Laparoscopy: Avoid It If You Can!

07 Apr
Dr. Walid Saleh

Dr. Walid Saleh of Sher Fertility Dallas Offers Insights on Laproscopy

Many doctors perform a laparoscopy for infertile women or “want to check that everything is ok prior to IVF”. Unfortunately, while it sounds effective, this is another useless procedure. I advise you to avoid it, no matter what your insurance covers. The reasons are simple: most of the time nothing is found, and even when there is something wrong (by laparoscopy or HSG), surgical repair is not effective.

The fact is that even in young women with normal ovarian reserve, the “yield” of laparoscopy in women with unexplained infertility is very low. In seventy percent of women (70%), the laparoscopy is completely negative. In the 30% with pathology, half have tubal adhesions (15%) and half are found to have endometriosis (15%).

In those with tubal disease, first time surgical correction is notoriously frustrating with a cumulative pregnancy rate of 30-40% over 24 months.  For those undergoing a second surgery, pregnancy rates are in the range of 5%.  In contrast, IVF is twice as effective over a shorter time without the surgical risks. Of those who ultimately conceive after tubal surgery, the risk of ectopic pregnancy is close to 30%, adding more risk, expenses and frustration to your infertility journey.

When endometriosis is discovered, surgical removal of visible lesions rarely improve the prognosis because endometriosis is a microscopic disease toxic to sperm, eggs and embryos. While the pelvic cavity looks great in the operating room, those lesions re-grow and scar tissue re-forms quickly after surgery. In other words, when the HSG is normal, if all the roads lead to IVF after 3-6 courses of clomiphene/IUI, why do the laparoscopy in the first place?

The only indication for surgery would be relief of painful intercourse or menstruation, not infertility treatment. If the ovaries have large endometrial cysts (“chocolate cysts”), then surgical correction may be justified but ultrasound guided cyst aspiration, a safer and non-invasive approach should also be considered because ovarian cyst removal (cystectomy) can seriously affect your ovarian reserve and affect your overall chances of pregnancy.

Learn more Dr. Walid Saleh and Sher Fertility Dallas, TX.

108 Comments

  • Raman says:

    Hi,
    I m 26 and I have never been pregnant. in 2013 I had a 10cm endometrioma cyst removed from my right ovary, I still have both ovaries. they said everything else looked good. Now I have a 6cm on left and a 2cm on right. I have been trying to get pregnant for about 3 months now. my question is should I go ahead and have a lap done to remove the cyst to increase my chances? or keep trying to get pregnant with these cysts? have you seen women get pregnant with endometrioma cyst please tell me whats the best thank you

    • Geoffrey Sher says:

      I think you should have the surgery and then move to IVF sooner rather than later.
      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: It is very common for women with mild endometriosis to do exactly this…have 1 pregnancy and then battle to conceive again. This is referred to 2ndary infertility and Endometriosis is the commonest cause I know of. The explanation is that ALL women with endometriosis (regardless of severity) are believed to have” toxic factors” in their pelvic peritoneal fluid. Eggs, as they pass from the ovary (ies) to the Fallopian tube(s) to reach the awaiting sperm, become exposed to these “toxins” which renders the egg envelopment (zona pellucida) resistant to sperm penetration. This reduces fertilization potential by a factor of at least 3 or 4. This means that if, in the absence of endometriosis, an egg has a 15% chance of being fertilized and thereupon resulting in a baby, that same egg, in a woman with endometriosis would have no more than a 5% chance. Thus if the overall chance of a having a baby per year of actively trying is about 12% then the chance in a woman with mild endometriosis (of the same age) would probably be no more than 3-4%. Only IVF or ICSI which by their very nature involve extracting eggs before they are released (ovulated) in to the “toxic peritoneal environment” can bypass this effect. This explains why a women with endometriosis who is lucky enough to become pregnant on her own or following the use of fertility drugs (with or without intrauterine insemination), often experiences secondary infertility later in her reproductive career. It also explains why normally ovulating women with endometriosis and patent Fallopian tubes do not benefit significantly from intrauterine insemination, with or without the use of fertility drugs, or from surgery to remove endometriotic lesions (since many endometriotic deposits are non-pigmented, thus invisible to the naked eye and cannot be removed surgically). In such cases only IVF improves the chance of a baby per month of trying. Simply put…. if a normally ovulating woman who has mild to moderate endometriosis conceives following IUI, surgery or the use of fertility drugs, it is probably IN SPITE OF, rather than due to such treatments.

