Melanie Cole, MS (Host): Endometriosis can be a painful, but manageable condition. Many women with this condition wonder if they can get pregnant.

Intro: The Reproductive Science Center of New Jersey combines a commitment to sensitive care with a state of the art program. We proudly present Fertility Talk with RSCNJ. Here's Melanie Cole.

Melanie Cole, MS: Welcome to Fertility Talk with RSCNJ, the Reproductive Science Center of New Jersey. I'm Melanie Cole. And today, we're joined by Dr. Alan Martinez. He's a specialist in reproductive endocrinology and infertility at the Reproductive Science Center of New Jersey.

Dr. Martinez, it's such a pleasure to have you join us today. I'm so glad you could be with us. Why don't you start by telling us a little bit about endometriosis, how common it is, really tell us what it is.

Alan Martinez, MD: Thank you for having me on today, Melanie. We appreciate it. So, endometriosis is a very common condition. It affects approximately one in 10 reproductive age women. And that's during the reproductive years, anywhere from the early teenage years up to menopausal age of around 52. And worldwide, it's estimated, I believe, to affect about 200 million women worldwide, so very common. It is the diagnosis of cells that normally line the endometrial cavity and glands that are lining the endometrial cavity that are located outside of the uterus. So, it could be on the ovaries, it could be in the pelvis, on the intestines, and even in distant sites like the upper abdominal cavity, the lungs. And it really is a chronic condition that causes pelvic pain, causes pain with intercourse. It can be related to infertility that we're discussing today, and just quality of life, affecting social, academic, professional aspects of one's life.

Melanie Cole, MS: Tell us who's affected by endometriosis. Who's at risk? Is it hereditary, Dr. Martinez?

Alan Martinez, MD: So yes, it does have a heritable or genetic component. So, the endometriosis is definitely found to run in families, so first-degree relatives, sisters, mother, grandmother. It can be up to seven times more common in those first-degree relatives. So, it definitely runs in family. There's a genetic component, but it's also associated directly with ovulation. And we know that women that ovulate normally have a menstrual period, that fluid refluxes back out of the endometrial cavity, and it seeds and allows those cells to implant in various parts of the pelvis.

Melanie Cole, MS: Before we get into the fertility consequences, as it were, of endometriosis, I'd like you to speak about the symptoms, Dr. Martinez, a little bit. Because I feel that this is an important part as we look at the woman trying to get pregnant. This is an important part. What symptoms does she experience?

Alan Martinez, MD: So classically, women will present with painful periods. It usually starts in the adolescent and teenage years. And it can progressively worsen to not only be during the menstrual period itself, but also throughout the menstrual month and outside of the period. Most commonly, pain, chronic pelvic pain is one of the main symptoms. As mentioned before, you can have pain with intercourse or pain with sex. And also, you can have abdominal bloating, feeling like your abdomen is distended, and that's a direct result of the physiological component of endometriosis. And it can change the activity of an individual, chronic pain, not responsive to medicine, so they may miss work. And so, the level of pain is a primary factor and a symptom experienced with endometriosis.

Melanie Cole, MS: So, does it cause infertility? Can women still get pregnant if they've been diagnosed with endometriosis?

Alan Martinez, MD: Yes, the good news is that it is one of the factors of achieving pregnancy. So although women with endometriosis have a lower rate of conceiving overall, what we call their natural fecundity, which is usually about 20% in a given month, provided that the woman's ovulating, it's similar that's decreased in the patient with endometriosis. So, it can be estimated from 2% or 3% a month up to 10%. It kind of follows that unexplained infertility patient. So, there definitely is effects in decreasing the likelihood of achieving pregnancy, but there's a lot that we can do with the condition.

Melanie Cole, MS: So as we get into what you can do to help women, is it worth trying to conceive on their own before seeking treatment?

Alan Martinez, MD: That answer is really two-fold. It depends on the level of endometriosis. We know that there are multiple stages. In more advanced stages, it may be more difficult to achieve pregnancy, especially on your own and even with fertility treatments and on the age of the patient. So in an ideal situation, the patient that is less than 35 without any medical conditions can attempt a pregnancy for up to a year. But with a chronic condition like endometriosis, it can be considered and it's acceptable to visit an infertility specialist earlier on as you're thinking about conceiving.

Melanie Cole, MS: Well then, speak to us a little bit about the fertility treatments that you might try with women for mild, moderate and even severe endometriosis.

Alan Martinez, MD: Yes. Once the diagnosis of endometriosis is made, it has stages I through IV that are clinically relevant. Some more advanced stages, which have either been primarily shown by surgery through a laparoscopy or laparotomy to diagnose endometriosis, the stages III and IV, that may warrant a patient to consider more advanced treatments such as in vitro fertilization from the start.

The lower level stages I and II, along with the patient's age, it can be considered to start with lower level treatments. It's on a case by case basis, but that may include things like oral medications to help out with ovulation and timing, chances of conception with intrauterine insemination.

Melanie Cole, MS: Dr. Martinez, if a woman has been taking birth control for her endometriosis, and she obviously has to go off of that when she wants to start trying to get pregnant, do the symptoms of endometriosis come back while she's starting her fertility treatments?

Alan Martinez, MD: Oftentimes and unfortunately, the answer is yes. So, ovulation is key to the symptomatology of endometriosis. And suppression of ovulation through the use of oral contraceptives do a very nice job in suppressing a patient's symptoms, especially in the early stages of the disease. However, once you stop the oral contraceptives, initiating the testing and fertility treatments as soon as possible can be advantageous because they can allow the patient to achieve pregnancy quicker. And then, during pregnancy, sometimes the symptoms can be very manageable or they can recede to a level that's acceptable for the patient.

Melanie Cole, MS: Is surgery ever an option for women that are trying to get pregnant?

Alan Martinez, MD: Yes. Surgery, it depends on the quality of life of the patient, how much symptoms they have, how much is the endometriosis affecting their various aspects of their life. So, that's a consideration. Two, they may have ultrasound evidence of ovarian cysts in their left or right ovary that is consistent with endometriomas, which is a cyst resulting from endometriosis, that may be warranted for them to go to surgery to remove those cysts. So, they may be better responders to medications as well as removing pelvic adhesions, which may either impede the travel of the egg and sperm to meet each other with the lower level treatments or even the potential response or symptoms associated with the treatment during their reproductive journey.

Melanie Cole, MS: Dr. Martinez, I'd like you to speak to couples out there that are considering fertility treatments and the woman that suffers from endometriosis. What do you tell patients every single day about hope for getting pregnant, even with this condition?

Alan Martinez, MD: Yeah. So first of all, I normalize it and I will tell them that they are not alone. It's a very common condition we see, especially in the infertility world. Some estimates and reports up to 30% to 40% of all infertility patients have an element of endometriosis as part of their diagnosis. So, I explain to them what endometriosis is, our reasoning of why we want to enter into the fertility treatment. But I also explain to them that while their fertility potential may be diminished, especially naturally, with more advanced fertility treatments, we can really increase the chances of them conceiving and give them a fairly strong possibility of conceiving and starting a family.

Melanie Cole, MS: Thank you so much, Dr. Martinez, for joining us today. You're always such a pleasure to speak with. For more information, please visit fertilitynj.com to get connected with one of our providers. That concludes this episode of Fertility Talk with the Reproductive Science Center of New Jersey. I'm Melanie Cole. Thanks so much for being with us today.