Why Women With Endometriosis Should Think About AMH Testing Now
Recently in the news, singer and pop-star Halsey opened up about her experience with endometriosis and her decision to freeze her eggs at age 23. Here Dr. Bowling answers some questions about the link between endometriosis and how it may effect both egg quality and egg quantity.
What is Endometriosis? Endometriosis is a disease which occurs in about 10% of all women. Within the infertile population, is found in 20-40% of our patients. Endometriosis is a condition involving endometrial glands. Normally, endometrial glands should only be located inside a woman’s uterus. These glands are needed for the monthly growth of the uterine lining in case of pregnancy, and then are shed through a woman’s period if pregnancy does not occur. With endometriosis, these glands are found in places they should not be: in the pelvic wall, and around the ovaries, fallopian tubes, and even the bladder and colon. These endometriosis lesions are benign, but they cause significant inflammation that can cause severe pain and infertility. The only way to diagnose endometriosis is through surgery; however, if a woman has very painful, she has a higher likelihood of having endometriosis.
How does endometriosis cause infertility? Endometriosis causes infertility in a number of ways. First, it can lead to inflammation and scarring of the fallopian tubes, which can in turn block the tubes and lead to the need for In Vitro Fertilization (IVF) to achieve pregnancy. Furthermore, endometriosis may impair the quality of the uterine lining; some studies have shown lower implantation rates in women with endometriosis. Finally, endometriosis can have a significant negative effect on both the quality of eggs in the ovaries and the number of eggs in the ovaries. Poor egg quality has been associated with lower success rates for women going through fertility treatments such as IVF.
Is there a relationship between endometriosis and diminished ovarian reserve? It’s likely, but poorly understood. As a fertility doctor, one of the biggest issues I face is that of diminished ovarian reserve (DOR), or “low egg count”. Once a woman’s egg count is low, there is no way to reverse it. All women are born with all of the eggs that they will ever have, and every day of their lives, egg are dying off until the time of menopause when a woman runs out of eggs on average around age 50. Women with DOR can still achieve pregnancy, but their ability to conceive each month is lower compared to women with normal egg counts, and their response to fertility medications is poor, leading to lower fertility treatment success rates. While not all women with endometriosis will have diminished ovarian reserve, we certainly see it more often in our patients with endometriosis. One theory is that the constant pelvic inflammation that occurs with endometriosis ultimately impacts egg survival and may lead to a higher egg loss rate than what the average woman experiences.
What do you want women with endometriosis to know about fertility preservation or egg freezing? For our average patients, we recommend freezing eggs before they turn 35 years old. However, if you know you have endometriosis, or if you have not yet been officially diagnosed but have ‘terrible periods’ and pelvic pain beyond what you think may be the norm, I would strongly encourage you to have your AMH tested. This way, we have a baseline number that helps us predict where you are compared to your peers. For a woman with a normal AMH, I advise them that natural fertility really starts to decline around age 35, and the end of childbearing years is usually around 40-42; and so the average woman has some reassurance from this. But, if your AMH is checked in your 20s and is lower than what we’d expect, this fertile window is shifted down. Maybe you are on a path for fertility decline in the late 20s and end of natural fertility occurring in the early 30s. Many women have educational and career plans and aren’t ready for a family until their 30s, and for some with endometriosis, by the time they are ready to conceive, it may be too late. This is where egg freezing can help stop the clock and allow women to freeze eggs that will remain the age they were when they were frozen.
What should women who are already trying to conceive know about endometriosis and AMH? Typically, we tell women under age 35 to come in to see a fertility specialist after 1 year of trying. However, for women with endometriosis or very painful periods, I would recommend coming in as soon as possible for an evaluation with a Reproductive Endocrinologist and Infertility specialist. I would evaluate both ovarian reserve testing through the AMH blood test, and fallopian tube testing through an x-ray test called the hysterosalpingogram (HSG). If the results are normal, then that’s great news and you have reassurance about trying on your own for a year before seeking help. If the results are not normal, we have many fertility treatments that are proven to help achieve pregnancy.
Any final thoughts? I think it is remarkable that more and more people like Halsey are opening up in a very public way about their struggle with infertility, fertility preservation, and reproductive diseases such as endometriosis. The more we talk about these conditions, the more normal they become. I appreciate the chance to talk about this topic, and encourage those with any concerns about having endometriosis to contact us at Carolina Conceptions (919-782-5911) to make an appointment with one of our 4 board-certified REI physicians to have your AMH tested. If you’d like to learn more about the egg freezing process, please watch my webinar.