Endometriosis affects up to 15–20% of women of reproductive age in Singapore, and yet, many silently live with the pain, not realising how much it could be affecting their fertility too.
If you’ve been trying without success, your doctor may recommend options like Intrauterine Insemination (IUI) or In Vitro Fertilisation (IVF) that can give your body the support it needs to conceive. Knowing which fertility treatment is suitable for you can bring peace of mind and help you plan your next steps.
What is endometriosis?
Endometriosis is a condition where tissue similar to the lining of your womb (endometrium) grows outside of its normal location. The endometrial-like tissue can grow in various locations throughout your pelvis, most commonly on your ovaries, fallopian tubes, and the tissue lining your pelvis.
In rare cases, it may also be found in more distant locations such as the intestines, bladder, or even the lungs. When it grows in the area it's not supposed to be, it can cause inflammation and scarring to the surrounding tissue.
This condition usually affects women of reproductive age, between 25 and 40 years old. However, endometriosis can also affect younger women during their teenage years.
How does endometriosis affect fertility?
Endometriosis can make it harder to get pregnant because it often grows on or around the reproductive organs. Here’s how it might affect your chances of conceiving:
Reduced ovarian reserve:
When endometrial tissue forms on your ovaries (called endometriomas), it may damage them and reduce the number of available eggs in them (ovarian reserve).
Tubal blockage:
If endometrial-like tissue grows around your fallopian tubes, it can cause blockages that prevent sperm from reaching the egg and fertilising it.
Pelvic inflammation:
This condition can cause chronic inflammation that can affect reproductive organs, making the environment less conducive to implantation.
Egg quality:
Endometriosis may also negatively impact egg quality, reducing the chances of successful fertilisation and healthy embryo development.
Hormonal disruption:
Since endometriosis also affects ovulation, the time between ovulation and the next period (luteal phase), and the endometrial receptivity to fertilised eggs, this condition can also lead to hormonal disruption inside the body.
If you experience endometriosis symptoms, such as painful menstrual cramps, or have been diagnosed with it, don't let this condition affect your quality of life or fertility goals. For further assessment and tailored treatment options, schedule a consultation with Thomson Fertility Centre.
Stage of endometriosis
Based on the severity and location of the tissue growth, endometriosis can be classified into four stages:
Stage I (minimal):
During this early stage, there are small patches of endometrial tissue that grow outside of the womb with little to no scarring around the growth.
Stage II (mild):
If the condition progresses, there are more areas that are affected by the endometriosis growth. However, these implants are relatively small with no scarring or tissue damage.
Stage III (moderate):
During this stage, multiple deep implants of abnormal tissue are present, along with the formation of small cysts on one or both ovaries.
Adhesions (scar tissue that causes organs to stick together) or ovarian endometriomas may also be present around the fallopian tubes or ovaries.
Stage IV (severe):
At this most severe stage, there is extensive abnormal growth throughout the pelvic area, large ovarian endometriomas, and significant scarring or adhesions that may cause organs to stick together.
Fertility treatment options for endometriosis
To improve your chances of conceiving, your doctor will usually recommend assisted reproductive technology (ART), such as Intrauterine Insemination (IUI) or In Vitro Fertilisation (IVF). Here's a table summarising the differences between the two procedures:
| IUI | IVF | |
|---|---|---|
| Procedure | Your partner's sperm sample is collected and "washed" to collect the healthiest and most active sperm. After this sperm preparation step, your doctor will inject sperm into your womb to allow natural fertilisation to occur in your fallopian tubes during ovulation. | During the IVF process, your doctor will first extract a mature egg from your ovaries. After the egg retrieval procedure, eggs and sperm are placed together in an incubator to allow fertilisation. Alternatively, the doctor can perform intracytoplasmic sperm injection (ICSI), where a single sperm is injected directly into a mature egg. The fertilised egg (embryo) is then placed back inside your womb. |
| Invasiveness | The procedure is minimally invasive because it only requires the insertion of a catheter into your womb during the insemination process. | More invasive, to perform the egg retrieval procedures, a thin needle guided by a transvaginal ultrasound is used. Additionally, just like IUI, a catheter is required to insert the embryo into the womb. |
| Cost | The cost of an IUI procedure is generally lower than the cost of IVF. In a public hospital, the procedure costs around SGD 1,500, while in a private clinic, it can cost between SGD 2,000 and 3,000. | The IVF procedure is more expensive than IUI because it involves additional lab procedures. However, with Medisave or government co-funding, the cost can be as low as SGD 15,000 per menstrual cycle. |
| Fertility medication | It can be used to help the release of the egg from your ovaries (ovulation); this procedure is called superovulatory IUI (SO-IUI). | The stimulation of the ovary is required to increase the number of eggs the ovaries produce. |
IUI or IVF for endometriosis
Before deciding on the right fertility treatment for you, your doctors will assess several factors, such as:
Your age
Your plans for future pregnancies
The severity of the endometriosis and your symptoms
Based on this evaluation, they will typically recommend treatment as follows:
For stages 1 and 2:
If your doctor's assessment shows that your condition is minimal or mild, you have a healthy egg reserve, and you are under 35 years old, you may benefit from IUI treatment.
