When women with infertility due to endometriosis seek treatment, they are often advised to first try ovarian stimulation (ovulation Induction) with intrauterine insemination (IUI). As with essentially all reasons for infertility, IVF offers a much higher chance of success than proceeding with multiple IUI cycles in endometriosis patients. This is not to suggest that all women with infertility-related endometriosis should automatically resort to IVF. Quite to the contrary; in spite of having reduced fertility potential, many women with mild to moderate endometriosis conceive on their own without treatment. It is just that the chance of this happening is so much lower than normal. The question becomes at what point is the convenience of IUIs outweighed by the improved pregnancy rates seen with IVF? Certainly women over age 35 are already in a category where IUI efficacy is already questionable. Undoubtedly, the presence of endometriosis also greatly lowers the threshold for IVF. Endometriosis is a fairly common condition, and although it is non-malignant, its pathophysiology is characterized by complex alterations, actually deteriorations, in the quality of life and the pelvic/reproductive health of women. The failure of less effective treatment approaches like IUI cycles allows endometriosis to progress over time, and the added estrogen exposure of such treatments can actually worsen the course of endometriosis before success, if ever, is reached. It is therefore not unreasonable to consider a more advanced treatment like IVF rather than IUI in women with known endometriosis. There are several reasons for this consideration.
- The toxic pelvic factor: Endometriosis is a condition where the lining of the uterus (the endometrium) grows outside the uterus. While this process begins early in the reproductive life of a woman, with notable exceptions, it only becomes manifest in the second half of her reproductive life. After some 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 membrane (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, through these toxic secretions to reach the sperm lying in wait in the outer part the fallopian tubes. In the process of going from the ovary to the fallopian tubes, these eggs become exposed to the “peritoneal toxins” which alter the shell of the egg (zona pellucida) making it much less receptive to being fertilized by sperm. As a consequence, even if they are chromosomally normal, such eggs are rendered much less likely to be successfully fertilized. Since almost all women with endometriosis have this problem, it is not difficult to understand why they are far less likely to conceive following ovulation (whether natural or induced through ovulation induction).
- The Immunologic Factor: About one third of women who have endometriosis will also have an immunologic implantation dysfunction (IID) linked to activation of uterine natural killer cells (NKa). This bears the consideration of selective immunotherapy with Intralipid infusions, and/or heparinoids (e.g. Clexane/Lovenox) that are much more effectively implemented in combination with IVF.
- Surgical treatment of mild to moderate endometriosis does not permanently cure or optimize pregnancy potential. The reason is that endometriosis can be considered to be a “work in progress”. New lesions are constantly developing. So it is that for every endometriotic lesion seen there are usually many non-pigmented deposits that are in the process of evolving which can nonetheless release the same toxins that compromise fertilization. It also explains why surgery to remove endometriotic deposits in women with mild to moderate endometriosis usually will fail 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 more beneficial in cases of endometriosis-related infertility.
- Ovarian endometriomas: Women, who have advanced endometriosis, often have endometriotic ovarian cysts, known as endometriomas. These cysts contain decomposed menstrual blood that looks like melted chocolate, hence the name “chocolate cysts”. These space occupying lesions can activate ovarian connective tissue (stroma or theca) resulting in an overproduction of male hormones (especially testosterone). An excess of ovarian testosterone can severely compromise follicle and egg development in the affected ovary. Thus there are two reasons for treating endometriomas. The first is to alleviate symptoms and the second is to optimize egg and embryo quality. Conventional treatment of endometriomas involves surgical drainage of the cyst contents with subsequent removal of the cyst wall (usually by laparoscopy), increasing the risk of surgical complications. We recently reported on a new, effective and safe outpatient approach to treating endometriomas in women planning to undergo IVF. We termed the treatment ovarian sclerotherapy. The process involves; needle aspiration of the liquid content of the endometriotic cyst, followed by the injection of 5% tetracycline hydrochloride into the cyst cavity. Such treatment will, more than 75% of the time, result in disappearance of the lesion within 6-8 weeks. Ovarian sclerotherapy can be performed under local anesthesia or under conscious sedation. It is a safe and effective alternative to surgery for definitive treatment of recurrent ovarian endometriomas in a select group of patients planning to undergo IVF.