Friday, July 23, 2010

Treating endometriosis in an infertile woman

I saw a patient who was at her wit's end. She had already had two laparoscopies for treating endometriosis. Since she was still not pregnant, she had gone to a third gynecologist. He did an ultrasound scan and found that the chocolate cyst had recurred; and was advising her to undergo a third surgery to "fix" the problem.

We find this is a very common tragedy which plays out frequently. The diagnosis of endometriosis is often done by the first doctor, while doing a diagnostic laparoscopy. He "treats" the problem by burning off the lesions, and dividing the adhesions. When the woman does not get pregnant after this, she gets a second opinion from an expert. This expert often pooh-poohs the surgical skills of the first doctor, and suggests that he needs to do another laparoscopy, in order to do a better job, to fix the problem once and for all ! The patient regrets having allowed the first doctor ( who appears to have not been very competent in hindsight !) to do the laparoscopy. She signs up for the second surgery and is now very hopeful. The doctor does the laparoscopy and "cleans" up everything - and shows her a beautiful video which demonstrates his surgical prowess. He then puts her on medications, and then tells her to "go forth and have babies " in her bedroom ! She is often quite happy for a few months, because her pain has now improved, and her symptoms are much better. However, when she still does not get pregnant, she goes back to him. Unfortunately, he has lost interest in her problem, because he is primarily a surgeon, and when you have a hammer, all you see are nails. He gives her some more medicines, and tells her to relax, go for a holiday and have more sex. When this also fails, she goes to a third doctor, who then finds the endometriosis has recurred; and suggests that he needs to do another laparoscopy, where he will compensate for the surgical shortcomings of the earlier surgeon, by using the " newest and latest " third generation laser and robotic equipment, which are available only in his clinic !

The sad truth is that endometriosis recurs, no matter how good the surgeon. We can never cure it - and even our treatment leaves a lot to be desired, because of our limitations ! This is hardly surprising, when you consider that we do not even know what causes this enigmatic disease ! While we are very good at suppressing this medically ( with GnRH analogs), this suppression is only temporary. Even worse, while these medicines are very effective as suppressing the endometriosis , they also suppress normal fertility ( because they stop ovulation). This medical treatment just wastes time and money ; and patients get fed up and lose confidence in doctors and in themselves !

What about laparoscopic surgery for removing the endometriosis ? While this is effective in some selected cases ( those patients with open tubes, good ovarian reserve, and anatomic distortion because of adhesions), it's not helpful for the majority. In fact, in some women, unnecessary surgery actually reduces fertility as normal ovarian tissue is also removed along with the wall of the chocolate cyst, thus reducing their ovarian reserve.

Unfortunately, patients believe that once the doctor has made a diagnosis of endometriosis, this disease is the cause of their infertility; and that once this is "treated", their fertility will be restored, and they will be able to get pregnant in their own bedroom. However, this is also a flawed assumption ! Endometriosis is a very common finding, even in fertile women; the endometriosis found on the laparoscopy in an infertile woman may just be a red herring, and not the cause of the infertility. This is why "treating" it may not help at all !

Let's go back to my patient.

" What do I do now , doctor ? I am completely fed up ! How do I manage my pain ? And what about having a baby ? "

I explained to her that she needed to set her priorities. " Which is more important right now ? managing the pain ? or having a baby ? We can't do both together - we need to do this one step at a time !"

" For me, having a baby is my first priority doctor".

" Fine, then let's focus on getting you pregnant. Let's forget about the pain and the endometriosis for now . The reason you are not getting pregnant is because your eggs and sperm are not meeting in your fallopian tubes. We need to get the eggs and sperm to do so; and we need to use assisted reproductive technology in order to do this."

The next step is to check the AMH level, to determine what the ovarian function . For young patients with a normal AMH level, the next step would be 3 cycles of superovulation with IUI. However, for older women; those with low AMH levels; and if the IUI fails, then the best course of action is IVF. After all, we need to find solutions , not waste time looking for problems !

Is there any need to surgically remove the endometriosis prior to doing IVF ? No ! The endometriosis is outside the uterus and will not affect embryo implantation, so it's best left alone.
If there is a chocolate cyst, we can always aspirate ( puncture) it under ultrasound guidance, when starting the IVF cycle.

The good news is that an additional bonus with this approach is that once you get pregnant, the endometriosis will also automatically improve !

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