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Woman With Stage 4 Endo Worries About Endometrioma: Will Not Interfere With IVF, Can Be Excised At A Later Date

Posted Jun 16 2010 12:00am


I am 28 years old & TTC for a while. Diagnosed with stage 4 endo in Dec. 09. I was told to do 6 months of lupron, then another laparascopy from an ob-gyn. I got a second opinion from a fertility doctor in may 09 after not getting pregnant naturally with the assistance of acupuncture and herbs. He said I could do another lap, or start on fertility drugs. I chose to start on clomid 50 mg CD 5-9. I do have a 2mm cyst on my left ovary and am concerned about the cyst growing.

Is Clomid something recommended for someone with stage 4 endometriosis trying to conceive? I asked my doc if the cyst posed a problem and he said if it was larger then he would be concerned, but he said given the size it's not an issue. Well, if the clomid causes the cyst to grow, then that scares me. Not sure if I should consult another fertility doctor? K. from the U.S.


Hello K. from the U.S.,

In general, if a patient has stage 3 or 4 endometriosis, then the treatment of choice is IVF. The reason is because the endometriosis, despite the laparoscopy and Lupron, causes the pelvis to be inflamed and is hostile to the egg. Basically the egg gets destroyed before it can make it into the tube. This is not 100% of cases, however. I have had patients with stage 4 endometriosis that become pregnant naturally. How they did it, I cannot explain, but they are definitely the exceptions to the rule. In general, natural pregnancy is very, very difficulty with stage 4. Therefore, if you consulted me, I would recommend IVF to you.

The cyst you had (2 mms) is a normal follicle and technically NOT a cyst. We don't worry about cysts unless they are 2 cms (20mms) or more. The clomid will cause a follicle or follicles to grow. That is what it is supposed to do. Those follicles contain the eggs and they have to grow to 24 mms in order to ovulate and for the egg within to mature.

Because you are young, your doc is probably thinking that you could try something easier for a few tries to see if you might be one of the exceptions to the rule. That is why he is suggesting Clomid. Then if that doesn't work, he might suggest IVF. I would recommend that you talk with him/her again and ask if he/she thinks the Clomid has a good chance of working and what treatment would be the best treatment in light of the severe endometriosis. He/She might change their opinion then. I don't think you need to consult another fertility doctor because you just consulted me. I hope I gave you the information you needed.

Follow-Up Question:

Thank you Dr. Ramirez! You did clarify things for me. I'm sorry I meant to put 2cm cyst, I don't know why I put 2mm. I was told it was a chocolate cyst when I had my laparoscopy in Dec. The ob/gyn said he drained it. It was 4cm then, and now by June it has grown to 2cm again. I guess that is the reason I have been feeling the pain again. Can endometrial cysts dissolve on their own? If not, if it continues to grow does that pose any risk to getting pregnant if my tubes are open, and if I succeed in natural pregnancy could the cyst create a problem during pregnancy?

I just don't know if I should have another laparoscopy so soon. Is 6-7 months too soon? Thank you for any insight on this issue.

Follow-Up Answer:

Hello Again,

The cyst that you have is called an Endometrioma. It is an endometriotic cyst or tumor. Draining it is not sufficient because the endometriosis is still located within the cyst and it will refill as it has done in your case. It should have been excised (cystectomy) at the time of the laparoscopy. It will not interfere with your ovarian function and will not interfere with an IVF treatment. Its presence, however, means that endometriosis and scar tissue are still present and an issue, which reduces the chances of a natural pregnancy (as I explained previously).

If you were lucky enough to become pregnant naturally despite the endometriosis, then pregnancy is a good treatment for endometriosis, and the endometriosis will not complicate the pregnancy. Neither will the endometrioma as long as it does not get too big or does not twist on itself (torsion). If needed, it can be removed during pregnancy.

Six to seven months for another laparoscopy is not too soon. We usually will do a second-look laparoscopy within 4 weeks if we are worried about recurrent scar tissue formation. My advice would be either to have another laparoscopy and this time make sure the cyst is removed, then proceed to IVF or proceed to IVF directly without the laparoscopy. My wife had an endometrioma at the time that we did our IVF which they were able to drain at the time of egg retrieval. It did not interfere and her cycle was successful.

Good Luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
Twitter with me at @montereybayivf and follow me on Facebook at

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