Question 36. Do I need endometriosis surgery if I am already planning to pursue IVF?

I wish sometimes that medicine was more like engineering. In engineering there are lots of straight lines and right angles. You can usually describe any problem with specific equations and most of the time there is clearly one right answer. Unfortunately, medicine is not engineering. There are some questions that cannot so easily be answered with a definitive "yes or no." My wife is an engineering PhD, so I can easily understand why very intelligent people can just want to scream when faced with some of the uncertainty inherent in medicine...especially reproductive medicine. Obviously, the "right" decision is the one that results in a successful pregnancy. But since more than one option may result in pregnancy (including no treatment at all) the situation can often seem "as clear as mud."

The Question of the Day returns to the subject previously raised in Question 34 concerning fertility and surgery for endometriosis. However, today we are specifically dealing with the issue of surgery prior to IVF. In patients that have failed non-IVF treatments and are wondering if they should do a laparoscopy at this junction I offer them the following advice...

If I do a laparoscopy and see terrible endometriosis then I am going to recommend IVF.

If I do a laparoscopy and see some endometriosis then I am going to recommend IVF.

If I do a laparoscopy and see no endometriosis then I am going to recommend IVF.

So why the heck are we off to the operating room? Indeed. That is why surgical volume for fertility patients has fallen off a great deal. However, patients with a known/suspected endometrioma cyst represent a different group and call for a different approach...and that is the topic of today's Question of the Day!


36. Do I need endometriosis surgery if I am already planning to pursue IVF?

The question of endometriosis surgery prior to IVF is a somewhat controversial area of reproductive medicine. Most reproductive endocrinologists do not recommend surgery prior to IVF unless the woman has advanced endometriosis, in particular, an ovarian endometrioma.

IVF is associated with excellent pregnancy rates (even without surgery) in women who have only mild to moderate endometriosis. When advanced endometriosis is present, such as an ovarian endometrioma, its surgical removal prior to IVF may enhance the chances for a successful IVF outcome and may decrease infectious complications related to egg collection. Thus, in such cases, most reproductive endocrinologists often recommend the removal of advanced endometriosis prior to treatment using IVF.

However, severe endometriosis with endometriomas may lead to diminished ovarian responsiveness, and ovarian surgery may further compromise fertility in such cases. So the decision to perform extensive surgery for endometriosis must be weighed against the potential impact of that surgery on the ovary. Also, advanced endometriosis may increase the likelihood for an early pregnancy loss or spontaneous abortion. By first removing the endometriosis, the outcome of pregnancy may be improved. Ultimately, the decision whether or not to remove perform surgery rests between doctor and patient. In general, we believe that the removal of a small 1-2 cm endometrioma is unlikely to impact IVF success but the removal of large endometriomas may be reasonable before attempting IVF. Some doctors advocate a threshold of 4 cm for endometrioma removal but the data supporting this contention warrant further study.

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Question 37. What is the difference (if any) between intrauterine insemination and artificial insemination?

What's in a name? Sometimes not much I guess and certainly we throw around medical jargon quite freely in our practice sometimes forgetting that all this can be quite confusing to patients. I recently had a patient that came in requesting IUI with ICSI. She was very frustrated when I explained that you really cannot do ICSI unless you do IVF. However, she was adamant that she didn't want IVF with ICSI she wanted IUI with ICSI. I just was unable to make her understand the difference between IUI, IVF and ICSI. Oh well, she probably posted on some website that I am an insensitive physician who was unwilling to help her....

Of course, I know that all of you would easily be able to explain the difference between these because you have read this blog (along with my Mother) and have purchased our book.

So for those a bit unclear on some basic terminology here is today's Question of the Day from the soon-to-published 2nd Edition of 100 Questions and Answers about Infertility.


37. What is the difference (if any) between intrauterine insemination and artificial insemination?

Artificial insemination (AI) is a historical term that encompasses any technique involving the introduction of sperm into the female reproductive tract without sexual intercourse. Semen can be placed into the vagina (intravaginal insemination) or into the cervix (intracervical insemination) without any special preparation of the specimen. However, if unprepared semen is placed directly into the uterus [intrauterine insemination (IUI)], then severe spasmodic uterine cramping can occur. Thus, when performing an IUI, the sperm must first be washed and prepared prior to placement inside the uterus. Washing the sperm removes prostaglandins, the hormones that cause the violent uterine contractions. Washing also eliminates substances that might lower the sperm quality and activates the sperm, thereby leading to improved sperm motility. Generally, the IUI specimen is prepared in the doctor’s office just prior to insemination.

The actual IUI is a painless, simple, in-office procedure that is often performed by a nurse. It usually takes just a minute to perform. Physicians typically ask patients to come in with a full bladder so that the angle between the uterus and cervix is altered, which allows for easy passage of the catheter into the uterine cavity.

