Endometriosis: IVF is Much More Succesful and Cost-effective Than IUI
What is the best infertility treatment when I have Endometriosis?
When women with infertility due to endometriosis seek treatment they are all too often advised to undergo ovarian stimulation with intrauterine insemination (IUI) as if to say that this would be just as likely to result in a baby as would in vitro fertilization (IVF). Nothing could be further from fact. It is time to set the record straight.
Let me start by saying that regardless of age or the severity of her disease, women with infertility due to endometriosis are at least 5 times more likely to have a baby per treatment cycle of IVF than with IUI. The recent introduction of lower cost Micro IVF, where qualifying women can undergo IVF at a per treatment cost that is comparable to gonadotropin medicated IUI, makes the understanding of this fact even more relevant. Besides, when one considers treatment in terms of the cost per baby rather than cost per treatment, then the benefit of doing IVF first rather than as a last resort becomes apparent.
So then, why is it that many doctors still recommend IUI preferentially to women with endometriosis? Perhaps it is in part self-serving, given the fact that most doctors do not have IVF programs but are still readily able to provide and be remunerated for IUI services. Or maybe it is because they believe that all such women (who usually have regular ovulation, patent Fallopian tubes and fertile male partners) need is to have multiple ovulations at a time and so increase the odds that at least one embryo will take and propagate a baby. But this is a total misperception. It fails to take important factors involved in the complex genesis of endometriosis-related infertility into account.
Let me take a stab at explaining why IVF is far more successful than IUI in the treatment of endometriosis-related infertility:
Endometriosis is a condition where the lining of the uterus (the endometrium) grows outside the uterus. After a time these deposits bleed and when the blood absorbs it leaves a visible pigment that can be identified upon surgical exposure of the pelvis. Such endometriotic deposits invariably produce and release toxins” into the pelvic secretions that coat the surface of the membrane (the peritoneum) that envelops all abdominal and pelvic organs, including the uterus, tubes and ovaries. These toxins are referred to as “the peritoneal factor”. Following ovulation, the egg(s) must pass from the ovary (ies), through these toxic secretions to reach the sperm lying in wait in the outer part the fallopian tube (s) tube(s) where, the sperm lie in waiting. In the process of going from the ovary(ies) to the Fallopian tube(s) these eggs become exposed to the “peritoneal toxins” which alter s the envelopment of the egg (i.e. zona pellucida) making it much less receptive to being fertilized by sperm. As a consequence, if they are chromosomally normal such eggs are rendered much less likely to be successfully fertilized. Since all women with endometriosis have this problem, it is not difficult to understand why they are invariably far less likely to conceive following natural or fertility-drug-induced ovulation. In fact because of this problem a young ovulating woman with (even mild) endometriosis is likely to have less than a 5% chance of conceiving naturally per month of trying as compared to 15-20% for women of comparable age, who do not have endometriosis. This “toxic peritoneal factor impacts on eggs that are ovulated whether spontaneously (as in natural cycles) or following the use of fertility drugs and serves to explain why the chance of pregnancy is so profoundly reduced in normally ovulating women with endometriosis.
Endometriosis can be considered to be a “work in progress” because new lesions are constantly developing. So it is that for every endometriotic seen there are many non-pigmented deposits that are in the process of evolving but are not yet visible to the naked eye. Please bear in mind that such evolving (non-visible) lesions also release the same “toxins that damage the egg. Accordingly even after surgical removal of all visible lesions the invisible ones continue to release “toxins” and retain the ability to compromise natural fertilization. It also explains why surgery to remove endometriotic deposits fails to significantly improve pregnancy generating potential. In contrast, IVF, by removing eggs from the ovaries prior to ovulation, fertilizing these outside of the body and then transferring the resulting embryo(s) to the uterus, bypasses the toxic pelvic environment and is therefore is the treatment of choice in cases of endometriosis-related infertility.
I am not suggesting that all women with infertility-related endometriosis should automatically resort to In Vitro Fertilization (IVF). In spite of having reduced fertility potential, many women with mild to moderate endometriosis can and do go on to conceive on their own (without treatment). It is just that the chance of this happening is so is much lower than normal. So for young ovulating women (under 35 years) with endometriosis, who have normal reproductive anatomy and have fertile male partners, expectant treatment is often preferable to IUI or IVF. However, if there is any other factor is added, to the equation (pelvic adhesions, ovarian chocolate cysts, male infertility, immunologic implantation problems, advancing age (over 35 years) or diminishing ovarian reserve, IVF becomes the treatment of choice. In such cases there is simply stated, no time to waste.
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