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Should endometriosis be treated before IVF?

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3 fertility expert(s) answered this question

Answer from: Ahmed Elgheriany, MRCOG, MD, MSc

Gynaecologist, Fertility Specialist
GENNET City Fertility
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Treatment of endometriosis, either surgical treatment as a definitive treatment, nowadays will not increase the fertility except for a short window of time. So you did the surgery, you have like between 6 months up to 18 months by far to fall pregnant in this time. If not happening, expect that your symptoms will happen again. So (surgery is) just creating a window. The only problem we have is that the surgery itself, if you have endometriosis inside the ovary causing this cyst (it’s chocolate cyst we are calling it, its endometriotic cyst), if we remove this cyst, can sometimes or not sometimes by the best expert in the world in the endometrial statement will affect the ovarian reserve even just a valve between lateral effect or high effect but all we can recommend is treating this endometrioma. If you are planning to have a baby, please stop postponing it – do IVF and then treat this endometrioma if it’s causing any problem for you. So please, surgery can be postponed according to all current literature and be done later on after completing your family if you still have symptoms.

Answer from: Anu Chawla, MRCOG, MBBS, M.S., DNB

Gynaecologist, Specialist in Reproductive Medicine
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Untreated endometriosis whether it has an impact? Yes, of course so, endometriosis can deplete the ovarian reserve, Even if it doesn’t affect the quality because we don’t have enough evidence to say that, although we think that is happening but we don’t know. We think ,in general, whenever the quantity is affected, the quality might also be affected but there is no evidence to that but definitely the quantity, meaning the the amount of the ovarian reserve can decline first of all due to endometriosis itself and secondly due to the surgery. Very important is to do the AMH before and after the surgery to see how much reserve has been affected by this surgery. It should be done very very carefully. Sometimes some surgeons are very aggressive and without consultation with the fertility specialist that decision of the surgery is taken and then the patient comes to the fertility consultant with a very very little number of eggs because they were all stripped off during the cystectomy that the surgeon did. So, endometriosis surgeries should either be done by the fertility specialist herself or himself or they should be done only after the doctor has liaised with them, so that they are aware of the scan findings, they’re aware of the AMH and they decide how much to do. These days there is new technique called “Donnez technique” which is getting very popular how to do the surgery so, rather than doing the whole cyst stripping, they cut the that cap the top and then they filgrate the base keeping the ovarian reserve intact as much as possible so, very very minimal, very gentle surgery. It is very clear that the first of all the only two indications of surgery in such patients is if there is pain which is not managed medically well with tablets or if the ovarian cyst is so big that it is coming in the way of egg collection only then surgery should be done. The egg collection should be done first and the surgery should be done after that so, that most of the follicles get stimulated and most of them are we are able to take them out and freeze them and then, if the surgery is done and the possibility of ovarian reserve getting depleted is there will not harm the patient as much because of eggs have already frozen rather it is always better if this patient is mainly not ready to get the pregnancy but if she has a partner she can always create all or few of her egg eggs with as the embryos because freezing embryos is less challenging as compared to freezing the eggs so, she can she or the couple, can do the egg freezing or the embryo freezing for future and then, do the surgery. Recently I had a patient last week and she actually was sent to me for IVF by another surgeon, not a gynecologist, generally I do my own surgeries or I might at least try to remain present in my surgeries if anyone else is doing so, I really keep a very very close eye on how aggressive is the surgery because I like to be very gentle for these patients when the surgery is done but for example, this patient the surgeon called me because one side there was a big mass which was something else maybe something sinister and the other side there was an endometrioma and the interesting situation was that because of this very sinister nature of the one side, he was very eager to do the surgery and because he was doing the surgery once he wanted to take out the endometrioma as well because otherwise the woman would be subjected to the surgery again but this woman was 41 years old and had a very good AMH to our surprise so, we decided to do the incomplete surgery and we decided only to do the sinister side of the surgery and take out that and send the sender to the histopathology lab to check if it is really something wrong but we still did not touch the other side and obviously it was done after discussion with the patient that if there is a need, we will do the surgery again but the need might never arise because she didn’t have any symptoms. So, in the absence of pain, like I said. The only two indications of the surgery for endometriosis is either the pain which is not controlled by the medical methods or tablets enough or the second is, when a fertility specialist feels that this endometrioma or the cyst is coming in the way of the needle of egg collection which is a very very unlikely scenario because when we generally stimulate the ovaries they become so big that they come become more accessible so, access is generally not the reason to do the surgery and we sometimes leave very very large endometriomas to the size of sometimes 10 to 12 centimeters unoperated if the patient is not having any symptom because still she does not complete her family and doing any surgery will mean that we’re depleting off her eggs.

Answer from: Andrew Horne, Professor

Gynaecologist, Co-Director EXPPECT Edinburgh, Chair of Academic Board RCOG, Professor of Gynaecology and Reproductive Sciences at The University of Edinburgh 
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If a patient presents with stage I or stage II disease, we would generally recommend that they had surgery and then rather than actually have IVF, try and see if they can get pregnant spontaneously because we know the surgery helps. If they have disease which involves the ovaries and they have cysts on their ovaries, there’s a lot of debate as to whether or not having surgery first is helpful and sometimes the surgery is actually is carried out really to, for example, improve the access to the ovaries during the treatment, so in these cases it’s a bit more grey in terms of what’s better. I suppose the thing that you always have to think about, if with regard to fertility and with regard to surgery which is involving the ovaries is that the surgery itself can damage the ovaries and reduce the ovarian reserve, so that’s always something that we’re bearing in mind and when we’re considering surgery for the condition.

About this question:

Do I have to take care about endometriosis before going through an IVF?

In patients with severe endometriosis, e.g. Stage IV, the abnormal scar tissue may block the ovaries from releasing the eggs. Hence, endometriosis patients often turn to IVF for solutions.

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