IntroductionTubal obstruction,ovulatory disorders, and semen abnormalities account to nearly 75% of infertilecouples, while the remaining 25% of infertility is due to endometriosis orclassified as unexplained.1 Endometriosisis a condition that is characterised by the presence endometrial like tissue(glands and stroma) outside the uterus, which induces a chronic inflammatoryreaction, 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 womenwith pain, infertility, or both, the frequency is 35– 50%.2 Endometriosis is mostcommon in young women, but its occurrence is not related to ethnic or socialgroup distinctions.
Patients with endometriosis mainly complain of pelvic pain,dysmenorrhoea, and dyspareunia and the associated symptoms can impact thepatient’s general physical, mental, and social well being.2 About 25-50% of infertilewomen have endometriosis, and 30-50% of women with endometriosis are infertile. According to recent data, the incidenceof endometriosis has not increased in the last 30 years and remains at2.37–2.49/1000/y, which equates to an approximate prevalence of 6–8%.
2Endometriosismanagement requires life-long personalised management plan with the goal ofmaximising medical treatment and avoiding repeated surgical procedures. But todate, it has not been possible to determine whether a medical approach is lessexpensive than a surgical approach in patients with chronic pelvic pain. Apartfrom that data regarding the cost of treating endometriosis in infertilepatients is lacking.
2 The followingcase study demonstrates infertility management in a woman with endometriosis. Case studyCase presentationA 37-year-old woman presentedto the clinic with a diagnosis of infertility. The patient had stage IVendometriosis, chronic fatigue, irregular and painful periods, ovarian cysts,breast pain and loss of libido. Medical historyPatient had a historyof chronic pain medication usage.Family historyPatienthad no family history of endometriosis but had a family history of cancer,diabetes, heart disease, hypertension, kidney disease.Laboratory investigations· A1298C MTHFR mutation:Heterozygous· Anti-Müllerian hormone: 0.3ng/mL· Vitamin D level: 21.2 ng/mL ManagementFollowingmanagement strategy was adopted for the patient.
The doctor also recommendedthat the patient keep a track of cycle length and ovulation based on basal bodytemperature.· Diet: The patient was recommended to reduce coffee to 8 oz perday, eat a vegetable-heavy diet with protein at each meal. The patient was alsoencouraged to eat a lighter dinner and to focus on balancing blood sugar byeating smaller meals every few hours. The diet increased her satiety, andreduced cravings for sugar and refinedcarbohydrates. The vegetable-heavy diet increased overall fibreintake and promoted the removal of excess oestrogen from the body. · Supplementation: The patientwas prescribed supplements, vitamin B-complex, omega-3 fatty acids, vitamin D,methylated B vitamins (including methylfolate) to support MTHFR, calcium andmagnesium citrate, and dehydroepiandrosterone (DHEA).
· Exercise: In addition to doing yoga the patient was encouragedto begin walking daily for exercise. · Sleep: The patient was emphasised to take adequate regular sleepas priority, as sleep is important for fertility. · Stress: Breathing exercises were introduced and practicedregularly to help calm the patient during times of stress.
Follow-upThe patient experiencedweight loss, improved sleep, and increased libido after adopting therecommended lifestyle changes. Her vitamin D level increased to 52.8 ng/mL. Themanagement strategy worked and the patient was able to conceive in spite of presentingwith endometriosis, irregular menstrual cycles, MTHFR mutation, and low AMH.The patient conceived 9 months after the initial appointment and withoutmedical intervention she gave birth to a healthy, full-term baby boy.
DiscussionCorrelation betweenendometriosis and infertility has been the topic of debate for many years. Normalcouple have fecundity in the range of 0.15 to 0.20 per month which decreaseswith age. Women with endometriosis tend to have a lower monthly fecundity ofabout 0.02–0.1 per month and also it is associated with a lower live birth rate.
2 Although 20–25% ofpatients are asymptomatic common symptoms common symptoms indicative ofendometriosis include pain and a heavy feeling in the lumbo-sacral column and/ orlegs; nausea, lethargy, chronic fatigue; any cyclical pain affecting otherorgans; haemoptysis; scapular or thoracic pain; and acute abdomen. The patientin the above study reported few symptoms from the above list. With age theseverity of endometriosis symptoms and the probability of its diagnosis increasewith age; the incidence peaks in women in their 40s.2 Management ofinfertility involves use of assisted reproductive technologies, and they areconsidered the main strategy to control the burden of infertility. The largecosts of these techniques and frequency of adverse events warrant theconsideration of alternative approaches to control infertility includingprevention.3Dietary factors play arole in human infertility and intake of some micronutrients may enhance femaleinfertility.
Many studies have reported higher pregnancy rates among users ofmicronutrient supplements either with or without fertility disorders.3ChavarroJE et al., conducted astudy to examine whether use of multivitamins and intake of specific nutrientsin multivitamins is associated with ovulatory infertility. The study concluded thatregular use of multivitamin supplements may decrease the risk of ovulatory infertility.In the above case, apart from suggesting lifestyle changes the patient wasgiven multivitamins supplementation to manage infertility due to endometriosis.
3 ConclusionEndometriosis is a commondisease in infertile women and women with endometriosis face infertilityissues. Dietary interventions have shown efficacy in improving the fertility.It is successful less expensive and safer method of reversing infertility than medicalintervention alone. Women take a much more active role in their own health byfocusing on methods that optimise health. Also, this approach has lasting positive effect for the long-term healthof both mother and baby.