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Endometriosis Update

Studies show that 25 to 50 percent of infertile women have endometriosis, and that 30 to 50 percent of women with endometriosis are infertile. In September 2012, the American Society for Reproductive Medicine (ASRM) updated its Practice Committee Opinion on endometriosis and infertility.

The Committee drew the following conclusions

  • Female age, duration of pelvic pain and stage of endometriosis should be considered when formulating a management plan.
  • The benefits of laparoscopic treatment of minimal or mild endometriosis is insufficient to recommend it solely to increase the chance of pregnancy
  • When laparoscopy is performed for other indications, the surgeon may consider safely ablating or removing visible endometriosis
  • In women under age 35 with Stage 1 or 2 endometriosis-associated infertility, ovulation induction with IUI can be considered as first-line therapy
  • In women age 35 or older, more aggressive treatment such as ovulation induction with IUI or IVF may be considered
  • In women with stage 3 or 4 endometriosis-associated infertility, conservative surgical therapy with laparoscopy or possible laparotomy may be beneficial
  • Surgical management of an endometrioma should include resection or ablation; resection is preferred
  • In women with stage 3 or 4 endometriosis who fail to conceive following conservative surgery or because of advancing reproductive age, IVF is an effective alternative.

    Medical Therapy and Treatment for Endometriosis

    “I think it’s very important to distinguish between medical therapy for endometriosis to treat pelvic pain and medical treatment for endometriosis to treat infertility,” says Mark Hornstein, MD, Director of the Division of Reproductive Endocrinology and Infertility at Brigham and Women’s Hospital in Boston, MA, and Co-director for the Boston Center for Endometriosis. Virtually all medical therapy to treat pain inhibits ovulation, and is not appropriate for women who are trying to get pregnant. Medical treatment of endometriosis to treat infertility may include laparoscopic surgery, ovulation induction with IUI or IVF.

    “The improvement [in pregnancy rates] by doing surgery is quite modest for low stage disease – stage one and stage two. Part of that may be that those patients have a pretty good prognosis for getting pregnant overall,” says Hornstein. In patients with stage three or four endometriosis, pregnancy rates following surgery are relatively better, but the prognosis isn’t as good. They go from a very low pregnancy rate to a very modest pregnancy rate.

    Owen Davis, MD, FACOG, was part of the Practice Committee. He is also a fertility doctor with The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine at Weil Cornell Medical Center in New York City. “Assuming everything else seems to be in working order, tubes are open, sperm is fine, and not just chronological age, but ovarian reserve is good, it’s reasonable to try a few cycles of IUI, with clomiphene or injectables,” says Davis. “If clomiphene IUI doesn’t work, there is good reason to go to IVF, rather than go to injectable IUI. It does seem to be cost effective, it does seem to get people pregnant quicker, and it has a lower risk of high order multiple pregnancies,” Davis adds.

    Age and Endometriosis Treatment

    As with non-endometriosis cases, fertility doctors tend to be more aggressive with fertility treatment upfront and/or to escalate treatment more rapidly if the women is older. Davis would be more apt to escalate to IVF for a 43-year-old woman who has what looks like endometriotic cysts on her ovaries. “You’d better cut to the chase,” he says.

    “Obviously I’d feel very different if someone walks in who’s 31 and has what looks like a big endometrioma on her ovary and has never had surgery before and she’s probably got stage three or stage four endometriosis,” Davis says. A fertility surgeon can do conservative surgery, remove the cyst, not remove any ovarian tissue, and take a woman from stage four to stage zero endometriosis with one procedure. In these cases, many patients can get pregnant on their own. Or if they don’t get pregnant pretty quickly after the procedure it might be appropriate to do ovulation induction with IUI. Again, Davis says it’s always appropriate to take ovarian reserve into account.

    Advice for Women Trying to Conceive

    Typically women under the age of 35 are advised to see a fertility doctor after one year of trying to get pregnant. Women 35 or older are advised to seek treatment after six months. “For someone who has endometriosis or there’s a reasonable probability that they do, I would say they should be evaluated after six months. That’s what I do in my own practice, because they have a known risk factor. If they’re over 35, I would truncate that time also, probably to 3 months,” Hornstein says.

    As a rule of thumb, Davis says, if you have had surgery that confirms you have endometriosis, or if you have a cyst that is suspected endometriosis, painful periods, pain with intercourse, it makes sense to see a reproductive endocrinologist rather than to a general ob/gyn. A reproductive endocrinologist, or fertility doctor, probably does or has a colleague who specializes in minimally invasive surgery and can also do IUI or IVF. And even within the field, some doctors will have more of a focus on surgery and endometriosis. “If you’re going to have your first surgery done by somebody it probably makes sense for that to be somebody who has a specialized interest in that area. Your first surgery is your best surgery for endometriosis,” Davis says. “The maximum for fertility after surgery with endometriosis is after the first year after the procedure.” Finding a fertility doctor who does a lot of laparoscopic surgery for moderate and severe infertility is important.


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