La endometriosis es una enfermedad crónica que consiste en la implantación y crecimiento benigno de tejido endometrial fuera del lugar habitual. Por lo general, es progresiva e incapacitante. Se calcula que entre un 10 y…
Este post se publicó originalmente el 28/01/2022 y ha sido actualizado en fecha 10/01/2025
La endometriosis está directamente relacionada con la infertilidad, se estima que un 30% de las mujeres afectadas por esta enfermedad tienen problemas para quedarse embarazadas de forma natural. En este post hablamos en profundidad de embarazo y endometriosis.
¿Qué es la endometriosis?
La endometriosis es una enfermedad que consiste en la presencia de tejido endometrial en zonas donde no debería haberlo. Este tejido, es similar a la capa que recubre la zona interna de nuestro útero y que crece, se desarrolla y se sangra por efecto de las hormonas en cada ciclo menstrual.
En el caso de tener esta patología, podemos encontrar tejido endometrial dentro de las paredes uterinas (adenomiosis), en el peritoneo, los ovarios, el intestino, la vejiga e incluso lejos del aparato genital, como en los pulmones o el estómago. Estos quistes reaccionan de igual manera a las hormonas del ciclo, especialmente a los estrógenos, produciendo sangrados, inflamación y la posterior fibrosis de la zona, causando dolor de forma crónica y a veces incluso invalidante.
Pese al gran impacto en la salud femenina que puede tener esta enfermedad, se considera que está infradiagnosticada. Su descubrimiento se puede llegar a demorar incluso 7-10 años, aunque la mitad de las mujeres refieren tener síntomas claros desde antes de los 20 años.
Se calcula que alrededor del 10% de las mujeres en edad fértil tienen endometriosis, pero la normalización del dolor menstrual junto con una banalización de las patologías femeninas por parte de la ciencia y la medicina tradicionales han llevado a que todavía estemos en pañales a la hora de diagnosticarla y abordarla.
Síntomas, diagnóstico y tipos
El 98% de las mujeres que sufren endometriosis van a tener dolor durante la menstruación en mayor o menor medida. De hecho, es la causa más probable de dolor pélvico en mujeres en edad fértil.
Otros de los síntomas más comunes son la dispareunia, el dolor pélvico crónico, dolor abdominal, dolor de espalda, al orinar, al defecar… y la infertilidad que se presenta hasta en un 30-40% de las ocasiones.
El diagnóstico pasa por una historia clínica completa, una exploración exhaustiva, ecografía e incluso laparoscopia. A veces el tejido está muy diseminado y es difícil de localizar, otras se presentan en forma de quistes normalmente en ovarios, ligamentos útero-sacros y fondo de saco uterino (la zona entre el fondo de la vagina y el recto es bastante habitual).
Según la Sociedad América de Medicina Reproductiva y también según la Sociedad Europea de Reproducción Humana y Embriología, existen cuatro grados de endometriosis:
- Grado I: con implantes de tejido aislados. La forma más leve.
- Grado II: placas superficiales de aproximadamente cinco cm, normalmente adheridas al ovario.
- Grado III: endometriosis moderada, nódulos que invaden estructuras. Adherencias en trompas y ovarios.
- Grado IV: severa o profunda. Placas diseminadas, múltiples superficies afectadas a mayor profundidad y grandes quistes en el ovario.
No se conoce la causa específica de esta dolencia, pero las hipótesis apuntan hacia la menstruación retrógrada (es decir, que va hacia las trompas y llega al peritoneo), aunque también se cree que hay factores inmunológicos, genéticos, inflamatorios y hormonales implicados en el desarrollo de estos tejidos ectópicos y la progresión de la enfermedad.
Infertilidad y endometriosis
La endometriosis está claramente relacionada con la infertilidad en muchos casos, sobre todo la de grado IV o profunda.
En la mayoría de estudios, las mujeres habían sido diagnosticadas por laparoscopia, así que se sospecha que la endometriosis tipo III Y IV (severa y moderada) es la que más puede afectar a conseguir o no embarazo. En el caso de las formas leves, no está tan clara esta asociación a nivel científico, aunque en la práctica, sí que se observan mayores dificultades que en una mujer que no la padezca.
Así, las posibilidades de fecundación en una pareja sin problemas de fertilidad son de 20% en cada ciclo, bajando a entre el 2 y el 10% aproximadamente en el caso de que la mujer sufra endometriosis. Así que el binomio embarazo natural y endometriosis, aunque no imposible, sí es bastante improbable.
