Treating Endometriosis

In this section we’ll review the treatment options for endometriosis, specifically various combinations of surgery, medications, and assisted reproductive technologies (like intrauterine insemination and in-vitro fertilization). Below is a chart that summarizes our findings:



Ultimately, we have the following observations:

• Surgery (for treatment, not diagnosis) effectively addresses pain. It can improve fertility in patients with endometriosis, but it’s inefficient for patients with mild endometriosis. In more advanced cases of endometriosis, post surgery conception rates equate to a single round of IVF but take much longer (months to years) to achieve.
  
  
• IVF offers the fastest time to pregnancy for patients with endometriosis related infertility. Cost and patient burden are the largest drawbacks. IVF does not directly address endometriosis pain, and the data is conflicting on whether becoming pregnant addresses pain.
  
  
• Medications alone can be effective in treating endometriosis pain, but in half of these cases pain returns. Medication does not improve fertility unless coupled with IVF.
  
  
• IUI does not address pain and is relatively ineffective at improving live birth rates. Generally speaking, after 3 - 4 cycles patients should likely discontinue treatment with IUI.

In our analysis, we categorize a treatment’s rate of success by the type of patient that is being treated. We characterize patients based upon their ASRM staging, which rates the severity of endometriosis on a 1 - 4 (mild to severe) scale. A few notes on the ASRM staging approach:

When it comes to improving fertility, this is how we’d characterize each treatments effectiveness, within the staging rubrik.

During diagnostic surgery, the surgeon visually inspects and/or biopsies surfaces of the pelvic organs. This is different than treatment with therapeutic surgery, where the surgeon will try to cut out or destroy any endometriosis lesions they see and then repair organs which have been damaged by endometriosis.

It’s important to note that the data for therapeutic surgery differs depending on the goals of surgery: the success rate for treating pain is different than the success rates for treating infertility. As such, it’s important to evaluate options for surgery depending on whether treating pain or infertility is the primary goal.

Treating Endometriosis Pain With Surgery

If you have endometriosis-related pain, particularly if treatment with medications has not been effective, therapeutic surgery improves pain and quality of life in the majority of patients.

Unfortunately 30 to 60% of patients will have recurrences within a year of surgical treatment unless they have additional treatment. These rates can be reduced through post-operative treatment with drugs, which we’ll discuss below.

Treating Infertility With Surgery

For patients whose primary symptom of endometriosis is infertility, surgery can also be helpful, but it can be extremely inefficient depending on the patient type.

Surgery For Stage 1 or 2

For patients with minimal or mild endometriosis, there are two randomized controlled trials where patients were assigned to receive either therapeutic surgery or diagnostic surgery only before trying to conceive. Again:

• Diagnostic surgery is where the surgeon just looks around to diagnose endometriosis but does not remove it
• Therapeutic surgery is where the surgeon removes or destroys endometriosis lesions

The results are conflicting. In one study, performing therapeutic surgery did not result in additional pregnancies. In the other study, performing therapeutic surgery did result in a small increase in the number of pregnancies.

In a study combining the two clinical trials, investigators calculated the “Number Needed to Treat” (NNT) which reveals how many surgeries must be performed to derive one extra pregnancy. Here are the findings:

Patients With Endometriosis: For patients who do in fact have endometriosis, the NNT is 12, which means for every 12 treatment surgeries performed on patients who have endometriosis, only 1 additional pregnancy was achieved (ASRM 2012, Jacobson 2010). If surgical treatment was risk-free, that might be tolerable, but as we’ll show in the next section, surgery has negative attributes too.

Patients Who May Have Endometriosis: Roughly half of patients suspected of having endometriosis truly have it. Thus, performing surgery on those who have symptoms of endometriosis yields an NNT of 24 or 24 surgeries per one additional birth.

Patients Who May Have Endometriosis Based On Infertility: Roughly one third of women with endometriosis suffer from fertility issues. Thus, performing surgery on women who just present with infertility yields an NNT of 40. Said differently, 40 women with infertility would need to be treated surgically to have one additional child.

For women with the symptoms of endometriosis, or infertility, but who have not been surgically-diagnosed, while surgery may increase the likelihood of getting pregnant, it is incredibly inefficient and there may be better options in light of the physical and financial burden it presents.

