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Endometriosis and infertility - surgery or IVF ?

Posted Apr 10 2010 2:36am

endometriotic lesions in the Douglas pouch and... Image via Wikipedia

Endometriosis is one of the commoner problem infertility specialists see. It is common in young women, so this is hardly surprising - but what is amazing is the amount of confusion and controversy it causes amongst infertility specialists.

There are many treatment options, but for treating endo in an infertile woman, doctors have to choose between endoscopic surgery; or IVF.

Most gynecologists like operating. They feel that it's obvious that the mechanism by which endo causes infertility is anatomical; and that surgically removing the lesions and the adhesions should fix the problem and restore fertility. Surgery is often less expensive than IVF - and if normal function is in fact restored after surgery, than you can make a baby in your own bedroom ! This is a common approach but is flawed because it is not an accurate representation of reality. After all, surgical correction can restore anatomy , but not function !

IVF specialists see many patients with endo who have had repeated surgeries, but have never been able to get pregnant. Because an operative laparoscopy is "minimally invasive" surgery and so easy to repeat, many surgeons just keep on doing it again and again ! Patients will often move from surgeon to surgeon, each of whom will promise to " fix the problem " by using the latest gizmo or toy they have just purchased , whether this is a laser , a bipolar cautery or a harmonic scalpel. Surgeons are nortoriously macho, and often believe they can do a much better job than the earlier surgeon ! The poor patient is subjected to surgery after surgery, until her belly resembles a battle field - but with nary a single positive HCG in sight !

So does that mean all patients with endo should be referred to IVF specialists for IVF treatment ? Of course not ! This would be overkill , as many patients with minimal endo can be treated with simpler treatment options.

If you go to a gynecologist or endoscopic surgeon, the odds are he will advise surgery. And if you go to an IVF specialist, he will advise IVF ! After all, if you have a hammer in your hand, all you see are nails !

So how is the patient to decide which is the best option for her ? Some will take an opinion from multiple doctors - and end up getting thoroughly confused, upset and frustrated !

The trick to finding out what your best plan of action is actually quite surprising - you need know what your ovarian reserve is ! Unfortunately, this is something very few patients know about - and very few doctors bother to check !

Your ovarian reserve is a marker of your fertility and gives us an indication of how many eggs you have left. It declines with age; is negatively impacted by endometrisis; as well as the surgery which is done to treat the endometriosis ! Unnecessary surgery reduces your fertility as normal ovarian tissue is also removed along with the cyst wall, thus reducing your impaired ovarian reserve even further .

The best test for your ovarian reserve is a blood test to check your AMH levels .

If you are older and/or have low AMH levels, then it's far better to not waste time with surgery, and move on to IVF directly . This is also true if your husband has a low sperm count.

However, if you are young and have normal AMH levels, it is quite reasonable to attempt reconstructive surgery to treat the endometriosis before considering IVF, which is usually much more expensive than surgery ! If you do choose to have surgery, make sure your doctor checks your AMH levels before and after the surgery ! Many doctors do not bother to do this - and this can reduce your chances of having a baby !

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