Pero, ¿por qué influye en la fertilidad?
Hay varias hipótesis y estudios recientes que apuntan a un origen multifactorial. El estado inflamatorio que se produce con esta patología, tanto a nivel local (ovarios, trompas, útero), como sistémico, es uno de los factores importantes que dificultan el conseguir un embarazo. Ese ambiente inflamatorio en el peritoneo y en el líquido que baña los ovarios puede afectar a su formación, a su calidad, y por tanto al desarrollo e implantación de esos futuros embriones. Digamos que además de esto, el ambiente uterino no es el más acogedor cuando llega el blastocisto.
Por un lado, existe una inflamación crónica, además de una hiperactivación de la inmunidad, cuando debería modularse para permitir la implantación. Las paredes uterinas pueden también verse dañadas tanto por las placas que se han fibrosado, en las que el tejido no es óptimo para la implantación, como por la resistencia a la progesterona que sufre el endometrio. Esta capa interna del útero crece gracias a los estrógenos, pero prolifera gracias a la progesterona, si no es capaz de reaccionar a ella, la “camita” que debería arropar al embrión estará más fina, contará con menos vasos sanguíneos y de menor calidad y sus glándulas no estarán desarrolladas correctamente, dificultando la implantación exitosa.
Por tanto, partimos de unos ovocitos en el ovario que se han desarrollado en un ambiente inflamatorio que les “ataca” y modifica incluso su carga genética, que llegan a un útero y unas trompas con adherencias, cuyas estructuras pueden estar alteradas y se tiene que implantar en una pared menos favorable de lo habitual.
Las adherencias que se van creando debido a las fibrosis producidas después de la inflamación, suponen a veces un obstáculo real para la fecundación a nivel de las trompas y puede disminuir la reserva ovárica si hay algún quiste en ellos (destruye los folículos en esa zona y luego se produce una zona cicatricial).
Otro factor que puede no ayudar en el proceso es que la contractilidad uterina puede estar alterada, poniéndoselo más difícil aun al embrión para una correcta implantación.
¿Se pude conseguir embarazo teniendo endometriosis?
Debido a los avances en las técnicas de reproducción asistida, el embarazo es posible en un porcentaje cada vez mayor de mujeres que la sufren. Por supuesto, se puede dar un embarazo espontáneo, pero ten en cuenta que, en este caso, se consideran suficientes seis meses de búsqueda para que os deriven a la unidad de fertilidad, frente a los 12 meses habituales en menores de 35 años.
¿Cómo quedarme embarazada si tengo endometriosis?: Tratamientos para conseguir la gestación
Muchas mujeres con esta enfermedad pasarán por tratamientos de reproducción asistida con el objetivo de conseguir su embarazo y la mayoría lo harán. De hecho, la tasa de éxito es del 80%. Aunque cada caso es único y puede haber situaciones más o menos graves. Por ejemplo, a nivel estadístico, las peores tasas de embarazo están relacionadas con endometriosis severa.
Uno de los tratamientos de elección en la fecundación in vitro (FIV), muy recomendada en caso de que la función de las trompas no esté bien, infertilidad asociada también al hombre o si se han probado otros tratamientos y no han funcionado. Se ha hablado mucho sobre si estas técnicas podrían conllevar un progreso de la enfermedad, pero la evidencia parece indicar que no es así.
En algunos casos, la FIV no será suficiente y habrá que recurrir a una ICSI. En ocasiones, puede ser necesario tratar algún quiste, desbridar adherencias o realizar un tratamiento hormonal previo la transferencia de embriones.
Es importante saber también que se puede acceder al programa de preservación de la fertilidad tanto en sanidad pública como privada, si se cumplen los requisitos estipulados para crio-preservar los ovocitos y utilizarlos en este tipo de técnicas, ya que la endometriosis puede evolucionar de un grado más leve a uno más grave poniendo en riesgo la reserva ovárica y los propios ovarios.
Es interesante la importancia que está adquiriendo un abordaje de esta patología desde los hábitos de vida diarios, no sólo para mejorar la sintomatología sino también para disminuir esa inflamación y modular el sistema inmune para hacer de ese entorno hostil, uno más acogedor para la fecundación y desarrollo fetal. Factores como la alimentación, el ejercicio, la suplementación adecuada, el descanso, la gestión del estrés… pueden ayudar, e incluso marcar la diferencia a la hora de convivir con esta enfermedad y también de conseguir la gestación.
