Herewith are  online links to 2  E-books recently  co-authored with  my partner at SFS-NY  (Drew Tortoriello MD)....... for your reading pleasure:

• From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf

 

• Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link ;https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view

 If you would like to  have an online consultation with me, please email Patti Converse at concierge@sherivf.com  and she will arrange it for you.

Geoffrey Sher MD

Sher Fertility Solutions (SFS)

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·      Endometriosis and infertility :

A Practical, Real-World Guide to Smart, Evidence-Based Treatment Decisions

Geoffrey SherMD

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INTRODUCTION: THE HIDDEN EPIDEMIC IN INFERTILITY

 

Endometriosis is one of the most common—and most underappreciated—causes of infertility worldwide.

 

It affects approximately 6–10% of women of reproductive age, yet in the infertility population, its prevalence rises dramatically—being present in 20–40% of women seeking fertility care. In many practices, it is one of the most frequently encountered underlying conditions.

 

Despite this, it is often misdiagnosed, underestimated, or entirely overlooked!

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Part of the problem lies in its deceptive nature.

 

Endometriosis is not simply a structural disease that can be seen, removed, and cured. Rather, it is a dynamic, biologically active condition that affects reproduction at multiple levels—many of which are invisible to routine testing.

 

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A Disease That Often Goes Unseen

 

In its earliest stages, endometriosis may exist in a microscopic or preclinical form:

• Lesions may be translucent and invisible
• Laparoscopy may fail to detect them
• Standard fertility tests remain normal

 

Yet, even in this “invisible” state, it can significantly impair fertility.

 

This is why so many women are labeled with “unexplained infertility”—when in reality, the explanation is present but hidden.

 

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Age and Natural History

 

Endometriosis is typically a disease that emerges and progresses over time.

• It is relatively uncommon in women under 25
• Its prevalence increases through the 30s
• It becomes even more common in the late 30s and early 40s

 

This progression reflects its nature as a chronic, evolving condition, rather than a sudden-onset disease.

 

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Why Does Endometriosis Occur?

 

The exact cause of endometriosis remains incompletely understood, but several theories exist:

 

1. Retrograde Menstruation (Most Widely Accepted)

Menstrual blood flows backward through the fallopian tubes into the pelvic cavity, carrying endometrial cells that implant and grow.

 

However, since retrograde menstruation occurs in many women who do not develop endometriosis, additional factors must be involved.

 

2. Immune Dysfunction

Some women may have an altered immune response that:

• Fails to clear misplaced endometrial cells
• Allows them to implant and proliferate

 

3. Genetic Predisposition

Endometriosis often runs in families, suggesting a hereditary component.

 

4. Stem Cell and Metaplastic Theories

Certain cells in the pelvis may transform into endometrial-like tissue under specific conditions.

 

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Epidemiologic Observations

 

An interesting and often under-discussed observation is the variation in prevalence across populations.

 

Endometriosis appears to be:

• Less commonly reported in indigenous African populations
• More prevalent in Caucasian populations
• Increasingly recognized among women of African descent living in Western societies

 

The reasons for this are not fully understood but may involve:

• Environmental exposures
• Lifestyle and dietary factors
• Delayed childbearing
• Differences in access to diagnosis
• Genetic susceptibility

 

While these observations are real, they remain incompletely explained and an area of ongoing research.

 

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More Than Infertility: The Miscarriage Link

 

Endometriosis does not only reduce the chance of conceiving—it may also increase the risk of early pregnancy loss.

 

In many cases:

• Fertilization occurs
• Implantation begins
• The pregnancy is lost so early that it goes unrecognized

 

This is often due to immunologic implantation dysfunction, a key concept discussed later.

 

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The Central Misconception

 

Many women are told:

 

“You have mild endometriosis—you should still get pregnant.”

 

And yet, they do not.

 

Why?

 

Because endometriosis does not primarily impair fertility through what we can see—it does so through what we cannot see.

 

Its most important effects occur at the:

• Microscopic
• Biochemical
• Immunologic level

 

These mechanisms interfere with:

• Fertilization
• Embryo development
• Implantation

 

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Purpose of This Guide

 

This booklet is designed to:

• Demystify endometriosis
• Explain how it truly affects fertility
• Provide a clear, rational, and biologically sound treatment strategy

 

The goal is not aggressive treatment.

