Very possibly Yes!

Endometriosis is a condition where the lining of the uterus grows in other places besides its usual spot inside the uterus. It can affect the Fallopian tubes, ovaries, and bowel and on rare occasions can even disseminate beyond the pelvis and abdominal cavity. While it may seem like a physical barrier to fertility is the main cause of infertility in endometriosis, this is an oversimplified view.

The truth is that even mild cases of endometriosis can make it harder to get pregnant. However, it doesn’t mean that women with this condition are completely unable to have children. Compared to women without endometriosis who ovulate normally and are the same age, women with mild to moderate endometriosis are about four to six times less likely to have a successful pregnancy.

Unfortunately, endometriosis commonly goes undiagnosed for many years. Women with this condition are often mistakenly labeled as having “unexplained infertility” until the lesions are seen during an abdominal-pelvic surgical procedure. It’s not surprising that many patients with “unexplained” infertility eventually discover they have endometriosis if they are followed over a period spanning several years.

The journey of women with endometriosis can be challenging, particularly when it comes to fertility. However, it’s important to remember that there is hope and numerous ways to overcome these obstacles.

Reasons behind the impact of endometriosis on fertility.

• Toxic Pelvic Environment: Endometriosis creates a toxic pelvic environment that can compromise the fertilization process. Even women with mild to moderate endometriosis, whose fallopian tubes are usually healthy, face difficulties in conceiving due to exposure to peritoneal toxins. Unlike what some may believe, surgical intervention or medication alone cannot eradicate this toxic influence. Visible endometriotic deposits are just the tip of the iceberg, as numerous translucent deposits produce toxins that impact fertility. Consequently, surgical removal of visible deposits or other treatments such as controlled ovarian stimulation (COS) with or without intrauterine insemination may not improve the chances of pregnancy. In such cases, IVF is the most effective method to enhance pregnancy potential by protecting the eggs from exposure to the toxic pelvic environment.
• Ovulation Dysfunction: Approximately 25-30% of endometriosis cases are associated with ovulation dysfunction. This often requires COS in an attempt to increase the chances of pregnancy. Unfortunately, the toxic pelvic environment often diminishes the effectiveness of anything other than in vitro fertilization (IVF) in enhancing pregnancy potential. Although this may seem disheartening, IVF offers great hope for women facing this challenge.
• Pelvic Adhesions and Tubal damage: Advanced endometriosis can lead to pelvic adhesions and scarring, which damage, immobilize or obstruct the fallopian tubes, preventing the union of sperm and eggs. This can present a significant obstacle to fertility.
• Endometriomas (chocolate cysts): Advanced endometriosis often involves the development of ovarian cysts called endometriomas or chocolate cysts. These cysts contain altered blood and can be large and multiple. When these endometriomas grow larger than 1cm, they can activate surrounding ovarian tissue leading to the local production of excessive male hormones such as testosterone. This hormonal imbalance can compromise egg development and increase the likelihood of chromosomal abnormalities, reducing the competency of eggs and embryos. Therefore, eliminating such cysts surgically or by sclerotherapy ( see below) before pursuing IVF is strongly recommended.
• Immunologic implantation dysfunction (IID). Endometriosis, regardless of its severity, is associated with immunologic implantation dysfunction (IID) in more than 30% of cases. This dysfunction ( among other effects) involves the activation of uterine natural killer cells (NKa) and cytotoxic lymphocytes (CTL). These immune cells attack the developing embryo’s “root system” ( trophoblast) as it tries to attach to the uterine wall, often resulting in undetected early losses , chemical pregnancies and miscarriages. Understanding this aspect of endometriosis-related infertility is crucial to provide appropriate care and support.

While advanced endometriosis can cause significant anatomical damage and infertility, it’s important to note that the quality of life for these patients is often severely compromised by pain and discomfort. In such cases, the priority may shift towards finding relief from symptoms through medical and surgical treatment options, thereby deferring or (sometimes) even precluding future pregnancies.

For patients with moderately severe endometriosis, there is a moderate amount of scarring, adhesions, and endometriotic deposits. However, the fallopian tubes are usually open and functional, offering a chance ( albeit markedly reduced) of natural conception.

Diagnosis:

The  identification of endometriosis as the cause of Infertility, starts with having a high index of suspicion. Symptoms such as heavy/prolonged and  painful menstruation with painful deep vaginal penetration and ovulation pain along with difficulty in conceiving are strong suggestions of underlying endometriosis. A definitive diagnosis requires surgical  visualization of endometriotic lesions and/or pelvic adhesive disease , and/or ultrasound /MRI detection of ovarian endometriotic cysts. However, the exception of cases that require removal of endometriomas or urgent relief of incapacitating symptoms, successful treatment of the underlying infertility in most cases will not require such confirmation. 