Y si ya estoy embarazada, ¿qué riesgos hay?
Actualmente no se considera un factor como para que el embarazo sea de alto riesgo, aunque hay algunos estudios y revisiones recientes que relacionan la endometriosis con patologías como la diabetes gestacional, los trastornos hipertensivos del embarazo o el parto prematuro. Hay que tener en cuenta que los resultados de los estudios pueden haberse visto afectados por el hecho de que muchos embarazos se obtuvieron por FIV/ICSI y con la edad materna.
Riesgos del embarazo si tienes endometriosis
Durante el primer trimestre son habituales las molestias derivadas del crecimiento uterino que suelen mejorar a partir de la semana 14-20. Es lógico si pensamos que un gran número de adherencias y fibrosis se dan en los ligamentos uterinos, sobre todo en los útero-sacros, pero también en ligamento ancho y redondo. Este malestar se puede tratar con fisioterapia y estiramientos o ejercicios específicos.
En la literatura podemos encontrar referencias que apuntan a un aumento del riesgo de aborto en las primeras semanas relacionado con esa contractilidad uterina, el ambiente inflamatorio y una formación de la placenta deficiente. También se ha relacionado a esta patología con el aumento del riesgo de embarazo ectópico, en parte por las técnicas de reproducción asistida, pero también por la inflamación de las trompas que puede dificultar el transporte del embrión hacia el útero (0,8% de los embarazos versus el 1,8% en presencia de endometriosis ), pero se necesitan más estudios para confirmar estos riesgos.
En cuanto al desarrollo del embarazo, más allá de la afectación a las estructuras pélvicas que puede ir desde leve a severa, se han documentado elevaciones del riesgo de padecer diabetes gestacional mayores en las mujeres con endometriosis, probablemente relacionados con la resistencia a la insulina producida por el estrés oxidativo y la inflamación sistémica. Concretamente, en estas gestantes el riesgo es un 26% mayor.
También parece que podría afectar al desarrollo de patología hipertensiva, como la preeclampsia, debido a los mismos factores: inflamación, inmunidad alterada y estrés oxidativo. Esto a su vez se puede relacionar con partos prematuros más frecuentes y bajo peso al nacer, por la formación deficiente de la vascularización placentaria.
Aunque todo esto de lo que te hablo son riesgos estadísticos, no significa que a tu bebé o a ti os vaya a pasar algo malo, simplemente cada vez está más claro que estos embarazos merecen un seguimiento especialmente cercano para intentar prevenir o abordar los problemas que puedan surgir. Aún se necesitan más estudios para corroborar estas hipótesis y sobre todo para descubrir el verdadero origen y desarrollo de esta patología.
Vivir un embarazo con endometriosis
En general, más allá de esas primeras semanas, el embarazo para las mujeres con endometriosis suele ser un periodo en el que el dolor desaparece debido a que a nivel hormonal no se estimula ese tejido endometrial igual que en los ciclos menstruales.
Embarazo y endometriosis, cuidados
En mi opinión, merece mucho la pena intentar tratar las adherencias con fisioterapia antes del embarazo y mantener una movilidad pélvica y uterina óptimas durante el mismo. En la Tribu CSC cuentas con varios especialistas de nuestro equipo de profesionales que pueden ayudarte en este sentido.
Además, podéis descargar gratis la app de Criar con Sentido Común tanto para plataformas Apple como para plataformas Android, y tenéis una semana gratis para probar todas las ventajas de la membresía a la Tribu, realizar todos los cursos online disponibles y consultar a nuestros/as especialistas.
A nivel de experiencia profesional es habitual ver a mujeres con endometriosis cuyos bebés se han posicionado de nalgas debido a la excesiva torsión uterina y el acortamiento de los ligamentos.
Después del parto, muchas mujeres refieren haber mejorado en el dolor pélvico, las hipótesis indican que por un lado esto es debido a la rotura de las posibles adherencias y por otro al estado hormonal que se ha producido en la lactancia, manteniendo los estrógenos bajos. Pero no pasa en todos los casos.
Y, por último, creo que a día de hoy hay que avanzar en el diagnóstico y tratamiento de esta patología y apostar por un abordaje multidisciplinar sabiendo que la modulación inmunológica y la inflamación se pueden modificar con hábitos de vida adecuados.
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