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How does Endometriosis Impact Egg Quality?

How to Improve Egg Quality and Fertility With Endometriosis 

Endometriosis contributes to infertility in a variety of ways. Most often structural changes to the uterus are blamed, but research suggests that endometriosis also reduces the number of eggs retrieved in IVF, and may be associated with lower quality too. In some ways this is good news, because it gives us new strategies to increase the chance of getting pregnant with endometriosis.

Endometriosis and Diminished Ovarian Reserve

On the quantity issue, specialists report that in women with endometriosis, diminished ovarian reserve (DOR) is much more common.  This is reflected in low AMH levels and fewer eggs retrieved in IVF cycles. Outside the context of endometriosis, the only proven strategy to address diminished ovarian reserve and increase AMH is to supplement with the hormone DHEA, which acts as a precursor to testosterone.  (How DHEA helps to boosts egg reserve is discussed in detail in Chapter 9 of It Starts with the Egg).

Historically, doctors have understandably been quite reluctant to prescribe DHEA to women with endo, because the hormonal implications are not well understood. But now, it is becoming clear that many women with endo have low levels of DHEA and testosterone. Some clinics are reporting good results with DHEA supplementation when testing reveals low levels of these hormones.

The Center for Human Reproduction, for example, describes a case report of a woman with endometriosis who had previously undergone four failed IVF cycles, with only 1-4 eggs retrieved per cycle. Her her AMH was 0.6 ng/mL and her free and total testosterone were both within the lowest 15th percentile of normal range.

She was then treated with CoQ10 and DHEA for 6 weeks, until her testosterone rose to the middle of the normal range. At that point she underwent IVF and the results were vastly better. 8 eggs were retrieved, leading to 5 embryos, and eventually 3 successful pregnancies.

If you have endometriosis and IVF failure, it is worth getting your DHEA-S and testosterone levels checked. (You can order these tests online through LifeExtension in the U.S. and Medichecks in the U.K).

If testing shows your levels are low, you could then ask your doctor about short-term supplementation with DHEA for 6-8 weeks before your next IVF cycle. (With the understanding that we don’t know the long term implications of DHEA on endometriosis). Preferred brands include Pure Encapsulations and Life Extension (UK link)

Endometriosis and Egg Quality

In addition to increasing the chance of having diminished ovarian reserve and fewer eggs retrieved in IVF cycles, endometriosis could possibly compromise the quality of those eggs. This is a more controversial issue, because several studies have found that in women undergoing IVF, endometriosis only reduces the number of eggs retrieved.  Those eggs that are obtained are just as likely to lead to a healthy pregnancy as for any other IVF patient.  But if there is a reduction in quality, New research indicates that this may be due to oxidative damage. For example, a 2018 study found higher levels of oxidative damage and fewer antioxidants in the follicles of women with endometriosis.

From a practical standpoint, this means the chapter on anti-oxidants in It Starts with the Egg may be particularly relevant for women with endometriosis.  As Supplements such as N-acetyl cysteine and Alpha-lipoic acid are likely to be particularly helpful in improving egg quality. Alpha-lipoic acid gets bonus points because it is also anti-inflammatory and immune-regulating. N-acetyl cysteine may also help to minimize part of the underlying disease process in endometriosis (study).  Additional Studies have even found that antioxidants such as vitamin C and E may help to reduce symptoms such as pelvic pain.

If you decide to add an alpha-lipoic acid supplement, the preferred form is R-alpha lipoic acid.  (Most brands include a mixture of this molecule and its inactive mirror-image).

Recommended brands include ThornePure Encapsulations, and Doctor’s Best. Alpha-lipoic acid best absorbed on an empty stomach. The optimal dose is not clear, with the dose used in clinical trials for a range of conditions ranging from 100 to 600mg per day. If you are taking the pure R-form, 100-200 mg twice per day is a good starting point.

 Antioxidants for Pain Relief in Endometriosis

Supplementing with alpha-lipoic acid and N-acetyl cysteine may not only help to address fertility effects of endometriosis, but also pain.

new clinical study published in 2018 found that women taking a combination of alpha-lipoic acid, N-acetyl cysteine and bromelian (an enzyme from pineapple) experienced a significant reduction in pain. (At baseline, 93% of the patients had pain intensity > 4; at 3 months of treatment, this percentage decreased to 87%, and at 6 months the percentage was 82.7%.  This study provides all the more reason to consider taking these antioxidants if you are battling endometriosis.

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