It is also important to recognize that early endometriosis can be free of the symptoms and signs referred to above while still having a profoundly deleterious impact on fertility. A newer endometrial biopsy test ( Receptiva/BCL-6) can help identify  such women thereby avoiding the need for invasive trans-abdominal surgery( e.g., laparoscopy) to detect and diagnose the condition. 

Dismissing “unexplained infertility” solely on the basis of viable anatomical disease overlooks these crucial aspects and can hinder the hopes and dreams of many women facing endometriosis-related infertility.

Management of endometriosis-related Infertility: :When it comes to managing endometriosis-related infertility, there are several important considerations. Let’s explore these concepts to understand the available treatments and their potential for success.

1. Controlled Ovulation Stimulation (COS) with/without Intrauterine Insemination (IUI): The toxins present in the peritoneal secretions of women with endometriosis have a negative impact on fertilization potential, regardless of how sperm reach the fallopian tubes. This explains why COS with or without IUI does not significantly improve the chances of pregnancy compared to no treatment at all. In these cases, in vitro fertilization (IVF) is the most effective option to bypass these challenges and increase the chances of conception.

1. Pelvic Surgery: While laparoscopy or laparotomy surgery can aim to restore the anatomical integrity of the fallopian tubes, it does not address the negative influence of toxic peritoneal factors or the IID, often associated with endometriosis. Pelvic surgery is generally not recommended as a primary treatment for infertility related to endometriosis, especially for women over 35 years of age, as time is of the essence. However, for younger women who have more time on their side, surgery can be a viable option, with approximately 30% of women conceiving within a few years following corrective pelvic surgery.
2.  

Sclerotherapy for Ovarian Endometriomas: Sclerotherapy ( often not a readily available medical service) offers a non-invasive, safe, and effective method to permanently eliminate ovarian endometriomas, without the need for invasive surgery. The procedure which involves draining the cysts and injecting a solution( e.g., tetracycline hydrochloride 5%) into the emptied cyst cavity, results in the disappearance of the lesions in over 75% of cases. This outpatient procedure is cost-effective, minimizes post-procedural pain and complications, and eliminates the need for laparoscopy or laparotomy.

1. Selective Immunotherapy: More than half of women with endometriosis have antiphospholipid antibodies (APA) that can hinder the development of the embryo’s “root system” ( trophoblast). Additionally, about one-third of cases involve the activation of uterine natural killer cells (NKa) and cytotoxic lymphocytes (CTL), which can significantly impede implantation. Diagnostic tests which cannot be adequately performed by most laboratories snd must be directed to a handful of Reproductive Immunology Reference laboratories in the United States, can identify such immunologic implantation dysfunctions (IID). Treatment options include heparinoids, such as Clexane/Lovenox, to improve IVF success rates in women with APA, and a combination of Intralipid (IL) and steroid therapy to down-regulate NKa/cytotoxic T-cells. IL therapy is a cost-effective alternative to Intravenous Gamma globulin (IVIg) with comparable efficacy and fewer side effects.

1. The Role of IVF: The toxic pelvic environment caused by endometriosis reduces natural fertilization potential. Consequently, women who are ovulating normally, have patent fallopian tubes, and suffer from endometriosis are much less likely to conceive naturally or with fertility agents alone, including IUI. In such cases, IVF is the most effective approach to overcome the adverse pelvic environment and increase the chances of pregnancy. It is important to note that not all women with endometriosis require IVF, but for those > 35y for whom time is a serious consideration and for women with endometriosis ( regardless of their age) where there are additional factors such male factor infertility, IID or diminished or DOR, IVF is often is the treatment of choice.

In summary, while endometriosis can present challenges on the path to fertility, there is hope, IVF offers promising solutions to enhance pregnancy potential. With the right medical care, support, and understanding, women with endometriosis can embark on a journey towards fulfilling their dreams of starting a family.  

In Summary:

For young women under 35 years of age with endometriosis and have adequate ovarian reserve , expectant treatment may be preferable if they have normal reproductive anatomy and fertile male partners. However, for older women or those with additional factors, such as pelvic adhesions, ovarian endometriomas, male infertility, IID, or DOR, IVF should be considered as the primary treatment option. 

