Monday, April 20, 2015

Should you treat the endometriosis before doing IVF ?

Lots of patients who have endometriosis are infertile , and they are not sure what they should do. Should they treat the endometriosis first? or should they treat the infertility first? Often the advice they get is conflicting !

A gynaecologist who specialises in laparoscopic surgery will tell them that we need to treat the endometriosis first,  before you can do anything further. They say that even if you need IVF,  we first need to remove your endometriosis surgically . The rationale for this apparently is that if the endometriosis remains behind , it will interfere with the IVF treatment cycle and reduce IVF pregnancy rates. This seems to make sense, but is actually quite illogical.

If you have endometriosis and need IVF , there is no need to do anything about the endometriosis per se, because the endometriosis is outside the uterine cavity and is not going to affect the embryos , which need to implant in the uterine cavity . In fact, unnecessary laparoscopic surgery can reduce your chances , because removing the chocolate cyst causes damage to normal adjacent ovarian tissue , and this reduces the ovarian reserve even further. As it is , patients with endometriosis have reduced ovarian reserve, because endometriosis eats into their ovaries , and doing surgery just makes a bad problem even worse.  When patients do the surgery, and then go for IVF, they find that they are not able to grow good quality eggs, because the surgery has reduced their ovarian reserve. They then complain that the doctor performed unnecessary surgery, only in order to make money !

A recent Human Reproduction paper, published in March 2015, " Surgical diminished ovarian reserve after endometrioma cystecomy versus idiopathic DOR: comparison of IVF outcome" , Audrey Roustan, et al) proves that the chances of IVF success are decreased in women with diminished ovarian reserve after cystectomy for endometrioma. This is especially true for women with bilateral endometriomas.

Why is there such a difference of opinion ? The reason is because of the over-specialisation in medicine today. Each specialist has a very myopic view, and is focussed only on his specialty. After all, when all you have in your hand is a hammer, you are likely to see only nails. Because gynecologists don't have any training or experience in IVF, they don't realise the inadvertent harm they end up causing their patients by doing this surgery.

The surgery can be quite gratifying for the surgeon, and  the before and after laparoscopic images are quite impressive, because the surgeon removes the adhesions and clears the pelvis. However, while the pelvis may look much prettier after the surgery, this is not very useful because it does not help to improve fertility.

So what is the poor patient to do ? You are likely to be confused, because you are getting such conflicting advice. After all, there are patients with endometriosis who do conceive after laparoscopic surgery ! And if the surgery can help you get pregnant in your own bedroom, and save you the expense of doing IVF, then isn't it worth considering ? And isn't Dr Malpani likely to be  biased towards advising IVF because he is an IVF specialist ?

The trick is simple - it lies in selecting the right patient for the right treatment. Thus, patients with endo who have a normal AMH level and a normal antral follicle count ( which suggests they have normal ovarian reserve) could consider trying surgery, if they are young, and their husband's sperm count is normal. The surgery may offer them a window of opportunity and if they understand the pros and cons, then it's an option worth exploring.

Ideally, endo patients should be treated by a multidisciplinary team of doctors, where both gynecologists and IVF specialists can provide their viewpoint, and the patient can balance both perspectives  and then make up her mind.

However, IVF is often a better option - for example, if you are older, your ovarian reserve is poor, your tubes are damaged , or your husband's sperm are abnormal. If you do need IVF, then you should could just go ahead , and not waste your time doing laparoscopic surgery before the IVF cycle .

What if you have a chocolate  cyst ? Will this affect your IVF treatment ? If it’s less than 3 cm , we can leave it alone because it doesn't affect IVF treatment at all . If it large , we can aspirated it before we start your super ovulation . This means it can be treated non-surgically .

Similarly, there's no need to suppress your endometriosis medically with GnRH agonists such as Lupron before starting IVF.  This temporary suppression jst wastes time and does not improve IVF pregnancy rates.

Just because you have a cyst on your ultrasound scan ; or have pelvic pain , this doesn't automatically mean that this needs to be treated. The good thing about IVF is it's a very effective shortcut, that bypasses all the problems , and maximizes your chances of getting pregnant quickly . The beauty is that once you do get pregnant with IVF , you will get dramatic relief of your pelvic pain, and your endometriosis will usually regress while you’re pregnant , and while you're breast-feeding as well.

Not sure whether you need IVF or laparoscopic surgery for your endometriosis ? Please send me your medical details by filling in the form at so that I can guide you better !


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