Endometriosis surgery or Pregnancy?

Question:

I'm 35 yrs old from California. Never had kids and planning on having one, hopefully soon! My husband and I have been trying to conceive for approx. a year with no luck. So the frustration (and old age), has led me to see a doctor. A month ago, ultrasound has shown that I’ve 2 cysts on my left ovary (sizes: 2.1cm and 2.5cm) and so I've been diagnosed with endometriosis (endometrioma). According to my doctor, is severe stage (didn’t specify level) Usually, I have no pain during my periods. Since my priority is having a baby, my doctor gave me the choice of either having the surgery first and then try to conceive, or try to get pregnant first (by using fertility aid, for like 3 months) and then go for the surgery. And that’s my dilemma.

1. What are my chances of conceiving with endo? He said that the endo will melt away if I get pregnant so I’m having a hard time deciding.

2. Will my chances of conceiving decrease after the surgery? Also, I’m worried about:

3. type of surgery: According to my doctor, he’ll not perform a laparoscopy (which is more common and recovery is faster), but a traditional incision surgery. I wonder why? I believe it’s the size of my cysts? Or maybe the cysts are not benign? (He said they were benign!) although there was something unusual about the cysts : they were still present on my ovary when I was having my period. He said they shouldn’t be showing on the ultrasound during that time.

4. will the surgery damage/deteriorate /affect my reproductive system?

5. Time. I’m going to be 36 early next year and the chances of conceiving will decrease if I do surgery firstPlease advise!!! Time is sensitive and I cannot come to a decision, I’m so confused!

Here’s some extra info that might help: I’m 5’3, 115 lbs. Every visit, I have a close to high blood pressure (135/90). On my 3rd menst.day, test showed FSH of 8.9 (which is close to bad) and around ovulation my estradiol was bad: 128.0. However, I ovulated by myself and size of egg was OK. My husband sperm test was good.I don’t know if stress can affect the results of my blood test, but I was going through some difficult times since I was diagnosed with endo (lost my job and my father had a terrible accident, all happening within 2 weeks)I appreciate your help and I thank you so very much in advance.
Answer:

Hello Sarah from California,

Prior to answering your questions specifically, I would strongly recommend that you go have a consult with a fertility specialist. I think that you can be counseled better that way. I am presuming that your doctor gave you the diagnosis of stage IV endometriosis (severe) based on the presence of the presumed endometriomas. This was seen on ultrasound but not based on a laparoscopic evaluation. Endometriosis can only be staged by laparoscopy and endometriomas can only be diagnosed by tissue biopsy obtained from laparoscopy. That being said, there is a high likelihood that your doctor is right since endometriomas have a certain look on ultrasound and the presence of endometriomas usually means severe scar tissue formation in the pelvis, which is stage IV endometriosis. However, that is all a presumption before the fact (as attorney's like to say).

In answer to your questions:
1. 20% of patients with infertility have endometriosis (1 in 5). Most of these patients will conceive, although the method will vary. There is no specific statistic for endometriosis. Studies have shown no relationship between stage I and II endometriosis and infertility, but there is definite reduction of fertility with stage III or IV. If you have stage III or IV endometriosis, IVF is the treatment of choice because the pelvis has been severely altered.

2. Your chances of conceiving can increase after endometriosis has been removed surgically and if you are treated with medication for a 3-6 month period after. However, this is very dependent on the type of surgery you will have. From the type that you say your doctor advises, there is a high risk that the surgery itself may compromise your fertility by increased scar tissue production and damage to your ovaries and tubes.

3. I would NOT recommend the type of surgery that your doctor recommends if it is for fertility. He is probably assuming that there is going to be severe scar tissue formation in the abdomen and the only way that he can remove the "masses" is through an open procedure. However, I usually will approach this by laparoscopy first to see if it is possible to remove by this less invasive and less destructive method. If it is not possible laparoscopically, then I schedule for an open procedure at a later date. The problem with the open procedure, other than the increased risks, hospital days and recuperation, is that it can be a more complicated procedure leading to more tissue destruction, scar tissue formation and the possible removal of the ovary. If you would consider proceeding directly to IVF, then the removal of the endometriosis is not required. However, as I mentioned previously, you cannot know what the masses are until you obtain tissue and that can only be tested after their removal. So that may be the indication for the surgery.

4. Yes, as mentioned above.

5. Your age is a significant issue because fertility decreases with age. With the combination of age and endometriosis (severe), I would strongly recommend that you consider going directly to IVF as the treatment of choice. This way, the surgery does not need to be done. You doctor is correct in saying that pregnancy is a great treatment for endometriosis. However, you have to become pregnant first and endometriosis interferes with this. Endometriosis causes the pelvis to become a hostile environment for the egg. IVF is best because we remove the eggs directly and take them out of the hostile environment. Endometriosis does not affect the inside of the uterus (uterine cavity).

I hope this helps,Sincerely,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology CenterMonterey Bay IVF Program
www.montereybayivf.com