Today, it is rare for patients to undergo other forms of insemination besides IUI because the pregnancy rates with IUI are better than those obtained by intravaginal insemination or intracervical insemination.

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Question 35. Are there medical treatments for endometriosis?

Occasionally I am asked to see a patient with endometriosis who is not interested in fertility. Although I can certainly manage these patients, I honestly think that they are better served by going to a non-fertility clinic RE. Our practice is pretty much 100% geared to the needs of fertility patients and I wonder if those patients who are not seeking pregnancy ultimately feel like a fish out of water in our waiting room....

Fortunately there are some effective medical treatments for endometriosis. Unfortunately, all of these treatments shut down reproduction so they are not appropriate for the endometriosis patient seeking pregnancy.

Meanwhile I wanted to share the exciting news that the 2nd Edition of 100 Questions and Answers about Infertility is at the printers! Let the presses roll!

35. Are there medical treatments for endometriosis?

Several medications are used to treat endometriosis. All of these medications suppress ovulation and cause a hypoestrogenic state. Understandably, suppressing ovulation also prevents pregnancy from occurring so medical therapy is not appropriate in patients actively seeking fertility. In patients who are not trying to conceive, medical treatment of endometriosis can be very beneficial and relieve symptoms of dysmenorrhea and pelvic pain.

One common medical treatment is to prescribe the combination oral contraceptive pill. Although each of these daily pills contains estrogen, the progestin (progesterone-like component) in the pill overrides the estrogen effect, resulting in suppression of endometriotic lesions. Oral contraceptive pills are effective in 30% to 60% of patients with endometriosis-related pain.

Many physicians prescribe gonadotropin-releasing hormone (GnRH) analogs (such as Lupron), which reduce estrogen levels to postmenopausal levels for their patients with endometriosis. These medications suppress estrogen production, prevent ovulation, and cause atrophy of the endometriosis in 70% to 90% patients. Unfortunately, GnRH analogs are expensive and must be given as injections either once a month or every 3 months. GnRH agonists can cause side effects including headaches, hot flashes, moodiness, insomnia, and vaginal dryness. To counteract these side effects experienced by many patients treated with GnRH agonists, physicians often prescribe oral contraceptive pills or supplemental progestin therapy (such as norethindrone) along with the GnRH analogs. This combined therapy ay allow for improved treatment acceptance through the alleviation of the many side effects associated with the use of the GnRH analogs as single therapy. Patients tolerate this combination very well and achieve maximal benefits in suppressing the disease and its symptoms.

As noted previously, medical therapy is not indicated for patients with endometriosis who are actively trying to conceive, since all of these treatments will suppress ovulation. Instead, for these patients, the goal should be to promptly establish pregnancy before the endometriosis causes any further damage to the reproductive organs. Generally, these women should seek treatment from a fertility expert to maximize their chances for successful pregnancy.

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Question 34. Does surgery for endometriosis improve pregnancy rates?

Where does all the time go? Seems like just yesterday that I was writing the last post before I went on vacation and now I realize that a whole month has passed. You may have wondered "where is Dr. Gordon?" "Why hasn't he posted a new blog that will make our day a little brighter and put a little more zip in our step?" "Why do the 6 of us keep reading this blog if he doesn't care enough about us to spend just a few minutes posting his words of wisdom?" "Why didn't I buy Apple stock at $25?" Wait that last question is the one that I keep asking myself. Not to be a name dropper but my son was in preschool in California with Steve Job's son Reed. Man, if only they had become best buddies.....unfortunately, my son thought that Reed was weird and wouldn't play with him. Apparently, when you are 3 years old it doesn't matter when some kid's father is worth 6 Billion dollars. But I digress....

So in a couple of weeks we are having a CME (doctor's continuing education) course at Fairfax Hospital. One of the questions concerns surgery for endometriosis. Guess what? No one is really sure of what to do in some of these cases. Overall, we seem to be moving away from surgery for the infertile patient, and yet, there are still occasional patients that would benefit from a laparoscopy. The problem is figuring out who would benefit from surgery and who will not. In starting to address that issue I will present today's Question of the Day from the 2nd Edition of 100 Q&A about Infertility (which is currently being printed!):

34. Does surgery for endometriosis improve pregnancy rates?

Well-designed medical studies clearly show that destroying even small implants of endometriosis 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 above 30% for a single treatment cycle. Nevertheless, because treatment of endometriosis at the time of surgery does improve pregnancy rates, most surgeons will do their best to destroy endometriosis at the time of 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, as medical therapy is ineffective in the treatment of endometriomas. The ultimate choice of whether to perform a laparoscopy or laparotomy depends on the operative findings and the skill and experience of the surgeon.

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