Friday, June 12, 2015

Should the Endometriosis be treated Before IVF treatment ?

Since many patients who have endometriosis are also infertile, they are not too sure about what they should do.  Should the endometriosis be treated first or should the infertility be attended to first? In most instances, this advice can be very conflicting.  A gynecologist who specializes in laparoscopic surgery will tell the patient that the endometriosis will have to be treated before she even considers getting infertility treatment.

A Logical Point

They say that even if you need IVF, the endometriosis will have to be surgically removed. Apparently the rationale behind this – it will in interfere with the IVF treatment cycle and reduce IVF pregnancy rates. Though this seems to make sense, it’s 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 (these need to implant in the uterine cavity).

The Problem

As a matter of fact, unnecessary laparoscopic surgery can actually reduce your chances of successful IVF, because removing the chocolate cyst causes damage to the normal adjacent ovarian tissue; in turn this reduces the ovarian reserve even further. As it is, patients with endometriosis have reduced ovarian reserve, because endometriosis eats into their ovaries; any surgery only adds fuel to the fire. When patients get the surgery done and then go for IVF, they find that they are unable to grow good quality eggs- this is because the surgery has reduced their ovarian reserve. They then complain that the doctor performed unnecessary surgery, only in order to make money!

What Experts Have to Say

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.

When Harm is Caused

Why is there such a difference of opinion? The reason is because the field of medicine  suffers from over-specialization. Every specialist wears  blinkers and focuses on nothing but his own 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 realize the inadvertent harm they end up causing their patients by doing this surgery.
The surgeon  can find  this particular  surgery very gratifying as the before and after laparoscopy images are quite impressive; this is because  the removes the adhesions and clears the pelvis. While the pelvis may look much prettier after the surgery, this is not very useful because it does not help to improve the patient’s fertility.

So what is the poor patient to do ?

Since  you have got conflicting advice, you are undoubtedly confused. 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 Simple Solution

There is a very  simple solution- The right patient  has to be selected  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. This is 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 weigh both perspectives and then make up her mind. However, IVF is often a better option - for instance, if a woman is older and her:

•    Ovarian reserve is poor
•    Tubes are damaged
•    Husband's sperm are abnormal

If she needs IVF, then she should could just go ahead, and not waste her time doing laparoscopic surgery before the IVF cycle .

What if you have a chocolate cyst?

•    If the chocolate cyst is  less than 3 cm, we can leave it alone because it doesn't affect IVF treatment at all
•    If it’s larger, we can aspirate 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 just wastes time and does not improve IVF pregnancy rates
•    Just because you have a cyst on your ultrasound scan, or have pelvic pain, it  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 significant relief from your pelvic pain, and your endometriosis will usually regress while you’re pregnant , and while you're breast-feeding as well.

Need more information? Please send me your medical details by filling in the form at so that I can guide you better!

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