Should Endometriosis Treatment Come Before IVF?

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.

They say that even if you need IVF, the endometriosis will have to be surgically removed. Apparently the rationale behind this is that the cysts it will 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 that implant in the uterine cavity.

The Problem

Actually, unnecessary laparoscopic surgery can reduce your chances of successful IVF. Removing the chocolate cyst causes damage to the normal adjacent ovarian tissue, in turn reducing the ovarian reserve even further. Women with endometriosis already have reduced ovarian reserve and surgery only further reduces it, making them unable to grow good, quality eggs after they go in for IVF treatments.

What Experts Have to Say

A recent Human Reproduction paper, published 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.

Conflicting Interests

Why is there such a difference of opinion? The reason stems from the over-specialization in the field of medicine. Every specialist focuses on nothing but his or her own specialty. 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. 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 physician 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 About the Patient?

Receiving conflicting advice can cause confusion but there is a very simple solution: The right patient has to be selected for the right treatment.

Endometriosis treatment is often a better option for women that:

• Have a normal AMH level
• Have a normal antral follicle count, which suggest that they have normal ovarian reserve
• Are younger
• Has a partner with a normal sperm count

Ideally, a multidisciplinary team of doctors should treat endometriosis patients where both gynecologists and IVF specialists can provide their viewpoint, and the patient can weigh both perspectives and then make up her mind. The surgery may offer them a window of opportunity and if they understand the pros and cons, then it's an option worth exploring.

IVF is often a better option for women:

• That are older
• With a poor ovarian reserve
• Has damaged tubes
• Whose husband's sperm is abnormal

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

For those with 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, it can be aspirated before your super ovulation is started. This means it can be treated non-surgically
• Similarly, there is 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.

If you are interested in receiving more information about your potential treatment options, please schedule an appointment with one of our board certified physicians today.

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