Endometriosis and Ovarian Reserve, Are They linked?

Ovarian reserve is a woman’s fertility potential, which refers to the number and quality of their eggs. Women are born with a finite number of eggs and their ovarian reserve naturally declines with age.

Endometriosis and the ovaries

Endometriosis is the growth of endometrial tissue outside the uterus. The disease affects up to 1 in 10 women worldwide. This ectopic endometrial tissue responds to the same hormones as the normal lining of the uterus. Therefore, symptoms of endometriosis often coincide with the onset of the menstrual cycle.

Endometriosis often occurs in and around the ovaries. Large, fluid-filled cysts that form on the ovaries are called ovarian endometriomas. They are present in up to 40% of endometriosis cases. Ovarian endometriomas are also known as “chocolate cysts” given their appearance. These cysts contain menstrual debris, fragments of endometrial tissue, thickened blood, and inflammatory enzymes.

Up to 50% of endometriosis patients also suffer from infertility or increased difficulty conceiving. This is primarily due to endometriosis lesions creating an inflammatory and “hostile” environment, distorting the anatomy of the uterus and fallopian tubes, or even permanently damaging the ovaries themselves.

Impact of endometriosis on ovarian reserve

There have been contradicting reports regarding the impact of ovarian endometriomas on ovarian reserve, but we believe endometriomas do alter the structure and function of the ovaries. The two most common ways to assess ovarian reserve are antral follicle count (AFC) and anti-Mullerian hormone (AMH).

AFC looks at the total number of antral follicles (immature eggs between 2 and 10mm in diameter). It is a better way to assess the ovarian function of a specific ovary. Some reports showed that ovarian endometriomas have a drastic impact on AFC. However, others indicated that the total number of antral follicles in women with ovarian endometrioma did not differ from that of women with healthy ovaries. A recent meta-analysis showed that women with endometriomas do have lower AFC, whereas women with endometriosis outside the ovary did not.

Anti-Mullerian hormone (AMH), is a hormone that the ovaries produce. It plays an important role in promoting egg development after puberty. AMH levels are made only by small ovarian follicles (<8mm) and therefore, are a predictor of ovarian reserve. Levels of AMH are significantly lower in women with endometriosis than in healthy controls.

The relationship between endometriosis and egg quality

Research has shown that eggs from women with endometriosis are more likely to fail in assisted reproductive techniques such as in-vitro fertilization than eggs from women with other infertility issues. Therefore, endometriosis may be impacting overall egg quality.

Researchers think that the environment within the ovaries of a woman with endometriosis prevents proper egg maturation and release. This includes inflammation, hormonal imbalance, and reduced blood flow.

Laparoscopic excision surgery for preserving ovarian reserve and fertility

Certain surgical techniques to treat endometriosis can lead to a drastic reduction in AMH levels and low ovarian reserve. Therefore, a proper surgical approach that preserves ovarian reserve as much as possible is necessary to give women their best chance of conceiving naturally.

The surgeons at Seckin Endometriosis Center (SEC) take great care in fully removing the cysts from the surrounding healthy ovary and using techniques for hemostasis that avoid “frying your eggs” with heat or electricity. This is done through laparoscopic deep excision surgery combined with our patented Aqua Blue Contrast (ABC)^TM technique. Proper removal of the cyst wall will help to minimize the risk of recurrence.

At SEC, we believe in oophorectomy as a last resort and with the full consent and understanding of the patient. Our goal is always to preserve a woman’s fertility to the maximum possible extent if that is their goal.

There’s no need to give up on motherhood

Laparoscopic deep excision surgery with minimal cautery can help preserve ovarian function to a large extent. The surgery can also increase your chance of conceiving with assisted reproductive options.

If you have a low AMH level, do not panic. AMH is a marker of egg quantity rather than egg quality. It can help predict responses to assisted reproduction cycles but is an overall poor marker of live birth rates. Many women with proper surgery and assisted reproduction have gone on to have healthy pregnancies and children.

At Seckin Endometriosis Center, we always adopt a patient-centered approach and involve you in key decisions. We believe in early family planning and fertility assistance if indicated. Our multidisciplinary team will explain to you all possible treatment options and all implications on current or future fertility.

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