Sclerotherapy

Here is an article I wrote on sclerotherapy, a procedure I pioneered >15 years ago. We should tak. Please email Patti , my assistant at concierge@sherivf.com and she can arrange for us to have an online consultation to discuss.

 

Addressing Ovarian Endometriotic Cysts, and Fertility

A Simpler, Safer Way to Treat  Ovarian Endometriomas (“Chocolate Cysts”) Without Surgery

 

 

By Geoffrey Sher, MD

 

If You’ve Been Told You Need Surgery to teat ovarian endometriotic cysts (endometriomas/”chocolate cysts”)—Pause!

If you’ve been diagnosed with one or more  ovarian endometriomas (“chocolate cysts”) and are trying to conceive—especially if IVF is being considered—you may have been told that surgery is necessary.

That has been the traditional approach.

But today, we know something important:

-Surgery is often not the best option for women who want to preserve fertility.

In many cases, there is a simpler, safer, and less invasive alternative that can treat the cyst while protecting your ovaries.

 

Why Endometriotic cysts  (Endometriomas) Matter

Endometriomas are cysts caused by endometriosis that develop inside the ovary.

They can:

• Reduce the number of eggs your ovary produces
• Affect egg quality
• Interfere with IVF egg retrieval
• Create a harmful environment around developing eggs

Even when everything else looks normal, they can quietly impair fertility.

 

The Problem with Surgery

Surgical removal of these cysts (laparoscopy) can be effective—but it comes at a cost:

Healthy ovarian tissue is often removed along with the cyst.

This can lead to:

• Lower egg reserve
• Poorer response to IVF
• Fewer eggs retrieved

And importantly:

Lost ovarian tissue cannot be replaced.

 

A Better Option: Ethanol Sclerotherapy (EST)

Ethanol sclerotherapy is a minimally invasive, outpatient procedure that treats the cyst without surgery.

How it works:

• The cyst is drained using a thin needle under ultrasound guidance
• A small amount of medical-grade alcohol is introduced
• This destroys the cyst lining so it cannot refill
• The cyst collapses- absorbs and in the vast majority of cases, is permanently gone

 

The procedure takes about 20–30 minutes and does not involve incisions.

Why This Approach Is Different

Unlike surgery, ethanol sclerotherapy:

 

• Preserves your ovarian tissue
• Avoids cutting or removing part of the ovary
• Has minimal recovery time
• It is less invasive and less costly

 Most importantly: it protects your egg supply

 

Does It Work?

Yes—and the evidence is strong:

• Pregnancy rates are similar to surgery
• IVF cycles often yield more eggs
• Outcomes may be better than leaving the cyst untreated
• Recurrence rates are low when done properly

You treat the problem—without harming your fertility

 

 

Why Not Just Leave the Endometriotic Cyst Alone?

Sometimes that’s reasonable—but larger cysts (>2cm) can:

• Block access to eggs during IVF
• Reduce egg yield
• Compromise egg quality
• Increase procedural risks

So the goal is not to ignore the cyst—but to treat it intelligently

 

Who Should Consider This?

This approach is especially valuable if you:

• Have an endometrioma larger than ~2 cm
• Are planning IVF
• Have low ovarian reserve (AMH of <1.5pg/ml or 10pmol/L)
• Have had prior ovarian surgery
• Want to avoid surgical damage to your ovari

When Is Surgery Still Needed?

Surgery may still be appropriate if:

• There is concern about cancer
• The cyst has unusual features
• There is severe, persistent pain
• Extensive disease requires surgical management

 

But for many women trying to conceive:

 

These are the exceptions—not the rule

 

A Smarter Way Forward

For years, women were told to remove the cyst first—and deal with the consequences later.

Now we understand:

We can treat the cyst while protecting the ovary

That shift changes everything.

 

Next Steps: Accessing This Treatment

If this approach resonates with you, it’s important to know:

This is not experimental—we actively offer this treatment.

We have established a dedicated Endometrioma Sclerotherapy Program at Sher Fertility Solutions in New York, led by Dr. Sitara Ravikumar, with whom I work closely.

Together, we provide:

• Expert consultation and case review
• Individualized treatment planning
• Access to ethanol sclerotherapy when appropriate
• Coordination of IVF care when needed

At present, very few centers offer a dedicated, accessible program like this.

But I believe that will change as awareness grows, because this approach is likely to reshape how we treat endometriomas in fertility care.

 

How to Get Started

If you would like to consult with me:

 

📱 Text: 702-533-2691

Be sure to Include:

 

• Your full name
• A reliable contact phone number
• Your email address

Our team will respond promptly to arrange a consultation with me and/or Dr. Ravikumar, and guide you through next steps.

Insurance Coverage

In many cases, consultations and sometimes the procedure itself, may be partially or fully covered by medical insurance, depending on your plan. We will help you navigate this.

Final Thought

If you’ve been told that surgery is your only option…

It may be time to reconsider.

