Endometriosis is an inflammatory disease in which the endometrium—the tissue that normally lines the insides of your uterine cavity—starts to grow outside your uterus, causing adhesions and pain in your lower abdominal cavity. In many women it is the cause of infertility, and patients wonder if they should opt for IVF or surgery for endometriosis.

There is no straightforward approach or standardized protocol that can be applied in all patients of endometriosis—the decision between IVF and surgery has to be made on case by case basis.

Endometriosis is common—it affects around 10% of all women and causes infertility in 30-50% of them, according to the American Society of Reproductive Medicine.

Despite so many cases of infertility being attributed to endometriosis, there is no fixed treatment protocol, because the extent of the problem varies from person to person and surgical excision may or may not be advised in your specific situation.

How does endometriosis cause infertility?

It is not clearly understood that why endometriosis causes problems in conceiving, unless it is severe enough to cause damage to female reproductive organs.

In women with moderate to advanced stage endometriosis, thick adhesions covering the ovaries and fallopian tubes may block the release of eggs from ovaries and their passage through the fallopian tubes.

Researchers haven’t been able to point a single reason for infertility in women with endometriosis but there are a few suspected reasons:

  • Inflammation produces cytokines, which attack the sperm cells and make fertilization difficult
  • Endometrial tissue can damage the ovaries, causing ovulation problems
  • Scarring and endometrial adhesions may cause blockage of fallopian tubes, so the egg and sperm cannot meet
  • When covering the ovaries, endometriomas raise the level of oxidative stress in the ovarian cortex, which may cause death of ovarian follicles and consequent reduction in ovarian reserve
  • Researchers have found that patients with endometriosis, especially those with severe endometriosis, are likely to have immature, morphologically poor oocytes that are difficult to fertilize
  • Endometriosis makes the uterine environment unfavorable for the embryo to grow

Does Surgical excision of endometriomas help infertility?

Around 40% of the cases of ‘unexplained infertility’ present with endometriosis but is surgical excision required in all cases? Definitely not.

The decision for surgery depends upon the extent of the problem, the size and location of lesions, and other factors for infertility, such as age and ovarian reserve.

In cases of mild to moderate endometriosis, surgical excision or ablation of the lesions is recommended to improve the symptoms as well as increase the chances of a successful pregnancy. In women with severe endometriosis, surgery will significantly improve the symptoms and to a certain extent, improve your chances of conceiving.

However, it is not advised in all cases.

The endometriomas developing in the ovaries are not distinct because they usually result from in-folding of ovarian surface.

Research suggests that endometriomas on the ovaries often cause lowered ovarian reserves (indicated by AMH levels) and removing them surgically may cause damage to the healthy ovarian tissue that contains oocytes, thus further reducing your ovarian reserve.

Normally, surgical excision enhances the chances of conceiving successfully and surgery is generally the first line of treatment for most cases of infertility resulting from endometriosis, but surgery can be harmful for ovarian function and if possible, it should be avoided in the below circumstances:

  • Women with low ovarian reserve
  • Endometriotic cyst or endometriomas on both ovaries
  • Previous surgery for endometriosis

In certain circumstances— such as hydrosalpinx—it may be necessary to remove the lesion to allow for a chance at natural conception. If it must be done, conservative surgery is preferred so the patency of tubes can be restored without touching the ovaries for the fear of damaging the tissue containing oocytes.

Surgical diagnosis of endometriosis:

Diagnostic laparoscopy was traditionally considered a standard technique for the confirmation of endometriosis, so the surgeon can see inside the body with a camera and remove a small segment of the tissue for biopsy.

However, laparoscopic diagnosis is not mandatory now because better quality images can be obtained with ultrasound and MRI, helping the doctor rule out endometriosis in the patient.

Besides, if the ovarian reserve is already low and there is an immediate indication for IVF, surgery is not advised as you may damage ovarian tissue and also lose precious time in the process.

Does endometriosis affect embryo implantation?

Implantation of the embryo is an important step in conception, and it is also affected by endometriosis.

Research has demonstrated that the embryo quality in endometriosis patients is similar to those without the conditions. However, if pregnancy rates are relatively lower in the former group, it is possibly because of the inability of the embryo to attach with the uterine wall.

Embryo implantation in women with endometriosis is found to be more complex than in those without the condition. This may be due to an altered response of the endometrial tissue to progesterone. Some experts have also suggested that administration of Lupron or oral contraceptive pills, negates this effect and implantation rates in endometriosis patients can be similar to others if ovarian suppression (IVF agonist protocol) is done ahead of the cycle.

Due to compromised ovarian reserve, patients of endometriosis also sometimes have fewer embryos and thus lesser chance of conceiving as compared to others.

Is IVF successful in endometriosis patients?

Endometriosis does not completely thwart your chances of IVF success, provided other factors are conducive for conceiving.

Even though the response to ovarian stimulation is lower in endometriosis, the quality of eggs in not affected.

It is believed that surgery for endometriosis can have a more harmful effect on a woman’s ovarian reserve that the condition itself, especially if the surgery is done to remove endometriomas on the ovaries.

Studies evaluating the impact of endometriosis on IVF outcome, have revealed that while the number of eggs are lowered, embryo quality and overall IVF outcomes are generally not much affected.

How to decide between IVF and surgery for endometriosis?

Investigations and a thorough examination are imperative to understand the presence and extent of the condition, before you can decide between IVF or surgery for endometriosis and devise your treatment plan.

Once confirmed, you can discuss with the doctor to see if surgery is advised in your situation or you can proceed straight to IVF. While surgery will provide some symptomatic relief and enhance your chances of conceiving naturally, it is only advised if:

  • You have good ovarian reserve and have enough time to dedicate 12-18 months for conception post the surgery
  • Your fallopian tubes are clear to allow for natural conception
  • Your partner’s sperm quality is good enough

If endometriosis is not severe but your doctor thinks that IVF would be eventually required, it is better to go for it sooner than later.

However, in advanced cases of endometriosis, surgery may be advised before IVF simply to relieve pain and improve endometrial receptivity.

Surgery, whenever done, should be performed conservatively to protect as much ovarian tissue as possible so that the chances of conceiving successfully with or without IVF are not compromised.

To plan IVF or surgery for endometriosis and for more information on treatment options, get in touch via the form on this page.

References:
Victor Yevseyevich Radzinsky, Mekan Rakhimberdievich Orazov, Igor Isaakovich Ivanov, Marina Borisovna Khamoshina, Igor Nikolaevich Kostin, Elena Varlamovna Kavteladze & Victoriya Borisovna Shustova (2019) Implantation failures in women with infertility associated endometriosis, Gynecological Endocrinology, 35:sup1, 27-30, DOI: 10.1080/09513590.2019.1632089

Shebl O, Sifferlinger I, Habelsberger A, Oppelt P, Mayer RB, Petek E, Ebner T.Acta Obstet Gynecol Scand. 2017 Jun;96(6):736-744. DOI: 10.1111/aogs.12941. Epub 2016 Jul 22.

Yılmaz Hanege, B., Güler Çekıç, S., & Ata, B. (2019). Endometrioma and ovarian reserve: effects of endometriomata per se and its surgical treatment on the ovarian reserve. Facts, views & vision in ObGyn11(2), 151–157. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/