This less invasive approach is generally effective when fertility issues are still manageable and your reproductive organs remain largely unaffected.
For stages 3 and 4:
If your condition has progressed to the moderate or severe stage, with blocked fallopian tubes or signs of a reduced egg reserve, and if you are over 35 years old, your doctor may recommend IVF due to these changes and related risks.
However, in cases of severe ovarian endometriomas or adhesions, your doctor may recommend laparoscopic surgery to remove the abnormal tissue growth before proceeding with IVF treatment to improve your chances of treatment success.
To discuss which procedure would be most suitable for your condition, schedule a consultation with Thomson Fertility Centre. Our fertility specialist can provide more information about IUI and IVF fertility treatment, including their benefits and any potential risks.
Success rates of IUI vs. IVF in different stages of endometriosis
The success rates for each fertility treatment may vary depending on the stage of endometriosis. Here is a general guide to help you make a more informed decision about your treatment options.
IUI success rates
If the endometriosis is in stages 1 or 2, IUI can achieve a success rate of around 5–10% per cycle. However, for stages 3 and 4, the success rate is significantly lower, at less than 5% per cycle.
Due to these lower success rates, your doctor may recommend proceeding directly to IVF treatment.
IVF success rates
If you're under 35 years old and have stage 1 or 2 endometriosis, IVF can achieve success rates of around 40–50% per cycle. This higher success rate may make IVF the preferred option even for milder cases, depending on your individual circumstances.
For stage 3 endometriosis, success rates are reduced to 30–40% per cycle. For stage 4 endometriosis, the success rates range from 20% to 30% per cycle. Your doctor may first recommend laparoscopic surgery to remove adhesions and endometriotic tissue, as this can improve your chances of IVF success.
FAQ
What age is best to get pregnant with endometriosis?
If you have endometriosis, the best time to conceive is before 35, when fertility and egg quality are at their peak. However, successful pregnancies are still possible at any age with the right treatment approach.
Under 35 years:
You have the highest chance of success with both IUI and IVF, making this the optimal window for family planning with endometriosis.
Aged 35 to 40:
Although fertility naturally begins to decline, IVF can still be highly effective. Your fertility specialist may recommend moving to IVF sooner rather than trying IUI first.
Over 40 years:
Egg quality and quantity decrease significantly, affecting IVF success rates. However, with the right treatment, pregnancy is still possible.
What factors affect successful conception with IUI or IVF for endometriosis?
If you have endometriosis, there are several factors that influence your chances of conceiving with fertility treatments, including:
Your age
Your ovarian reserve
The stage of your endometriosis
Embryo and implantation environment
Surgical history of endometriosis removal
Sperm quality, including count, motility, and overall health
Pre-treatment with medications for moderate to severe endometriosis
Is IVF better than IUI for endometriosis?
Yes, IVF is generally more effective than IUI for treating endometriosis and is particularly recommended for:
Multiple failed IUI attempts
Moderate to severe endometriosis (stage III or IV)
Cases involving blocked tubes or endometriomas
Which IVF protocol is best for endometriosis?
The most effective protocol depends on your age, ovarian reserve, and the severity of your condition. There are two main approaches that your doctor may recommend:
The long GnRH agonist protocol (ultralong protocol):
Before starting IVF, you take special hormone medication for two to six months. This medication temporarily "switches off" your body's natural hormone cycle.
This helps to reduce endometriosis activity and inflammation in your pelvis, preparing your body for pregnancy when IVF begins.
Antagonist protocols:
With this approach, you start IVF treatment straight away and take medication for a shorter time. These medicines control your cycle and prevent your eggs from being released too early.
This protocol is quicker and involves fewer injections and less waiting compared to the ultralong protocol.
How successful is IVF with endometriosis?
Although success rates vary based on factors such as age, stage of endometriosis, and egg quality, IVF can be very successful for women with endometriosis.
For the minimal to mild stage, the success rate is 40-50%
For moderate-stage endometriosis, the success rate is 30-40%
For the severe stage, it is 20-30% per cycle, though this can improve with pre-IVF treatment
Can IUI be performed in cases of endometriosis?
Yes, intrauterine insemination (IUI) may be an option if you have mild to moderate endometriosis. It may increase your chances of becoming pregnant by placing prepared sperm directly into your womb at the time of ovulation. IUI may be suitable if:
At least one of your fallopian tubes is open to allow the sperm and egg to meet
Your partner's sperm has a good count and motility
You are ovulating regularly so that the doctor can determine the best time to perform the procedure
Your fertility specialist will perform a series of tests, such as ultrasound scans and hormone blood tests, to check these factors and determine whether IUI is appropriate for you.
What is the success rate of IUI for endometriosis?
Success rates for IUI vary significantly depending on the severity of your endometriosis and your age. If your endometriosis is in stages 1 or 2, IUI can achieve a success rate of around 5–10% per cycle.
However, for stages 3 and 4, the success rate is significantly lower, at less than 5% per cycle.
If you're considering IUI or IVF as fertility treatments for endometriosis, schedule an appointment with Thomson Fertility Centre. Our fertility specialist will be able to provide you with personalised treatment and advice based on the stage of your endometriosis.