Endometriosis is a common and often debilitating condition affecting up to 1 in 10 women of reproductive age, and it’s one of the leading causes of infertility. Studies suggest that as many as 50% of women with endometriosis experience difficulty conceiving.

General practitioners (GPs) play an important role in early detection, management, and timely referral of women struggling with fertility issues related to this condition. Recognising the signs, initiating fertility discussions early, managing patient expectations, and knowing when to refer to specialists are essential in supporting women with endometriosis. This blog will explore when to start fertility conversations, managing patient expectations around fertility outcomes, and appropriate referral protocols for GPs.

 

When to Start Fertility Discussions

Fertility is a sensitive topic for many women, and when it comes to endometriosis, early discussions are crucial. GPs should be proactive in initiating fertility conversations, even with newly diagnosed patients. Early intervention can help patients make informed decisions and plan their fertility journey effectively.

Key indicators for fertility discussions include:

• Age: Women over 30 are more likely to experience difficulties in conceiving, and those with endometriosis may face additional challenges. As age increases, the ovarian reserve naturally declines, making early conversations essential.
• Severity of Symptoms and Endometriosis Stage: The severity of symptoms and the extent of the disease can directly impact fertility. Women with advanced endometriosis (stage III or IV) may face more significant challenges in conceiving, and these patients should be prioritised for fertility discussions.
• Duration of Unsuccessful Attempts to Conceive: If a couple has been trying to conceive for over 6-12 months without success, fertility should be part of the conversation. For women with endometriosis, this timeline may be shortened due to the potential for reduced ovarian reserve and other fertility-related factors.

A proactive approach to fertility planning should include lifestyle changes (such as weight management, smoking cessation, and stress reduction) and medical interventions, including fertility preservation options if appropriate.

Managing Patient Expectations

Fertility outcomes for women with endometriosis vary widely, and as such, it’s important for GPs to manage patient expectations effectively. The prognosis depends on several factors, including the stage of endometriosis, the age of the patient, and the presence of other fertility factors. GPs can provide valuable guidance by offering evidence-based treatment options and explaining the likely outcomes for each approach.

Treatment Options and Effectiveness:

• Hormonal Therapies: Hormonal treatments such as birth control pills, progestins, and GnRH agonists can help manage endometriosis symptoms by reducing oestrogen levels. While these treatments help control pain and lesions, they do not necessarily improve fertility and may even impact ovarian reserve. It’s important to discuss both the pros and cons of these therapies in relation to fertility goals.
• Surgical Options: Surgical treatment, such as laparoscopy for the removal of endometrial lesions, is often considered in women with moderate to severe endometriosis. While surgery can improve fertility by removing adhesions and lesions, it carries the risk of ovarian reserve depletion, especially if there is significant scarring or damage to the ovaries. Discussing these risks is essential for informed decision-making.
• Assisted Reproductive Technologies: For women struggling to conceive after medical or surgical treatment, assisted reproductive technologies such as intrauterine insemination (IUI) and in vitro fertilisation (IVF) may be recommended. IVF, in particular, has proven highly effective for women with severe endometriosis, offering a higher success rate for pregnancy.

Endometriosis Considerations:

Fertility struggles can take an emotional toll on patients, and GPs are well-placed to offer empathetic support. Women with endometriosis may experience feelings of grief, frustration, or isolation due to infertility. Providing emotional reassurance and support during these difficult times can help improve overall wellbeing.

Referral to Fertility Specialists

While GPs can manage the initial aspects of fertility, there are specific criteria for when to refer patients to fertility specialists. Knowing when to make a referral is key to ensuring that women with endometriosis receive the advanced care they need.

• Women Under 35: If a woman under 35 has been trying to conceive for 12 months or more without success, a referral to a fertility specialist is warranted. Endometriosis may be a factor contributing to her difficulties, and a fertility clinic can provide targeted treatments and advanced techniques.
• Women Over 35: For women over 35, the referral window is shorter. If they have been trying to conceive for 6 months without success, a referral is appropriate, as age plays a significant role in fertility outcomes.
• Severe Endometriosis or Ovarian Involvement: Women with severe endometriosis or significant ovarian involvement should be referred early, as these cases may require advanced treatments, such as IVF or egg retrieval.

Reproductive Endocrinologists and Fertility Clinics

Reproductive endocrinologists are specialists in managing fertility issues, including those related to endometriosis. Fertility clinics provide access to cutting-edge technologies like IVF, egg freezing, and other advanced reproductive options.

GPs should support patients throughout the referral process, ensuring that they are well-informed about what to expect. This may include conducting pre-fertility assessments, such as blood tests for ovarian reserve and imaging studies, to facilitate the referral process and provide comprehensive care.

 

Fertility and endometriosis are often intertwined, and GPs play an important role in addressing fertility concerns early on. Fertility outcomes vary, but with timely interventions and a coordinated care approach, women with endometriosis can access the treatments and emotional support they need to achieve their reproductive goals.

If you’re a GP looking for expert guidance or a referral to a fertility specialist, Toowoomba Obstetrics and Gynaecology is here to support your patients with expert fertility care. Please don’t hesitate to contact us for assistance or to discuss referral options.