Endometriosis and Infertility: Common Misconceptions

22 May
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Endometriosis is one of the most common conditions associated with infertility. I say “associated with” rather than “causing” infertility because in many cases, it can be an ( added) contributing factor to another underlying issue that is the root cause of a woman’s infertility.

Many times, women are given an oversimplified picture of the correlation between endometriosis and infertility – in essence, that:

  • The primary effect of endometriosis is that it impedes the eggs from reaching the fallopian tubes…

and therefore,

  • That the severity of infertility is directly proportionate to the anatomical severity of the endometriosis itself.

This gross over-simplification and erroneous view is often used to justify the performance of many unnecessary surgeries for the removal of small innocuous endometriotic lesions, on the basis that such “treatment” can evoke a cure of the infertility.

It is indeed indisputable that even the mildest form of endometriosis can compromise fertility. It is equally true that mild to moderate endometriosis is by no means a cause of absolute “sterility”.

When compared with normally ovulating women of a similar age who do not have endometriosis, women with mild to moderate endometriosis are about three to four times less likely to have a successful pregnancy. Two important reasons for such reduction in fertility potential are:

  1. Endometriosis is associated with the release of local pelvic “toxins” that significantly reduce the fertilization potential of eggs as they pass via the pelvic cavity from the ovary to the awaiting sperm in the outer fallopian tube
  2. Given that the origins of endometriosis almost certainly also involve an abnormal immune response of the uterine lining, many such women tend to reject the embryo (fertilized egg) as it attempts to gain attachment to the uterine wall (endometrium).

The reason that women with mild to moderate endometriosis have a much poorer reproductive performance has less to do with ovulation dysfunction or anatomical disease than the two factors mentioned above. Therefore, it should come as no surprise that the use of fertility drugs, surgery (to ablate small endometriotic deposits and free pelvic adhesions), as well as treatment by intrauterine insemination (IUI) which do not address the primary causes, are unlikely to provide any improvement in pregnancy rate over no treatment at all.

Of course, there are women with mild to moderate endometriosis who are under 35 years and who, in spite of such barriers to fertility, do conceive following fertility hormone therapy, intrauterine insemination (IUI) or surgery. But these women should realize that they probably became pregnant in spite of – rather than due to – such treatment. Then, there is the danger that women who conceive in spite of mild to moderate endometriosis might be lulled into a false sense of complacency, thinking that because they were able to achieve a pregnancy once, they will have no problem doing so again. In reality, the achievement of a viable pregnancy by a woman with mild/moderate endometriosis (by whatever means), does not improve her chances or provide assurance that she will be able to do so again.

Younger women (under 30 yrs.) with mild/moderate pelvic endometriosis (who have patent fallopian tubes, are ovulating normally, and have fertile male partners), have about a 30-40% chance of having a baby within 3 years. Accordingly, they would be fully justified in taking a “wait and see” approach, avoiding surgery, fertility drugs and intrauterine insemination (none of which, in my opinion, is likely to improve their chance of a successful pregnancy over no treatment at all). However, if they prefer to take a more active approach to conception, their best bet is In Vitro Fertilization. The nature of the IVF procedure allows eggs to be removed without their being exposed to the “toxic” pelvic environment. The eggs are then fertilized outside the body and transferred as embryos to the uterus. This nullifies one of the major factors in endometriosis-related infertility.

In addition to this toxic “peritoneal factor” present in all women with endometriosis, our research has shown that up to 1/3 of women with endometriosis (regardless of severity) have an immunologic barrier to implantation. That is, the body’s natural immune response rejects the embryo as a foreign body before it can implant in the uterus. This population of women is not generally able to conceive until the immunologic problem has been diagnosed and suppressed through selective immunotherapy.

It therefore behooves all women with endometriosis who are planning to have a family to be thoroughly tested for immunologic factors including Antiphospholipid Antibodies (APA) and Natural Killer cell activation (NKa). These tests should only be performed by a reproductive immunology reference lab. To my knowledge, no more than a half dozen exist in the United States that are capable of performing these tests with the required sensitivity.

Given the effect of the biological clock, women over 35 years of age who have endometriosis-related infertility need to be very proactive, as they do not have time to waste. Such women should, in my opinion, do IVF as a first line approach.

In the absence of clear evidence of immunologic implantation dysfunction (increased NK cell activity), I often recommend a conservative approach in women under 35 years (who potentially can afford the time to wait). However, it is my opinion that regardless of age, women who have increased NK cell activity should undergo IVF accompanied by immunotherapy with Intralipid (and sometimes with heparin, Clexane or Lovenox added ). Without such treatment, they are not likely to conceive regardless of the treatment approach.

39 Comments

  • Chaitanya Praveen says:

    Hi,
    I have stage 4 endo and I also have a condition called luteinized unruptured follicle syndrome. .. i am 26 years old ,wil I be able to conceive through ivf..

    • Geoffrey Sher says:

      I respectfully, very strongly differ from that opinion.

      1. Luteinized unruptured follicle syndrome (LUFS) is in my opinion almost always preventable with a strategic protocol of stimulation (see below).

      2. Endometriosis is associated with an immunologic implantation dysfunction (IID) in 1/3 of cases and when present it can be treated .

