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Pregnancy and Endometriosis: Diagnosis, Treatment, and Healing

Jessica Joseph, RN, BSN, MHA
August 16, 2023
Uterus displaying endometriosis
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Endometriosis is a chronic condition that is shrouded in misconception. Women with infertility often overlook this condition because they may not have the so-called hallmark symptoms.  Pregnancy and endometriosis are two distinct but interconnected aspects of reproductive health. Without minimizing what women experience, especially those with the debilitating painful symptoms of endometriosis, this article aims to unravel the mystery and empower those affected.


Guided Fertility™ interviewed Alexander D. Kofinas, MD, FACOG, for his professional standpoints on treating and diagnosing endometriosis.  Dr. Kofinas is board certified in Maternal-Fetal Medicine, a clinical associate professor at Cornell University’s College of Medicine, the founder and director of Kofinas Perinatal, and the author of The Working Womb.  He has over 35 years of practice in Obstetrics, Gynecology, and Maternal-Fetal Medicine.  He has published extensive world-renowned research on placenta health. He has dedicated his life to solving the mysteries of infertility. 


What is endometriosis?


“Endometriosis is uterine tissue growth outside the uterus, including the bladder, liver, rectum, ovaries, diaphragm, and other parts of the pelvic and peritoneal cavity.  Endometriosis is divided into stages 1-4, which correlate to the anatomical description of the lesions.  Stages are surgically necessary; the more ectopic/endometrial tissue, the more severe the disease is classified”. 


Does silent endometriosis exist?


“I do not carry any weight to the term “silent” endometriosis. Silent endometriosis claims to be asymptomatic endometriosis, meaning not displaying the symptoms of pelvic pain, painful menstruation, and pain with intercourse.  However, what most people fail to realize is that the majority of women who have endometriosis do not have any symptoms.  Therefore, physicians should still test for endometriosis, even if symptoms are absent”.

What is the cause of endometriosis?


“There is a false theory that endometriosis occurs because of the backflow of blood during your period, clinically referred to as retrograde menstruation. However, all women have backflow.  When women menstruate, they shed blood into the peritoneal and pelvic cavity.  What sets women with endometriosis apart is an underlying inflammatory condition. Women with endometriosis have an autoimmune disturbance that allows the endometrium cells to implant outside the uterus”.


What is the best way to diagnose endometriosis with all the new testing available? 


“Despite widespread belief, MRIs do not diagnose endometriosis.  The gold standard to diagnose endometriosis is via laparoscopy.   With laparoscopy, you visualize and remove these lesions by surgical excision or laser destruction and perform lysis of adhesions, if present.  Depending on the type of physician you see and their training, physicians may not offer this as a first-line diagnostic tool, which is a shame”.


What about performing a biopsy to test for BCL6 cells instead of a laparoscopy?


“If elevated, BCL6 is a protein that has been shown to give you a risk of 94% of endometriosis.  An independent study from Harvard states that the risk is about 88%.  However, the testing must be done only during a natural cycle. All fertility specialists perform BCL6 testing during the ERA biopsy. This test was only validated on a natural cycle, and it gives too many false negative results when done simultaneously with the ERA biopsy”.


“A study published this month in the Fertility & Sterility Journal revealed that BCL6 levels are suppressed to the normal level due to progesterone effects when patients receive hormones to prepare for the ERA biopsy. So, a woman suffering from endometriosis who undergoes BCL6 measurement at the time of the ERA testing will test negative for endometriosis.  Such mistakes lead to recurrent implantation failure and miscarriage”.


“Regardless of accurate testing, the most crucial fact patients need to realize with BCL6 testing is that it is used for screening, not diagnosing endometriosis”.


How do you treat endometriosis? 


“First, you need to document the presence of endometriosis via laparoscopy and excise the lesions.  When you excise or pulverize, you remove the effect of those lesions, which is highly inflammatory. Removing the lesions gives a big healthy boost to the woman’s pelvis and reproductive system”.


“However, this procedure does not treat the underlying condition.  It is important to understand that endometriosis is a chronic, systemic, inflammatory auto-immune disorder, and the underlying systemic inflammation must be addressed since these lesions can come back”.  


“I verify the level of inflammation by performing a test called the endometrial immune profile as well as peripheral blood inflammatory cytokines. Treating fertility patients who suffer from endometriosis is highly individualized based on the results of such testing.  Based on the woman’s endometrial and peripheral blood immune profile results, I may start her on anti-inflammatory supplementation, including prednisone and low-dose naltrexone.  Clinical trials do not exist for naltrexone treating endometriosis. However, there are case studies and anecdotal reports that naltrexone has been successful in women with endometriosis who have had failed IVF cycles.  Naltrexone is commonly and safely used in pregnancy for women with opioid addiction.  The dose I use to manage endometriosis is much lower.  Furthermore, we usually stop naltrexone during the first trimester based on how the placenta develops. It is crucial to monitor the placenta's development in women with a history of endometriosis”.

What is the correlation between AMH and endometriosis?


“If you have follicles visualized on a sonogram and your blood work indicates low AMH, it does not automatically translate into ovarian failure for women. Instead, these women may have follicles that cannot be recruited because the endometrial functional environment is disturbed. Many things can disturb it, but endometriosis is one of the most common. At least as common as insulin resistance.  Endometriosis causes massive oxidative stress, which causes low AMH.  However, it does not destroy the eggs. Once the endometriosis is treated correctly, women will see a rise in AMH within a few months”.


For more information on endometriosis and other infertility topics, please visit Dr. Kofinas’ website:


For more information on placental health/science and how to prevent miscarriages, please refer to Dr. Kofinas’ book The Working Womb.

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