Endometriosis and Recurrent Pregnancy Loss

Dr. Braverman discusses the complexity of treating patients with endometriosis and why so many of these patients present themselves to his practice for help.

Many patients present to our practice with a diagnosis of endometriosis and a history of recurring pregnancy loss, miscarriages or failed IVF cycles. Most of the patients have already been treated with IVF prior to seeing us because the assumption was that this was not much more than a tubal blockage problem and that IVF will overcome this, but after countless tries at IVF resulting in miscarriages or complete failure to conceive many of these patients are incorrectly driven to pursue repetitive IVF cycles or to even move onto to donor egg cycles and many of those as expected do not succeed. The reason for these failures is an incomplete understanding of the ways that endometriosis can cause miscarriages or IVF failure.

Dr. Braverman speaks about infertility as first symptom of silent endometriosis at Endometriosis Foundation of America

Eighty percent of women have retrograde or backwards flow of menses into the abdominal cavity but actually only ten percent get endometriosis. The reason is that these women have high levels of anti-inflammatory chemical called interleukin‐10 that deactivates the immune cells that are sent by the woman's immune system to try and destroy the endometriosis. These cells are called natural killer cells and when they get deactivated in the abdominal cavity, the mother's immune system responds by making even more natural killer cells and making them even more aggressive in the attempt to eradicate the endometriosis.

Well in the abdominal cavity they won't win because the interleukin‐10 continues to deactivate the natural killer cells but in the uterine cavity where there is no interleukin‐10 the embryo is the victim of these activated natural killer cells. The natural killer cells are numerous and they are activated and essentially lead an immune attack against the invading embryo causing miscarriages or failed in vetro fertilization cycles. Many women with endometriosis are also found to make antibodies against their endometrial tissue and these high levels of antibodies have also been found to play a part in miscarriages. This is the reason why many of our patients who are told their failures are due to poor egg quality and are in turn prompted to move to donor egg cycles continue to fail or have miscarriages. The natural killer cell problem and even the antibody problem must be dealt with prior to recommending donor egg cycles.

However, endometriosis can and, in fact, does have an impact on egg quality. When a young women presents to our clinic an elevated FSH which is a sign of poor egg quality and she has no other explanation, we actually look for endometriosis as the cause of the elevated FSH. It seems that for endometriosis to grow and implant, it needs an inflammatory chemical called tumor necrosis factor. TNF helps the endometriosis develop its own blood supply these levels of TNF are therefore elevated in the abdominal fluid of the women with endometriosis and the exposure of the woman's eggs to TNF over a prolonged period of time can lead to damage to the eggs by a process called oxidative stress.

In fact studies have shown that in women with endometriosis with poor egg quality there are high levels of a chemical called ROS (reactive oxygen species) in the growing follicles which is a byproduct of this oxidative stress and we know that high levels of ROS lead to and cause poor egg quality. You see, these patients are not starting out with poor eggs. The eggs are only damaged through the growth phase when they come in contact with the ROS. Supplements and medications to lower the TNF and ROS with women with endometriosis have been shown to improve egg quality and our patients are always placed on these medications during their course of their treatment with us and the changes that we witness are many times quite dramatic.

As you can see, there are many factor of endometriosis that must be taken into account in order to achieve success. We usually go back to square one with our patients that were told to move onto donor egg. We treat the immune complications that prevent implantation while maximizing egg quality by reducing oxidative stress on the developing eggs. This combination therapy in patients with endometriosis will significantly improve a woman's chances of successfully initiating and completing a pregnancy with her own eggs and if donor egg is required, these treatments will also have a significant impact on its success.

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