Endometriosis and Your Fertility
Understanding the condition and its treatment
Surgical Treatments for Endometriosis
The obvious goal of surgical therapy is the elimination of all the endometrial implants. There are many different techniques for surgically treating endometriosis, but there are two important principles that need to be stressed:
- a major surgical procedure is rarely indicated to treat endometriosis for purposes of increasing your chances of getting pregnant, and
- if there is no alteration of normal anatomy as a result of scarring from endometriosis, surgery to eliminate the endometriosis does not improve one’s chances of getting pregnant.
Surgical therapy for endometriosis must be considered from the standpoint of the two major symptoms of endometriosis; that is, pain and infertility.
As noted above, endometrial implants are small collections of blood surrounded by scarring. The progressive nature of these implants causes more blood to accumulate while the scarring around it increases, often causing severe pain. The surgical removal of these implants is an excellent means of reducing if not eliminating endometriosis-associated pain. Even a small single implant can cause severe pain and there is little correlation between the amount of endometriosis present and the amount of pain. Therefore, if the history and physical exam are suggestive enough, laparoscopy and destruction of any endometriosis encountered should be considered for the potential relief of pain.
Laparoscopy is a minor surgical procedure done under general anesthesia and usually performed on an outpatient basis. A small incision less than an inch long is made under the belly button and a telescope-like instrument is inserted. A small amount of carbon dioxide is placed in the abdominal cavity to allow the surgeon to see the abdominal and pelvic organs. One to three additional incisions less than a quarter inch may also be used to introduce additional instruments. Through the laparoscope, the surgeon should be able to treat all but the most severe cases of endometriosis. Full recovery usually takes only a few days. Major surgery is typically required only if there is significant involvement of the bowel with endometriosis.
It does not seem to matter how the endometrial implants are destroyed. There are several different types of lasers available to do the job, including carbon dioxide, argon, KTP, and YAG. The physician can also use electro-cautery. All that is important is that the cells of the implant are destroyed without causing significant damage to the surrounding tissue. Surgical therapy can bring tremendous relief for pain associated with endometriosis.
Surgical therapy for endometriosis-associated infertility is an entirely different matter. If there is no significant alteration of normal pelvic anatomy associated with endometriosis, there is little if any improvement of conception rates as a result of surgical treatment of the endometriosis. If you have less than moderate endometriosis, according the classification mentioned above, there is no benefit to doing a laparoscopy and destroying the lesions.
How do you know how much endometriosis there is without doing a laparoscopy? First of all, the physician has done a pelvic exam, which will provide reliable information about pelvic anatomy. Second, an initial pelvic ultrasound has revealed whether or not there is an endometrioma present in the ovaries. It is very uncommon to have moderate endometriosis without some ovarian involvement that will be visible on ultrasound, or significant findings on the pelvic exam. Therefore, a good initial evaluation will allow a reliable determination of the potential extent of disease.
If there is ovarian involvement or significant scarring (adhesions) present, laparoscopic surgical intervention is warranted. Any endo-metrioma(s) can be removed from the ovaries, any adhesions cut and removed, and all visible lesions destroyed. This can and should all be done through the laparoscope rather than with major surgery. Aside from the fact that recovery is much easier and quicker for a laparoscopy than for major surgery, studies have shown that the results achieved from laparoscopic treatment are every bit as good if not better than those achieved with major surgery. We now have the technology and instrumentation necessary to perform thorough treatment for all but the most severe cases of endometriosis through the laparoscope. If you are going to have an evaluation for the presence of endometriosis, ask your surgeon how she or he intends to treat it. Do not have major surgery to treat endometriosis unless it is determined to be very severe.
There is no rationale for doing a laparoscopy to treat minimal or mild disease when dealing with endometriosis-associated infertility. Many studies have been done, and all but one demonstrate that surgical treatment of mild endometriosis is not associated with any improvement in the chances of getting pregnant.
Remember that there are many mechanisms by which endometriosis impairs fertility. None are really altered by eliminating the endometrial implants. For example, if the endometriosis has altered the ability of the fallopian tube to pick up an egg from the ovary, it is difficult to imagine that treating the implants will restore this function. The same is true for most of the other proposed mechanisms of endometriosis-associated infertility.
There is ample evidence showing that the chances of getting pregnant with mild endometriosis are the same whether you pursue “expectant management” (simple continued attempts at conceiving without any intervention) or have a laparoscopy to destroy the endometriosis. Couples with infertility associated with endometriosis without anatomic alteration should be treated and approached like couples with unexplained infertility, and this does not include doing a laparoscopy.
Endometriosis and Conception
Overall, the chances of successfully conceiving with endometriosis are inversely proportional to the extent of the disease: The worse the endometriosis is, the harder it becomes to get pregnant. Fortunately, truly severe endometriosis is uncommon. Results obviously are very individual, but with proper management and treatment, the vast majority of women with endometriosis will successfully conceive.
If you have mild endometriosis and are going to have a laparoscopy in hopes of helping you conceive, your doctor may use that laparoscopy to do gamete intrafallopian transfer (GIFT). Pregnancy rates as high as 40 to 50 percent can be achieved after a single laparoscopy and a GIFT procedure. This percentage is far better than that which can be achieved following a laparoscopy and laser or cautery of endometriosis. And GIFT works just as well when endometriosis is present as it does when the endometriosis has previously been treated.
Of course there will be cases and circumstances where surgical intervention for endometriosis is clearly indicated. But the point is this: In the past, the possibility of finding a small amount of endometriosis and treating it has been the justification for many, many surgical procedures. Some women have actually had several laparoscopies, or even major surgeries, for this reason. Not only is this invasive, in that an individual must endure one or more surgical procedures, it is also expensive.
There are now far more effective ways of achieving pregnancy—ones that are more cost-effective and far less invasive. Some of these approaches will include ovulation induction and other assisted reproductive technology, or ART procedures.
John C. Jarrett II, M.D., is co-author of The Fertility Guide: A Couples Handbook for When You Want to Have a Baby (More Than Anything Else)
YOU MIGHT BE INTERESTED IN