Introduction occurrence is not related to ethnic or social


Tubal obstruction,
ovulatory disorders, and semen abnormalities account to nearly 75% of infertile
couples, while the remaining 25% of infertility is due to endometriosis or
classified as unexplained.1 Endometriosis
is a condition that is characterised by the presence endometrial like tissue
(glands and stroma) outside the uterus, which induces a chronic inflammatory
reaction, scar tissue, and adhesions that may distort a woman’s pelvic anatomy.
The condition is common in 6-10% of the general female population. In women
with pain, infertility, or both, the frequency is 35– 50%.2

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Endometriosis is most
common in young women, but its occurrence is not related to ethnic or social
group distinctions. Patients with endometriosis mainly complain of pelvic pain,
dysmenorrhoea, and dyspareunia and the associated symptoms can impact the
patient’s general physical, mental, and social well being.2  About 25-50% of infertile
women have endometriosis, and 30-50% of women with endometriosis are infertile.
 According to recent data, the incidence
of endometriosis has not increased in the last 30 years and remains at
2.37–2.49/1000/y, which equates to an approximate prevalence of 6–8%.2

management requires life-long personalised management plan with the goal of
maximising medical treatment and avoiding repeated surgical procedures. But to
date, it has not been possible to determine whether a medical approach is less
expensive than a surgical approach in patients with chronic pelvic pain. Apart
from that data regarding the cost of treating endometriosis in infertile
patients is lacking.2


The following
case study demonstrates infertility management in a woman with endometriosis.


Case study

Case presentation

A 37-year-old woman presented
to the clinic with a diagnosis of infertility. The patient had stage IV
endometriosis, chronic fatigue, irregular and painful periods, ovarian cysts,
breast pain and loss of libido.

 Medical history

Patient had a history
of chronic pain medication usage.

Family history

had no family history of endometriosis but had a family history of cancer,
diabetes, heart disease, hypertension, kidney disease.

Laboratory investigations

A1298C MTHFR mutation:

Anti-Müllerian hormone: 0.3

Vitamin D level: 21.2 ng/mL



management strategy was adopted for the patient. The doctor also recommended
that the patient keep a track of cycle length and ovulation based on basal body

Diet: The patient was recommended to reduce coffee to 8 oz per
day, eat a vegetable-heavy diet with protein at each meal. The patient was also
encouraged to eat a lighter dinner and to focus on balancing blood sugar by
eating smaller meals every few hours. The diet increased her satiety, and
reduced cravings for sugar and refined
carbohydrates. The vegetable-heavy diet increased overall fibre
intake and promoted the removal of excess oestrogen from the body.


Supplementation: The patient
was prescribed supplements, vitamin B-complex, omega-3 fatty acids, vitamin D,
methylated B vitamins (including methylfolate) to support MTHFR, calcium and
magnesium citrate, and dehydroepiandrosterone (DHEA).

Exercise: In addition to doing yoga the patient was encouraged
to begin walking daily for exercise.


Sleep: The patient was emphasised to take adequate regular sleep
as priority, as sleep is important for fertility.


Stress: Breathing exercises were introduced and practiced
regularly to help calm the patient during times of stress.


The patient experienced
weight loss, improved sleep, and increased libido after adopting the
recommended lifestyle changes. Her vitamin D level increased to 52.8 ng/mL. The
management strategy worked and the patient was able to conceive in spite of presenting
with endometriosis, irregular menstrual cycles, MTHFR mutation, and low AMH.
The patient conceived 9 months after the initial appointment and without
medical intervention she gave birth to a healthy, full-term baby boy.


Correlation between
endometriosis and infertility has been the topic of debate for many years. Normal
couple have fecundity in the range of 0.15 to 0.20 per month which decreases
with age. Women with endometriosis tend to have a lower monthly fecundity of
about 0.02–0.1 per month and also it is associated with a lower live birth rate.2

Although 20–25% of
patients are asymptomatic common symptoms 
common  symptoms indicative of
endometriosis include pain and a heavy feeling in the lumbo-sacral column and/ or
legs; nausea, lethargy, chronic fatigue; any cyclical pain affecting other
organs; haemoptysis; scapular or thoracic pain; and acute abdomen. The patient
in the above study reported few symptoms from the above list. With age the
severity of endometriosis symptoms and the probability of its diagnosis increase
with age; the incidence peaks in women in their 40s.2

Management of
infertility involves use of assisted reproductive technologies, and they are
considered the main strategy to control the burden of infertility. The large
costs of these techniques and frequency of adverse events warrant the
consideration of alternative approaches to control infertility including

Dietary factors play a
role in human infertility and intake of some micronutrients may enhance female
infertility. Many studies have reported higher pregnancy rates among users of
micronutrient supplements either with or without fertility disorders.3

ChavarroJE et al., conducted a
study to examine whether use of multivitamins and intake of specific nutrients
in multivitamins is associated with ovulatory infertility. The study concluded that
regular use of multivitamin supplements may decrease the risk of ovulatory infertility.
In the above case, apart from suggesting lifestyle changes the patient was
given multivitamins supplementation to manage infertility due to endometriosis.3



Endometriosis is a common
disease in infertile women and women with endometriosis face infertility
issues. Dietary interventions have shown efficacy in improving the fertility.
It is successful less expensive and safer method of reversing infertility than medical
intervention alone. Women take a much more active role in their own health by
focusing on methods that optimise health. 
Also, this approach has lasting positive effect for the long-term health
of both mother and baby.