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.