Ovarian Endometrioma: Surgery or IVF?

Endometriosis is a common cause of infertility. Findings associated with endometriosis include: painful periods that are getting progressively worse, pain with intercourse, infertility and ovarian cysts. Some patients may have bowel or bladder symptoms. A significant number will have no symptoms.

When endometriosis involves the ovary, it often manifests as cysts that are called endometrioma. These will have a typical “ground glass” appearance on ultrasound. Endometrioma may reduce fertility by causing focal inflammation in the outer shell of the ovary (ovarian cortex), which manifests as massive fibrosis and loss in the part of the ovary that maintains the eggs (cortex-specific stroma). This loss of eggs may may eventually result in loss of fertility.

The optimal treatment of infertile patients with endometrioma (shown to the right) has been debated for many years. In a recent issue of Fertility and Sterility, Bruce Lessey et al. have once again debated this issue (Fertil Steril 2018; 110 (7) 1218 – 1226). The reproductive surgeons and IVF specialists have each given their arguments in favor of surgery or IVF.

Here is my summary of the issue.

What are the pros and cons of endometrioma surgery?

Pros:

• With laparoscopic surgery you can make a definite diagnosis of endometriosis and treat it at the same time.
• Patients with pain related to endometriosis will often get relief from surgery.
• Endometriosis will often progress with time. In young patients with endometriosis, surgery will resect out the disease before it progresses and has a negative impact on the rest of the “normal” ovarian tissue.
• Twenty-five percent of patients will conceive naturally after surgery alone. Some groups have shown an even higher pregnancy rate (50 – 60%) within a year after surgery.

Cons:

• Surgery can have major complications. These include injury to bowel, bladder, infections, bleeding and risk of anesthesia. There can be a recurrence of the endometrioma in patients with “aggressive” endometriosis or if the surgeon is inexperienced and did not resect the cyst completely.
• Even in expert hands, normal ovarian tissue is removed along with the cyst wall. This results in loss of eggs and can result in diminished ovarian reserve or ovarian insufficiency (premature menopause). This is especially the case when both ovaries have endometrioma. Anti-mullerian hormone (AMH) levels (which indicate the number of eggs remaining in the ovaries) will drop by as much as 40% after surgery. The operated ovary will show a reduced antral follicle count, will produce lower number of mature follicles and will have a higher risk of producing no eggs during IVF stimulation.

What are the pros and cons of IVF for endometriosis patients?

• With IVF, patients can get pregnant very quickly.
• Egg freezing prior to surgery may be an option in patients where loss of ovarian reserve is a concern and are symptomatic (e.g. patients with bilateral endometrioma). This could also be an option in patients who are not quite ready to have a child (or another child).

Cons:

• There is no definite diagnosis of endometriosis. There are very rare instances where endometrioma can be associated with cancer (I, however, have never seen one after being in practice for more than 25 years).
• There have been several studies that have shown no improvement in IVF pregnancy rates with or without surgery.
• When IVF is performed after surgery, patients require higher doses of gonadotropins (fertility drugs used to stimulate the ovaries for IVF), show lower estradiol levels and produce fewer eggs.
• IVF can be expensive, especially in states where it is not covered by insurance.

So, what does all this mean?

As a rule of thumb, surgery of the endometrioma before IVF should not be performed unless the patient has pain that interferes with her daily life or when we detect on ultrasound either a rapid growth of the cyst or sonographic features of malignancy (cancer).

IVF should be the primary treatment in patients who are older, have endometrioma on both ovaries or have other factors that require IVF (male factor, tubal disease). Infertile patients with recurrent endometrioma, should avoid repeat surgery and go to IVF instead.

Surgery is indicated when quality of life issues are present (severe pain, pain with intercourse) or when cancer is suspected. It should be performed by an experienced laparoscopic surgeon.

Care of patients with endometrioma should be individualized based on the patient's specific situation. The Board-Certified Reproductive Endocrinologists at InVia Fertility Specialists have decades of experience in managing endometrioma. We have four convenient locations in the Northwest and North suburbs of Chicago. Please call 847-884-8884 to schedule an appointment. We are here to serve you and help you achieve your dream of having a baby.