TTC After Surgery For Stage Four Endometriosis

Question:

Hello,

I was diagnosed with stage 4 endometriosis in 2011 (26 yrs old) after a laparoscopy found a large endometrioma. I've never had painful periods prior so that diagnosis was surprising to me.I then grew back another large endometrioma and had my 2nd lap in June 2013. I am now 29 and have been TTC (trying to conceive) since my surgery in June. I was told to try naturally for the 1st 6 months. I am now on my 7th cycle and beginning to look into other options. I have seen that with stage 4 endo the treatment of choice is IVF over trying clomid / IUI. Can you explain why?  I understand surgery can affect ovarian reserve but am looking for better understanding.

What would you recommend my next steps be? How aggressive should I be in getting pregnant right away since I only had a two years between surgeries was regrowth or large endometriomas?  Thank you.

C. from California

Answer:

Hello C. from the U.S. (California),

Unfortunately, Stage 3 and 4 endometriosis have been found to significantly decrease fertility rates.  This is because endometriosis cause a chronic inflammation of the pelvis that recruits inflammatory cells and these cells attack and destroy the eggs when ovulation occurs (this of course is putting is very simply for ease of understanding).  In stage 4 endometriosis, severe adhesions or scar tissue formation occurs in the pelvis.  These adhesions are like spider webs so that when the egg exits the ovary and moves into the pelvis, prior to finding the tube, the eggs get caught in these spiker webs or the webs block the tubes so that the egg never gets into the tube where fertilization takes place.

Because of this, the only way to achieve pregnancy is to bypass the tubes, which you cannot do by natural means.  For that reason IVF is the only option.  Now, even I have had patients with stage 4 endometriosis get pregnant, and as a Catholic I believe in miracles, and so don't doubt that this can happen.  However, statistically speaking these cases are very, very few.

In terms of the recurrence of endometriosis or endometriomas, this is a chronic disease and new implants are continuously forming.  For that reason, you can form new endometriomas, despite the previous ones being removed.

Good Luck,

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

Monterey, California, U.S.A.