Because in fertility care, the goal is not just to treat a condition—

It’s to protect your ability to have a baby.

And in many cases, ethanol sclerotherapy may be the smartest way to do exactly that.

____________________________________________________________________

Endometriosis and Infertility

The Hidden Disease: What Every Woman Trying to Conceive Needs to Know

 

____________________________________________________________

Few conditions in reproductive medicine are as common, as misunderstood, or as underestimated as endometriosis.

It affects an estimated 6–10% of women during their reproductive years. Among women struggling to conceive, however, the numbers rise dramatically. Studies suggest that between 20% and 40% of infertility patients have endometriosis, making it one of the most common underlying causes of infertility worldwide.

Yet despite its prevalence, endometriosis is often overlooked, misdiagnosed, or discovered only after years of frustration and failed attempts to conceive.

Part of the problem is that endometriosis does not behave like most diseases. It is not simply a structural abnormality that can be identified, removed, and cured. Rather, it is a dynamic biological process that can interfere with reproduction long before it becomes visible on scans, during surgery, or even under direct observation.

This is why so many women hear the frustrating diagnosis of “unexplained infertility” when, in reality, the explanation may be present all along—hidden in plain sight.

 

 

 

One of the greatest misconceptions about endometriosis is that it must be visible to exist.

In its earliest stages, endometriosis may be microscopic. Lesions can be tiny, transparent, and virtually impossible to identify. Ultrasound examinations may appear normal. Even laparoscopy—the traditional “gold standard” for diagnosis—can fail to detect these early changes.

Yet despite being invisible, these microscopic lesions may already be causing substantial reproductive harm.

This hidden phase of the disease is particularly important because it often interferes with fertility years before a woman develops pelvic pain, ovarian cysts, or other classic symptoms.

Endometriosis is generally not a condition that appears suddenly. It tends to evolve gradually over many years.

It is relatively uncommon in women younger than 25 years of age. Its prevalence increases steadily through the thirties and becomes even more common during the late thirties and early forties.

This progressive pattern reinforces an important concept: endometriosis is usually a chronic, evolving disease rather than a sudden event.

Despite decades of research, no single theory fully explains why endometriosis occurs. Several mechanisms likely work together.

The most widely accepted explanation is retrograde menstruation, in which menstrual blood flows backward through the fallopian tubes into the pelvic cavity. This backward flow may carry endometrial cells that implant and grow outside the uterus.

However, because retrograde menstruation occurs in many women who never develop endometriosis, additional factors clearly play a role.

Researchers have identified several possibilities:

• Altered immune function that fails to eliminate misplaced endometrial cells
• Genetic predisposition, which explains why the condition often runs in families
• Stem-cell and metaplastic mechanisms that may allow pelvic tissues to transform into endometrial-like tissue

The reality is that endometriosis is probably not caused by a single factor but by a combination of genetic, immunologic, hormonal, and environmental influences.

 

Researchers have also observed differences in the reported prevalence of endometriosis among various populations.

Historically, the disease has been reported less frequently among indigenous African populations and more commonly among Caucasian women. However, increasing recognition among women of African ancestry living in Western societies suggests that environmental factors, lifestyle influences, delayed childbearing, diagnostic access, and genetic susceptibility may all contribute.

While these observations are intriguing, they remain incompletely understood and continue to be the subject of ongoing investigation.

Most people think of endometriosis as a disease that prevents conception.

The truth is more complicated.

In many women, fertilization occurs normally. Embryos form. Implantation may even begin. Yet the pregnancy fails so early that the loss is never recognized as a miscarriage.

Increasing evidence suggests that endometriosis may contribute not only to infertility but also to recurrent implantation failure and very early pregnancy loss through mechanisms involving inflammation and immune dysfunction.

Many women are told:

“You only have mild endometriosis. You should still be able to get pregnant.”

Unfortunately, this statement often reflects a misunderstanding of how endometriosis affects fertility.

The disease does not impair reproduction primarily through what we can see.

Its most important effects occur at levels that are invisible:

• Microscopic
• Biochemical
• Immunologic

These hidden changes can interfere with fertilization, embryo development, implantation, and pregnancy maintenance even when pelvic anatomy appears completely normal.

In my opinion, the single most important mechanism by which endometriosis causes infertility is the creation of a hostile biochemical environment within the pelvis.

Endometriotic implants release inflammatory substances into the pelvic fluid that surrounds the reproductive organs.

As the egg is released from the ovary and enters the fallopian tube, it passes through this inflammatory environment. During this journey, exposure to inflammatory toxins may alter the egg’s outer shell, known as the zona pellucida, impair sperm binding, and reduce the likelihood of successful fertilization.

The result is not complete infertility—but dramatically reduced fertility.

 

A healthy fertile couple has approximately a 15–20% chance of conception each month and roughly an 80% chance of conceiving within one year.

In women with significant endometriosis, monthly fertility rates may fall to as low as 2–4%.

This represents a five- to six-fold reduction in reproductive efficiency.