      3. At 26Y you should be able to have an IVF baby if you have sufficient ovarian reserve.

      Please go to the home page of this blog, http://www.IVFauthority.com . When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.
      1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)

      2. Ovarian Stimulation for IVF: The most important determinant of IVF Outcome” (Nov. 2103)

      3. “Agonist/Antagonist Conversion Protocol”

      4. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.

      5. “Luteinized Unruptured Follicle (LUF) Syndrome”

      6. “Endometriosis”

      7. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)

      8.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)

      9. “IVF success: Factors that influence outcome”

      10. “Use of the Birth Control Pill in IVF”
      Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype with me so we can discuss your case in detail.

      Finally, perhaps you would be interested in accessing my new book (recently released). It is the 4th edition (and a re-write) of “In Vitro Fertilization, the ART of Making Babies”. The book is available through “Amazon.com” as a down-load or in book form. It can also be obtained from most bookstores.

      Geoff Sher

      P.S: Please go to http://www.youtube.com/watch?v=Vp3GYuqn2eM&feature=youtu.be
      To view a video-tutorial by Linda Vignapiano RN, Clinical Manager at SIRM-Las Vegas.

  • TinaP says:

    Dr Sher,

    I have stage 3-4 endo, I am 35 years old, I have high level of egg quantity, both tubes are open. I had 2 cysts removed in Jan 2013 but have both my ovaries still. I ovulate regularly. 2 questions: 1) is it worth trying IUI 2) what is the success rate of IVF for severe endo?

    • Geoffrey Sher says:

      Endometriosis is a condition where the uterine lining (endometrium) grows on pelvic structures outside the uterine cavity. In early stage- endometriosis there is usually little, if any, visible evidence of anatomical distortion sufficient to compromise the release of an egg (ovulation) or its transportation from the ovary to the fallopian tube. In contrast, more advanced endometriosis, is characterized by the presence of pelvic adhesions sufficient to distort normal pelvic anatomy and interfere with fertilization as well as egg/embryo transportation mechanisms.
      While it is tempting to conclude that normally ovulating women with mild to moderate endometriosis would have no difficulty in conceiving if their anatomical disease is addressed surgically or that endometriosis-related infertility is confined to cases with more severe anatomical disease…nothing could be further from the truth.
      The natural conception rate for healthy ovulating women in their early 30’s (who are free of endometriosis) is about 15% per month of trying and 70% per year of actively attempting to conceive. Conversely, the conception rate for women of a comparable age who have mild or moderate pelvic endometriosis (absent or limited anatomical disease) is about 5-6% per month and 40% after 3 years of trying. The reduced conception rate in women with endometriosis can, in large part be explained by:
      1. Toxins in the Peritoneal fluid: Women with endometriosis (regardless of severity) are believed to have” toxic factors” in their pelvic peritoneal fluid. These “toxins”, reduce the fertilization potential of eggs discharged during ovulation. Assisted Reproductive (AR) techniques such as IVF, GIFT or ZIFT, which involve extracting eggs before they are released bypass this effect. Any other treatment does not do so This, at least in part explains why, normally ovulating women, who have mild to moderately severe pelvic endometriosis are 3-4 times less likely to conceive of a viable pregnancy per month of trying, than do women with other causes of infertility due to other causes of organic disease. It also explains why there is a negative effect on fertility even in cases of mild pelvic endometriosis (without significant evidence of organic disease), and why such women have very much reduced fecundity in spite of prior pelvic surgical ablation of endometriotic deposits or following the use of fertility drugs , with or without concurrently performed intrauterine insemination (IUI). Simply stated. The use of fertility drugs, IUI or corrective surgery in ovulating woman with mild to moderate endometriosis hardly improves the chance of effecting a successful pregnancy.

      2. Immunologic Implantation failure: We have previously reported that about 30% of women with endometriosis show evidence of increased Natural Killer Cell activity (NKa). In such cases selective immunomodulation with Intralipid can counter associated immunologic implantation dysfunction and lead to successful IVF in such cases. To be effective Intralipid therapy must commence well in advance of embryo transfer.

      3. Endometriomas: These are cystic lesions within the ovary that result from the accumulation of altered “menstrual blood” produced by the endometrial lining within these “chocolate cysts’. Endometriomas can activate the surrounding ovarian connective tissue (stroma) that can compromise egg development and quality. Thus any ovarian endometrioma that is more than 1cm in size should be surgically removed or through a simple office procedure called “sclerotherapy” at least 6 weeks prior to the IVF cycle . ..

      4. Scar tissue: Endometriosis and/or its surgical treatment can result in local scarring. This can compromise tubal function

      Please go to the home page of this blog, http://www.IVFauthority.com. When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.

      1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)

      2. “Ovarian Stimulation for IVF: The Most important Determinant of Outcome! (November 18th 2013)”

      3. “Agonist/Antagonist Conversion Protocol”

      4. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.

      5. “Endometriosis, a Rational Basis for Treatment”

      6. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)

      7.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)

      8. “IVF success: Factors that influence outcome”

      9. “Use of the Birth Control Pill in IVF”

      Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype with me so we can discuss your case in detail.

      Finally, perhaps you would be interested in accessing my new book (recently released). It is the 4th edition (and a re-write) of “In Vitro Fertilization, the ART of Making Babies”. The book is available through “Amazon.com” as a down-load or in book form. It can also be obtained from most bookstores.

      Geoff Sher

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