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:

  1. The primary effect of endometriosis is that it impedes the eggs from reaching the fallopian tubes.
  2. 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 years) 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.


  • Ana says:

    Hi Dr. Sher,

    I have been recently diagnosed with Stage 3 Endometriosis after a laparoscopy a couple of weeks ago. The doctor has presented me with IUI and IVF as options. I am 35 years old and my FSH was 10.3. Above you mention that women should get tested for the immunological factors that could prevent the embryo from implanting. Do you think I should be tested for this prior to IVF?

    Thank you.

    • Geoffrey Sher says:

      Thank you for connecting! I am updating my entire blog, so kindly-go to http://goo.gl/4hvjoP and re-post your question/comment there, and I will respond promptly. Henceforth I will be responding on that site.

      Thank you.

      Geoff Sher

  • fiona says:

    Hi Dr. Sher,

    I have been having a severe pelvic pain for almost a year. Going in and out to several doctors, a few gynae doctors said there’s nothing wrong with my uterus, cervix, ovary and fallopian tubes. They got the results by looking through the transvaginal ultrasound.

    During my fertile period, the doctors could point out the eggs through the screen during the transvaginal ultrasound and they said the shape of the reproductive organs are fine.

    So i went to a gastro doctor, and he did a CT Colonography, found out that I have a twisted colon caused by adhesives ( The cause of adhesive is not confirmed yet ) But he did suspect endometriosis did the adhesions to my colons therefore the colon got jumbled up and causes the pain. I got worried and I asked him did the adhesions causes any adhesions to my reproductive organs? He said no, but I somehow I feel unsure because I have the recurring pains mostly from my pelvic region.

    After that appointment, I went to my gynae talking about the possibilities of the endometriosis that my gastro doctor mentioned. He said the first thing he could do is by CA-125 blood test, so I took the test and the result was normal range.

    So he concluded that even there is any endometriosis, it could be mild because the result isnt shown in the blood test.

    My question is doctor, does a twisted, adhesive colon cause the pain to the pelvic region? Because mostly i feel on that region, every single day. I feel constant sharp pain with pressure on it that often times it makes me need to pee very frequently even if I only drink a little.

    What other test should I do beside laparoscopy to detect endometriosis? and to diagnose this pelvic pain?



    • Geoffrey Sher says:

      When confronted with repeated “unexplained” IVF failures where morphologically good embryos were transferred, the question arises as to whether the problem is due to inherent egg/embryo “incompetence” (which usually equates with an irregular chromosomal configuration [aneuploidy]) or whether it is due to an implantation dysfunction. The younger the woman and the higher the quality of available embryos (preferably blastocysts), the less likely it is that the fault lies with embryo “incompetence” and the greater is the likelihood that it is due to underlying implantation dysfunction.
      The most common causes of implantation dysfunction are:
      a) A “thin uterine lining”
      b) A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
      c) Immunologic implantation dysfunction (IID)
      Implantation dysfunction (anatomical or immunologic) is a common cause of repeated “unexplained” IVF failure with good embryos. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women.
      Please go to the home page of 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. “Thyroid Autoimmune Disease and IVF”

      6. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)

      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”

      11. “Endometriosis”

      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.

      Important Announcement:

      Dr Al Peters (Medical Director at SIRM-New Jersey), and I ,recently established the “SIRM Reproductive Immunology Forum(SRIF) which will provide a venue where you can address and hopefully find solutions to problems relating to Immunologic Implantation dysfunction (IID) that often manifest with “Unexplained” infertility, IVF Failure and Recurrent Pregnancy Loss (RPL..

      To this end we established http://www.InfertilityImmunology.com , a dedicated website where you can:
      • Register with SIRF
      • Request and receive (free of charge) a PDF copy of our book: “Unexplained” Infertility and Miscarriage : The Immunologic Link”
      • Be kept abreast of what is current in the IID arena
      • Post questions for Dr Peters and I to respond to and,
      • Interact with other patients on a separate discussion board dedicated to this.

      We look forward to hearing from you!

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