Endometriosis and IVF

Sorry for the large gap between posts but I actually took some vacation and have been paying for it ever since. Usually it takes at least a week to catch up and handle all the questions that have been raised over the previous week. This torture explains why my vacation schedule is pretty sparse!

Once back here at Dominion I was interested in the Grand Rounds lecture given at Inova Fairfax Hospital this past Monday. The topic was the surgical treatment of endometriosis and infertility. Specifically the question of removal of endometriomas was raised and discussed. Basically, there are no good randomized studies so one is left with the choice of doing IVF with an endometrioma just sitting there, or taking a patient to the operating room before IVF. There may be an increased risk of infection after egg collections where an endomtrioma is pierced. However, the absolute risk of infection after egg collection remains very low. Removing the endometrioma removes this risk but may further damage the ovary reducing the egg count… Decisions, decisions…

Ultimately, there is no clear cut answer here so I try to individualize based upon the patient and her history. Hopefully, your RE will do the same.

So after much delay here is today’s Question of the Day from the book that we shamelessly promoted on the Kane Show (click here to hear us on the air) on 99.5 FM here on Tuesday .

37. Does surgery for endometriosis improve pregnancy rates?

Well-designed medical studies clearly show that destroying even small amounts of endometriotic tissue can improve fertility by as much as 50%. In a large Canadian study, the monthly pregnancy rate following surgical treatment of minimal endometriosis rose from 3% to 4.5%. Although this finding represented a 50% improvement in the patients’ monthly chance of pregnancy, it does not compare very favorably with IVF pregnancy rates, which average around 30% for a single treatment cycle.

Nevertheless, because treatment of endometriosis at the time of surgery does improve pregnancy rates, most doctors will destroy the abnormal endometriotic tissue at the time of the diagnostic laparoscopy by using either laser or coagulation techniques. In addition to improving fertility, surgery may often eliminate or improve symptoms of dysmenorrhea and pelvic pain. Ovarian cysts that contain endometriotic tissue may grow quite large. They are often called “chocolate cysts” because of the dark brown fluid found within them, although endometriosis cysts are more correctly referred to as endometriomas.

If left untreated, these growths may destroy part or all of the normal ovarian tissue, including the eggs. Endometriomas must be surgically removed, usually via laparoscopy. Sometimes, however, laparotomy is required. The ultimate choice of which surgery is performed depends on the operative findings and the skill and experience of the surgeon. Medical treatment of endometriomas is insufficient and will not cause these cysts to resolve.