the same. What to do instead?
  • Read your body signs; Observe. Listen to your body. One of the reliable symptoms is increased mucus around the time of ovulation. If you have endometriosis, you may feel some pain/light cramping in your lower abdomen or even see light spotting. These sensations can signal fertile time. I know, it may be confusing to rely solely on your body signs. The next step is to get ovulation prediction strips.
  • Ovulation tests; They are very reliable. 97-99% accurate at predicting ovulation. How do they work? They measure a hormone (LH) that peaks about 36-48 hours before ovulation. Start using them daily a couple of days after your period bleeding stops. If you get a positive at about the same time two months in a row, you can narrow the testing window. You don’t need fancy ones. Get inexpensive ovulation tests online.
  • Temperature charting; Finally, if you’re keen to understand your cycle a lot better, there is a more involved method – charting. You will take your temperature every morning and write it down in a calendar or an app. In this case, the tracking apps are actually ok, because they will calculate ovulation based on your personal data. Temperatures, even if they may look like a mess, can help you understand not only when you are ovulating. They will teach you about your cycle. If you’re keen to learn more check out this great book.
  • Go to see GP; If you are over 35 and diagnosed with endometriosis, I’d recommend not to delay your visit to your GP. There are some helpful hormone tests he/she can run to understand your fertility situation better. Get your partner’s sperm tested while you’re at it.
  • Fertility acupuncture; If you want to speed things up, or have been trying to conceive for a longer time, or you if worry about your chances, consider fertility acupuncture. We have some encouraging research showing that fertility acupuncture may shorten time to pregnancy. As a bonus, it may also help with endometriosis symptoms.

In terms of long-term contraception for management of endometriosis symptoms/disease, what would you consider is the better option – the Mirena, or the implant (Implanon)? And why?

Dr Lakshmi Ravikanti

Implanon contains Etonogestrel and Mirena contain Levonogstrel, both of them work in similar fashion as both are progestin only contraceptives. Implanon is inserted subcutaneously under local anaesthesia into arm. Mirena is inserted into the uterus under Local anaesthesia or with oral analgesia. Brazilian RCT showed that both of them equally improved significantly non cyclical pelvic pain, dymenorrhoea and healthy related quality of life in endometriosis.

Mirena has little more advantage as it lasts for 5 yrs compared to Implanon which lasts 3 years only.

I would recommend implanon to woman with cervical stenosis if they are not keen to undergo general anaesthesia.

Dr Phill McChesney

Both Implanon and Mirena are very acceptable long acting contraceptive options for medical treatment of Endometriosis. A study published in Fertility and Sterility in 2018 found no significant difference between Implanon and a product similar to Mirena in terms of treatment of pain and quality of life. However, in practice, about 25% of women have Implanon removed early due to side-effects, particularly irregular bleeding and headaches.  Mirena tends to be better tolerated with >90% of irregular spotting stopping within 6 months and 30% of women becoming amenorrhoeic (no periods) which is higher than Implanon. Systemic side effects also tend to be less common with Mirena than Implanon.

In my practice I prefer Mirena as I find my patients do well with few side effects. On the odd occasion someone wants it removed early, it is also much easier to remove than Implanon.

Prof Neil Johnson

No doubt – the Mirena. We have far more high quality information on the effectiveness for Mirena.  With Implanon, the info is much more limited – and as any effectiveness for treating endometriosis relies on a systemic dose of hormone, the side effect profile would be expected to be higher with Implanon.

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