      2. Immunologic Implantation failure: We have previously reported that 66%% of women with endometriosis (regardless of severity) have antiphospholipid antibodies (APA) in their blood. Also, and perhaps much more significant is the fact that, approximately thirty percent (30%) of women who have endometriosis (regardless of severity) show evidence of increased Natural Killer Cell activity (NKa) in there peripheral blood and in their endometrial linings. In such cases there is a high likelihood of early or later immunologic implantation failure. In the case of early immunlogic implantation failure, rejection occurs prior to embryo attachment to the uterine wall, usually even before the pregnancy hormone, HCG can be detected in the woman’s blood. Strictly speaking, rather than suffering from “true infertility” such women are experiencing are having “mini miscarriages “which occur so early that they don’t even realize that they were pregnant in the first place. In the case of the latter (later implantation failure), poor implantation might manifest as a miscarriage. It is not certain whether APA’s themselves cause implantation failure. We believe that they could be “markers”, pointing to those women who are at increased risk of immunologic implantation failure.
      Selective immunomodulation with heparin and/or Intralipid can often effectively counter immunologic implantation failure and lead to successful AR-induced pregnancies in women who have APA and/or increased NK cell cytotoxicity.
      Fewer than a dozen Immunology reference laboratories in the U.S are capable of measuring blood levels of the eighteen to twenty, IgA, IgG and IgM-related APA’s that are directed against six or seven specific phosholipids or are able to adequately assess Natural Killer (NK) cell activity (cytotoxicity) as measured by their killing effect on K-562 target cells, …with the required degree of sensitivity. Accordingly all reproductive immunology tests should be performed at one of these Immunology reference laboratories.
      3. Endometriomas: These are cystic lesions within the ovary that result from the accumulation of “menstrual blood” which is produced by the endometrial lining that lines these “cysts”. Decomposition of this blood causes the blood to become like molten chocolate in color and consistency. Hence the name “chocolate cysts’. Endometriomas can activate the surrounding ovarian connective tissue (stroma) leading to the excess production of testosterone. This can severely compromise egg production and quality. In my opinion, any ovarian endometrioma that is more than 1cm in size should be removed. The traditional way of doing this is surgically. A few years ago, we introduced “sclerotherapy” in the US. This is, a relatively non-invasive, safe and effective outpatient method to permanently eliminate endometriomas without surgery being required.
      Sclerotherapy for ovarian endometriomas involves; needle aspiration of the liquid content of the endometriotic cyst, followed by the injection of 4-5% tetracycline into the cyst cavity. Treatment results in disappearance of the lesion within 6-8 weeks, in more than 75% of cases so treated. Ovarian sclerotherapy can be performed under local anesthesia or under general anesthesia. It has the advantage of being an ambulatory office- based procedure, at low cost, with a low incidence of significant post-procedural pain or complications and the avoidance of the need for laparoscopy or laparotomy.
      4. Scar tissue: Endometriosis and/or its surgical treatment can result in adhesions and/or scarring. This can compromise tubal function and can as a very late manifestation of endometriosis block the tubes. Scarring can also compromise blood flow to the ovaries and result in reduced ovarian reserve and resistance to ovarian stimulation with fertility drugs.Sclerotherapy for ovarian endometriomas involves; needle aspiration of the liquid content of the endometriotic cyst, followed by the injection of 4-5% tetracycline into the cyst cavity. Treatment results in disappearance of the lesion within 6-8 weeks, in more than 75% of cases so treated. Ovarian sclerotherapy can be performed under local anesthesia or under general anesthesia. It has the advantage of being an ambulatory office- based procedure, at low cost, with a low incidence of significant post-procedural pain or complications and the avoidance of the need for laparoscopy or laparotomy.

      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!

      • Raman says:

        but why would I got ivf so soon when I haven’t even been trying to conceive on my own for long? im ony 26 ivf what be my option is all else fails. I have read several stories where woman with endo that have surgery get pregnant naturally soon after the lap.

        • Geoffrey Sher says:

          Because of your advanced endometriosis and its potential impact on ovarian reserve.. Please read the aricles I referred you to on my blog.

          Geoff Sher

  • Jenny says:

    Hi.. Dr.
    My self and my husband both are 30. we have started TTC from last year and conceived in 1st tried, but i have to go through the D&E because of the blighted ovum. After that we are trying from around 11 months but not successed. Following are the procedure which we followed/
    1. From june 2014 we have started trying again after Blighted ovum.
    2. After 4 cycle of natural trying we went to Fertility specialist.
    3. Did all test of mine and found as normal and tried 5 cycles on tablets siphene but no result.
    4. Post this dr. suggest for my husband sperm analysis and results found was 10 million/ml with 70% motility, so dr suggest him tablets sipheneM and folinext D
    5. Again did semen analysis after a month and result found 52 million/ml with 50% motility
    6. yesterday we went to a dr. and he is suggesting us that tried for 2 cycle on siphene (because sperm count is increased) and then to go for laproscopy. we have asked for IUI but he suggest that if there is tubal blockage the IUI fails so its better that we went first laproscopy and then IUI
    Can you please advice us whether we should to go for laproscopy OR IUI?

    • Geoffrey Sher says:

      In my opinion, laparoscopy is probably not that urgent. An HSG could determine tubal patency. Since you have conceived in the past (albeit a blighted ovum), at least one tube should be open. So and if the tubes are patent, then I would probably go to IUI with fertility drugs for at least 3 tries before considering IVF.

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

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

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

      7. “IVF success: Factors that influence outcome”

      8 “Use of the Birth Control Pill in IVF”

      9. “Intrauterine Insemination (IUI): Setting the Record Straight on when it is to be considered”.

      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.
      try

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