 

The goal is precise, informed, and individualized care.

 

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UNDERSTANDING THE DISEASE

 

Endometriosis is a chronic condition in which tissue resembling the uterine lining grows outside the uterus.

 

It most commonly involves:

• The ovaries
• Fallopian tubes
• Pelvic peritoneum
• Uterosacral ligaments
• . Pouch of Douglas/cul de sac

 

These implants respond to hormones and bleed cyclically—but the blood cannot exit the body.

 

This leads to:

• Chronic inflammation
• Adhesions
• Endometriomas
• Distortion of pelvic anatomy

 

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THE MASTER OF DISGUISE

 

One of the most important truths:

 

Endometriosis can impair fertility long before it becomes visible.

 

This “invisible phase” is responsible for many cases of unexplained infertility.

 

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THE PRIMARY MECHANISM: A TOXIC ENVIRONMENT

 

The dominant mechanism is not anatomical—it is biochemical.

 

Endometriotic implants release inflammatory substances into pelvic fluid.

 

As the egg travels from ovary to tube:

• It is exposed to these toxins
• The zona pellucida is altered
• Sperm binding is impaired

 

Fertilization becomes inefficient—even when everything appears normal.

 

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THE MAGNITUDE OF IMPACT

 

Normal fertility:

• ~15–20% per month
• ~80% per year

 

With endometriosis:

• ~2–4% per month

 

A 5–6 fold reduction in fertility

 

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WHY SURGERY RARELY HELPS FERTILITY

 

Endometriosis is:

• Progressive
• Microscopic
• Recurrent

 

Removing visible lesions does not eliminate:

• Hidden disease
• Ongoing inflammation

 

Surgery should be reserved for symptoms—not fertility enhancement alone.

 

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WHY IUI AND STIMULATION FALL SHORT

 

They increase egg number—but not fertilization efficiency.

 

The egg still passes through a hostile environment.

 

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WHY IVF WORKS

 

IVF bypasses the toxic pelvic environment entirely.

 

Fertilization occurs outside the body.

 

This is the single most important advantage in endometriosis-related infertility.

 

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ENDOMETRIOMAS: A CRITICAL TARGET

 

Endometriomas:

• Reduce egg quality
• Disrupt ovarian function
• Complicate IVF

 

Cysts >2 cm should generally be treated

 

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SCLEROTHERAPY: A FERTILITY-PRESERVING SOLUTION

 

Ethanol sclerotherapy:

• Drains cyst
• Destroys lining
• Preserves ovarian tissue

 

A safer alternative to surgery

 

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IMMUNOLOGIC IMPLANTATION DYSFUNCTION (IID)

 

Occurs in ~30% of cases.

 

Leads to:

• Implantation failure
• Early miscarriage

 

Requires:

• Diagnosis
• Targeted immunotherapy

 

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THE SEED AND SOIL PRINCIPLE

• Embryo = seed
• Uterus = soil

 

Both must be optimized.

 

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WHY GnRH AGONISTS ARE OVERUSED

 

They suppress estrogen—but may impair uterine receptivity.

 

Often counterproductive before IVF

 

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MODERN DIAGNOSIS

• Ultrasound
• MRI
• Receptiva (BCL6)

 

Laparoscopy often unnecessary.

 

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THE ROLE OF PGT-A

 

Selects chromosomally normal embryos.

 

Improves outcomes.

 

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A SMART STRATEGY

1. Suspect early
2. Diagnose intelligently
3. Avoid unnecessary surgery
4. Treat endometriomas (sclerotherapy)
5. Use IVF when appropriate
6. Optimize stimulation
7. Use PGT-A
8. Evaluate IID
9. Treat before transfer

 

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FINAL PERSPECTIVE

 

Endometriosis is a biological—not just structural—disease.

 

Success comes from precision, not aggression.

 

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CLOSING MESSAGE

 

Hope is not a strategy.

 

Understanding biology—and acting on it—is.

 

With the right approach, most women with endometriosis can achieve a healthy pregnancy.