What is Endometriosis: Symptoms, Diagnosis, Treatments
Patient: Dr Malpani, I’ve just been told I have endometriosis. I’m terrified. Is this the reason I can’t get pregnant? And will this ruin my chances of becoming a mother?
Dr. Malpani: I understand why you’re worried. Endometriosis, often called 'endo', is common among infertile women, though the relationship between the two is complex. Let’s unpack what it really means, how it affects fertility, and what your options are.
What Exactly Is Endometriosis?
Patient: I thought the endometrium was just the lining of the uterus. How does it end up outside?
Dr. Malpani: That’s what makes endometriosis so puzzling. In this condition, normal endometrial tissue grows outside the uterus — on the ovaries, fallopian tubes, or even intestines. Just like the lining inside the uterus, these patches respond to your monthly hormonal cycle. They swell, break down, and bleed — but because they’re trapped, they irritate surrounding tissue and can cause pain, scarring, and sometimes infertility.
Why Do Some Women Develop It?
Patient: Do doctors know what causes it?
Dr. Malpani: We have several theories. One is retrograde menstruation — when menstrual blood flows backward into the pelvis. These endometrial cells can then implant on pelvic organs. But it’s not the only explanation. Genetics, immune system changes, and environmental factors may also play a role. It’s an enigma — which is why we often call it “a mystery wrapped inside an enigma.”
What Are the Symptoms?
Patient: Is the pain I feel during my periods normal?
Dr. Malpani: Painful, worsening menstrual cramps — dysmenorrhea — are a classic symptom. Some women also feel pain during sex (dyspareunia). Others may notice spotting before their periods. But here’s the confusing part: the severity of pain doesn’t always match the severity of the disease. Some women with severe endometriosis have no pain at all, while others with minimal disease suffer terribly.
How Does It Affect Fertility?
Patient: And infertility — how exactly does it block pregnancy?
Dr. Malpani: In several ways. Endometriosis can trigger inflammation that releases chemicals like cytokines, which interfere with egg development, fertilisation, and implantation. Scar tissue (adhesions) may bind ovaries, tubes, and intestines, making it difficult for eggs to be released and picked up. Large ovarian cysts, called chocolate cysts or endometriomas, can also reduce ovarian function.
That said, not every woman with endometriosis is infertile. Some get pregnant naturally, while for others the condition is only part of the problem.
How Is Endometriosis Diagnosed?
Patient: My doctor mentioned laparoscopy. Is that always necessary?
Dr. Malpani: In the past, laparoscopy was the gold standard. It allows us to see endometriotic spots — the classic “powder-burn” marks or chocolate cysts — and to stage the disease from I to IV. Today, however, we often rely on ultrasound to pick up cysts. A laparoscopy may still be needed in some cases, but we’re more cautious now because unnecessary surgery can reduce fertility.
Medical and Surgical Treatments
Patient: I was told medicines can help. Is that true?
Dr. Malpani: Medicines like birth control pills or GnRH analogues can suppress the disease by creating a “pseudopregnancy” or “pseudomenopause”. They reduce pain, but they don’t cure endometriosis — and they don’t improve fertility, since ovulation is switched off.
Patient: So then, is surgery better?
Dr. Malpani: Surgery can help by removing adhesions and cysts, but it has risks. Removing endometriomas can damage normal ovarian tissue and lower ovarian reserve. That’s why I advise women to check their AMH levels before consenting to surgery. If your ovarian reserve is already low, surgery can make things worse. Sometimes, instead of removing a cyst, aspirating it under ultrasound guidance is safer.
IVF and Endometriosis
Patient: If medicines and surgery have limits, does IVF work better?
Dr. Malpani: IVF is often the best option for infertile women with endometriosis, especially when other treatments fail. It bypasses many of the barriers — like blocked tubes or adhesions. Success rates may be slightly lower if egg quality is affected, but IVF still offers an excellent chance.
Patient: So IVF doesn’t cure endometriosis, but it helps achieve pregnancy?
Dr. Malpani: Precisely. Endometriosis is a chronic condition we can manage but not cure. The goal is to focus on what matters most: helping you achieve your dream of motherhood.
Surgery vs IVF: A Common Dilemma
Patient: My gynaecologist wants to operate first. Should I agree?
Dr. Malpani: This is where many women get misled. Surgeons naturally favour surgery. But evidence shows that operating first doesn’t always improve fertility. In fact, overenthusiastic surgery can harm ovarian reserve and make IVF harder later. For many women, going straight to IVF is safer and more effective.
The Bottom Line
Patient: So what should I do next?
Dr. Malpani: Step one — don’t panic. Endometriosis is not cancer, and it doesn’t mean the end of your fertility. Step two — get the right tests, especially AMH, so we can evaluate your ovarian reserve. Step three — tailor treatment to your goals. If your main concern is pain, medicines or surgery may help. If your goal is pregnancy, IVF is often the best strategy.