While endometriosis can present challenges on the path to fertility, there is hope. Medical advances such as IVF, offer promising solutions to enhance pregnancy potential. With the right medical care, support, and understanding, women with endometriosis can embark on a journey towards fulfilling their dreams of starting a family.

 _____________________________________________________

PLEASE SHARE THIS WITH OTHERS AND HELP SPREAD THE WORD!!

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

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

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

I invite you to visit my very recently launched “Podcast”,  “HAVE A BABY” on RUMBLE;   https://rumble.com/c/c-3304480

If you are interested in having an online consultation with me, please contact my assistant, Patti Converse at 702-533-2691 or email her at concierge@sherivf.com\

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If you’ve undergone in vitro fertilization (IVF) and didn’t achieve a successful pregnancy, you may be wondering why. It’s important to know that IVF outcomes can be unpredictable, but there are factors that can affect your chances. Let’s explore some common reasons for IVF failure in simpler terms.

1. Age: A woman’s age is a significant factor in IVF success. Generally, women under 35 have a higher chance of getting pregnant through IVF, around 35-40% per embryo transfer. However, this success rate decreases as women get older. For women in their mid-forties, the success rate drops to under 5%. This decline is mainly because the quality of eggs decreases as women age, affecting their ability to develop normally.

1. Egg/Embryo Competency: Apart from age, the quality and competency of embryos also affect IVF success. The quality of eggs and embryos is influenced by a woman’s age. However, for older women or those with fewer eggs, the specific IVF protocol used to stimulate the ovaries becomes crucial. A more aggressive approach may be needed to maximize the chances of success. Previously, it was thought that the uterus was better for embryo development than the lab environment. So, early-stage embryos were transferred to the uterus based on their appearance. However, we now know that embryos that have progressed further in development are more likely to be successful. Embryos that don’t reach the blastocyst stage within 5-6 days after fertilization are considered less competent and not suitable for transfer. Additionally, Preimplantation Genetic Sampling / Testing (PGS/T) allows us to check the chromosomes of embryos. This technique helps select the most competent embryos for transfer, especially for older women, those with fewer eggs, repeated IVF failures, and recurrent pregnancy loss.

1. Number of Embryos Transferred: Some people believe that transferring more embryos increases the chances of success. While this may have some truth, it’s essential to know that if the problem lies with the ovarian stimulation protocol, transferring more embryos won’t solve it. Also, transferring more embryos doesn’t fix issues related to embryo implantation dysfunction, such as anatomical or immunologic problems. Moreover, multiple embryos can lead to higher-order multiple pregnancies, which pose risks. To minimize these risks, it’s generally recommended to transfer a maximum of two embryos, or even just one, especially when using eggs from young women.

1. Implantation Dysfunction (ID): Implantation dysfunction is often overlooked as a cause of unexplained IVF failure, especially in young women with normal ovarian reserve and fertile partners. Failure to identify and address these issues can result in repeated IVF failures. If transferring competent embryos repeatedly fails to result in a viable pregnancy, implantation dysfunction should be considered. The most common causes include:

1. 1. Thin Uterine Lining: When the lining of the uterus is too thin, it can affect the embryo’s ability to implant and grow.
   2. Surface Lesions in the Uterus: Polyps, fibroids, or scar tissue in the uterus can interfere with embryo implantation.
   3. Immunologic Implantation Dysfunction (IID): Sometimes, the immune system can mistakenly attack the embryo, preventing successful implantation.
   4. Endocrine/Molecular Endometrial Receptivity Issues: Hormonal or molecular issues in the uterine lining can impact the embryo’s ability to attach and develop.
   5. Ureaplasma Urealyticum (UU) Infection: This infection in the cervical mucous and uterine lining can lead to unexplained early pregnancy loss or IVF failure. Both partners should be tested and treated if positive to prevent transmission.

Certain causes of infertility are difficult or impossible  to reverse, e.g.; advanced age of the woman, severe male infertility, and immunologic implantation dysfunction associated with certain specific genetic factors.

Understanding the common factors contributing to IVF failure can help you have informed discussions with your doctor and make decisions for future attempts. Factors like the number of embryos transferred and implantation dysfunction play significant roles. While success cannot be guaranteed, knowing these factors can guide you in maximizing your chances and addressing potential issues.