When viewed from this perspective, it becomes much easier to understand why so many couples struggle for years despite apparently normal fertility testing.

For many years, surgery was considered the primary treatment for endometriosis.

While surgery can be highly effective for pain relief, its role in improving fertility is far less convincing.

The reason is simple.

Endometriosis is frequently microscopic, progressive, and recurrent. Removing visible disease does not necessarily eliminate invisible disease. Nor does it completely eliminate the inflammatory environment that may be impairing fertilization.For this reason, surgery should generally be reserved for symptom relief or specific clinical indications rather than being performed solely to improve fertility.

Controlled ovarian stimulation and intrauterine insemination (IUI) increase the number of eggs available for fertilization.

What they do not do is eliminate the hostile pelvic environment.

The egg must still travel through the same inflammatory surroundings. Therefore, while these treatments may improve fertility somewhat, they often fail to overcome the fundamental biological problem created by endometriosis.

 

This is where in vitro fertilization (IVF) offers a distinct advantage.

IVF bypasses the toxic pelvic environment altogether.

Eggs are removed directly from the ovaries. Fertilization occurs in the laboratory rather than within the pelvis. Embryos can then be carefully evaluated and transferred to the uterus under controlled conditions.

In many women with endometriosis, this ability to bypass the hostile environment represents the single greatest advantage of IVF treatment.

Among the many manifestations of endometriosis, ovarian endometriomas deserve special attention.

These cysts can:

• Damage surrounding ovarian tissue
• Compromise egg quality
• Interfere with ovarian response during IVF
• Increase treatment complexity

When larger than approximately 2 cm, they often warrant treatment before fertility treatment proceeds.

Historically, surgery was the standard treatment for endometriomas.

Unfortunately, surgical removal may also remove healthy ovarian tissue, potentially reducing ovarian reserve.

For this reason, ethanol sclerotherapy has emerged as an attractive alternative.

The procedure involves draining the cyst and then using ethanol to destroy the cyst lining while preserving surrounding ovarian tissue.

In carefully selected patients, this approach may offer effective treatment while minimizing damage to ovarian reserve.

 

Approximately one-third of women with endometriosis may also have an associated condition known as Immunologic Implantation Dysfunction (IID).

This condition can interfere with:

• Embryo implantation
• Placental development
• Early pregnancy maintenance

Women may experience repeated implantation failure, recurrent miscarriage, or seemingly unexplained IVF failure despite the transfer of high-quality embryos.

When present, IID requires specific diagnosis and targeted treatment.

Successful pregnancy depends upon two critical elements.

The embryo is the seed.

The uterus is the soil.

Even the healthiest seed cannot flourish in poor soil. Likewise, the most receptive uterus cannot compensate for a genetically abnormal embryo.

Both must be optimized if pregnancy is to occur.

 

Many treatment programs continue to use prolonged GnRH agonist suppression before IVF.

While these medications suppress estrogen production and may reduce endometriosis activity, they can also negatively influence endometrial receptivity.

For this reason, prolonged suppression is often used more frequently than the available evidence justifies.

Treatment should always be individualized rather than applied routinely.

 

Today, diagnosis increasingly relies on noninvasive approaches.

These may include:

• High-quality ultrasound imaging
• Pelvic MRI
• Biomarker testing such as ReceptivaDx (BCL6)

As a result, many women can be diagnosed and treated effectively without undergoing diagnostic laparoscopy.

 

Preimplantation Genetic Testing for Aneuploidy (PGT-A) can help identify chromosomally normal embryos.

Although it does not treat endometriosis, it can improve embryo selection and reduce the transfer of embryos that are unlikely to result in a healthy pregnancy.

 

Successful treatment of endometriosis-associated infertility does not require aggressive intervention.

It requires intelligent intervention.

A practical strategy includes:

• Recognizing the disease early.
• Using modern diagnostic tools thoughtfully.
• Avoiding unnecessary surgery.
• Treating significant endometriomas conservatively when possible.
• Utilizing IVF when appropriate.
• Optimizing ovarian stimulation protocols.
• Considering PGT-A when indicated.
• Evaluating immunologic implantation dysfunction.
• Correcting uterine and immunologic factors before embryo transfer.

 

Endometriosis is far more than a structural disease.

It is a complex biological disorder that influences fertility through inflammatory, biochemical, immunologic, and hormonal pathways—many of which remain invisible to conventional testing.

The greatest mistake is to underestimate it.

The greatest success comes from understanding it.

The future of endometriosis treatment is not more aggressive surgery, more medication, or more intervention.

It is precision.

When diagnosis is accurate and treatment is individualized, most women with endometriosis can achieve what they desire most—a healthy pregnancy and the opportunity to build a family.

 

 

-Hope matters. But hope alone is not a strategy.

Knowledge is!

 

-Understanding the biology of endometriosis

and acting on that knowledge, gives patients

their best opportunity for success.

 

-And with the right diagnosis, the right treatmen

and the right timing, the outlook for most women

remains remarkably positive.