First of all, thanks to all you ladies who wrote back about your relationships. I was especially touched by the last comment, and it's so true that endo affects more than just the spousal relationship, but also the ones with your kids, your parents, your friends. Seeing the pain our patients go through before getting any relief is what drives me to excellence, because it's only by my ability to do what Dr. Redwine does that I'll be able to carry on his legacy of helping patients who find no help elsewhere. It's gratifying to know that David thinks I'm almost there - I can successfully excise all endo in about 95% of our patients, and it's only the really really tough cases (who most other endometriosis surgeons have failed) where I need his help. I'm pretty excited about that. But I digress.....
I was asked to write about endo and infertility by Nancy Peterson. I guess she's had a lot of questions about this and thought I might shed some light on this. I told Dr. Redwine about my quest, and he said "it's a black hole"....
So, what can be said about infertility within the context of endometriosis?
First, endo patients typically are slightly less fertile than women without endo. That being said, there are many different etiologies for sub-fertility, and many may be at play in any one couple. Plenty of women with endo conceive and carry perfectly normal pregnancies, so why is it that some can't? There are the obvious reasons such as those with tubal adhesions where the tubes are stuck to the back of the uterus, or to the colon, or anything else, really. But those people are few and far between. Why does mild endo affect fertility? I pulled a couple of articles yesterday that pertain a little to this. For women with mild-minimal endo, the conception rates and delivery rates after IVF were much better in those women who underwent surgical excision of the endo prior to IVF. This suggests that even when bypassing the tubes via IVF, the endo living in the pelvis has a negative impact on fertility. Probably this is mediated by some local inflammation, but the exact reason hasn't been elucidated yet. Treatment with any medicine, whether birth control, lupron, or aromatase inhibitors only decreases fertility, and has never been proven to enhance fertility in patients with endo.
Finally, conservative surgical excision (what we do - remove the disease, not uninvolved innocent organs) has a beneficial effect on fertility. Dr. Redwine wrote a paper about conservative excision for obliteration of the culdesac (stage IV endo), and 40% of the women who wanted to conceive after surgery did. That's pretty good, considering that most of those women hurt too much beforehand to even think of getting pregnant. Surgery is the only treatment for endometriosis that improves fertility, although it is not a guarantee of fertility. The only time fertility is challenged by surgery is when the patients have large bilateral endometriomas, and after removing the cysts, at times there is not a lot of normal ovary left in place, so the number of follicles (potential eggs) is greatly decreased after surgery. Unfortunately, there's no other way of treating endometriomas that works without risk of recurrence, so pretty much that's what we have to do to get pain relief. Luckily, this is a rare situation and occurs mostly in women in their late 30s and 40s. Stimulating ovaries such as with clomid or pergonal (used with IVF cycles) is contraindicated in women with large cystic ovaries, so there's really no other alternative to ovarian cystectomy in patients with large endometriomas.
So, to summarize this rambling stream of consciousness blog, surgery preferably with excision of endometriosis lesions is the best first-line treatment for women with endo and infertility. If pregnancy is not achieved spontaneously after surgery, then success rates with IVF will still be better after surgery than before.
For those of you with endo who haven't tried to get pregnant - don't give up. Plenty of women with endo get pregnant spontaneously, the old fashioned way, without any help. For those of you with pain, excision is the most effective way to permanently get rid of the endo and preserve fertility, as well as natural hormone production.
Take care, and have a great week.
Dr. Mos