   _________________________________________________________________________________________________________________________________________

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

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

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

I invite you to visit my very recently launched “Podcast”,  “HAVE A BABY” on RUMBLE;   https://rumble.com/c/c-3304480

If you are interested in having an online consultation with me, please contact my assistant, Patti Converse at 702-533-2691 or email her at concierge@sherivf.com\

Dear Dr Dorr,

We do not manage patients during pregnancy.We only address reproductive dysfunction.

Might I I suggest that you reach out to an obstetrician to look after your wife while you are in NY. If you need help in finding one., please let me know and I will try to assist!

Geoff Sher

__________________________________________________________________________________________________

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

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

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

I invite you to visit my very recently launched “Podcast”,  “HAVE A BABY” on RUMBLE;   https://rumble.com/c/c-3304480

If you are interested in having an online consultation with me, please contact my assistant, Patti Converse at 702-533-2691 or email her at concierge@sherivf.com\

Your TSH is modestly elevated. In my opinion this is an indication to evaluate for antithyroid antibodies, which if present, could suggest an underlying autoimmune, immunologic implantation dysfunction linked to activation of uterine natural killer cells (NKa). This should be addressed in advance of undergoing FET in my opinion..

Between 2% and 5% of women of the childbearing age have reduced thyroid hormone activity (hypothyroidism). Women with hypothyroidism often manifest with reproductive failure i.e. infertility, unexplained (often repeated) IVF failure, or recurrent pregnancy loss (RPL). The condition is 5-10 times more common in women than in men. In most cases hypothyroidism is caused by damage to the thyroid gland resulting from of thyroid autoimmunity (Hashimoto’s disease) caused by damage done to the thyroid gland by antithyroglobulin and antimicrosomal auto-antibodies. 

The increased prevalence of hypothyroidism and thyroid autoimmunity (TAI) in women is likely the result of a combination of genetic factors, estrogen-related effects and chromosome X abnormalities.  This having been said, there is significantly increased incidence of thyroid antibodies in non-pregnant women with a history of infertility and recurrent pregnancy loss and thyroid antibodies ^can be present asymptomatically in women without them manifesting with overt clinical or endocrinologic evidence of thyroid disease. In addition, these antibodies may persist in women who have suffered from hyper- or hypothyroidism even after normalization of their thyroid function by appropriate pharmacological treatment. The manifestations of reproductive dysfunction thus seem to be linked more to the presence of thyroid autoimmunity (TAI) than to clinical existence of hypothyroidism and treatment of the latter does not routinely result in a subsequent improvement in reproductive performance.

It follows, that if antithyroid autoantibodies are associated with reproductive dysfunction they may serve as useful markers for predicting poor outcome in patients undergoing assisted reproductive technologies.

Some years back, I reported on the fact that 47% of women who harbor thyroid autoantibodies, regardless of the absence or presence of clinical hypothyroidism, have activated uterine natural killer cells (NKa) cells and cytotoxic lymphocytes (CTL) and  that such women often present with reproductive dysfunction. We demonstrated that appropriate immunotherapy with IVIG or intralipid (IL) and steroids, subsequently often results in a significant improvement in reproductive performance in such cases.

The fact that almost 50% of women who harbor antithyroid antibodies do not have activated CTL/NK cells suggests that it is NOT the antithyroid antibodies themselves that cause reproductive dysfunction. The activation of CTL and NK cells that occurs in half of the cases with TAI is probably an epiphenomenon with the associated reproductive dysfunction being due to CTL/NK cell activation that damages the early “root system” (trophoblast) of the implanting embryo. We have shown that treatment of those women who have thyroid antibodies + NKa/CTL using IL/steroids, improves subsequent reproductive performance while women with thyroid antibodies who do not harbor NKa/CTL do not require or benefit from such treatment.

 _________________________________________________________________________________________________

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

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

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

I invite you to visit my very recently launched “Podcast”,  “HAVE A BABY” on RUMBLE;   https://rumble.com/c/c-3304480

If you are interested in having an online consultation with me, please contact my assistant, Patti Converse at 702-533-2691 or email her at concierge@sherivf.com\

Pleased post your question/comment in English!

Geoff Sher

________________________________________________________________________________________________

PLEASE SHARE THIS WITH OTHERS AND HELP SPREAD THE WORD!!

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

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

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

I invite you to visit my very recently launched “Podcast”,  “HAVE A BABY” on RUMBLE;   https://rumble.com/c/c-3304480

If you are interested in having an online consultation with me, please contact my assistant, Patti Converse at 702-533-2691 or email her at concierge@sherivf.com\

I sincerely do not believe that this would impact embryo implantation one way or another.

Geoff Sher