Surgery For Stage 3 or 4

For women with moderate to severe endometriosis, several studies demonstrate that 44 - 63% of women conceive naturally within 2 - 3 years of endometriosis surgery.

Amongst this patient population, this success from surgery rates favorably versus not having any treatment (0 - 25% pregnancy rates), or fertility interventions like IUI (10% success rates after four months). However, it looks roughly comparable to undergoing a single cycle of IVF, which is costly and invasive but delivers similar outcomes to surgery in a matter of months, not years.

The Endometrial Fertility Index (EFI) can be a useful tool to determine if a woman will conceive naturally after endometriosis surgery.

The inputs of the EFI come in two batches. On the left-hand panel, the patient provides basic quantifiable information on their age, years they have tried to conceive and if they’ve conceived in the past.

In the middle panel, doctors provide information (often gathered during surgery as a diagnosis) that measure the extent to which endometriosis has spread and the impact it has had on the anatomy.

However, even without having information to fill in the middle panel, the EFI can still be useful in determining the best course of treatment.

Thereafter, a patient and doctor can calculate the patient’s odds of conceiving naturally three years after therapeutic surgery. It is important to note that the EFI specifically pertains to people who would not need assisted reproduction for other reasons, meaning they don’t have something like blocked tubes or severely low sperm count, as the estimated success rates would not apply to these patients.

For instance, if a young couple has a score of 9, they likely have a 75% chance of conceiving in the next three years and might be encouraged to undergo surgery. If an older couple has a score of a 4, they have a 30% chance of conceiving after 3 years and may be better suited to advancing to IVF.

Some scores can be estimated without diagnostic surgery to help determine if treatment surgery is the most appropriate option. For instance:

Example 1: 40 year old woman, 4 years of infertility, No Previous Conceptions

Her “history total,” on the left-hand panel, is 0, meaning even if her “Surgical total,” on the middle panel, is as high as possible (5), her maximum score possible is 5, which corresponds to a 10 - 45% pregnancy rate over the next 3 years.

Thus the probable outcome is that she will not conceive after surgery. Meantime, the likelihood IVF will work for her would plummet in that time, as she would have gone from age 40 to 43.

The implication is that if this woman did surgery but later needed to resort to IVF (again, the probable outcome), she would be staring at the possibility of needing to do 10 - 15 IVF cycles to have a live birth. Whereas, if she started with IVF she would likely need on average to 2 - 3 cycles to have a live birth.

Example 2: A 29 year old women, trying to conceive for 18 months, has conceived before

This patients “history total” (left-hand panel) score is 5, meaning that her least possible total score is a 5. That correlates to a minimum projected 45% pregnancy rate over the next three years. And those projections could reach 75% depending on her findings during surgery (middle panel). This may be more acceptable to a younger patient, particularly if they cannot afford IVF.

More likely than not this patient will conceive after surgery, but if not and she must resort to IVF, she is still within an age range where IVF is highly likely to succeed within a few cycles.

Surgery Before Starting IVF

It’s unclear whether having therapeutic surgery performed before starting IVF leads to better success rates compared with immediately starting IVF without therapeutic surgery. Most studies are similar to the one shown below and reveal there is no benefit.

In one study where surgery was being done to treat ovarian endometriosis, patients subjected to surgery required more stimulation during IVF to get fewer eggs and yet ultimately had similar outcomes to women who bypassed surgery and proceeded directly to IVF. We can extract from this that surgery does not improve egg quality or likely improve odds of success with IVF.

Surgery Between Retrieval and Transfer

In general it’s unclear if surgery between IVF retrieval and transfer improves transfer success rates.

But one scenario where we know surgery is highly likely to improve IVF outcomes is in the case of a hydrosalpinx, which can be associated with endometriosis.

A hydrosalpinx occurs when scarring traps fluid in the fallopian tube. In the fluid there can be debris and inflammatory material which can travel from the fallopian tube to the uterus, lowering the likelihood that an embryo can implant in the uterus and a pregnancy can proceed.

As a result, removing a hydrosalpinx (effectively, removing the tube) can double success rates compared to leaving it in place.

So, if you have a hydrosalpinx, surgery after IVF egg retrieval and before embryo transfer is warranted, and otherwise it’s unclear. We’ll soon address how taking certain medications between IVF retrieval and transfer may improve outcomes for endometriosis patients.

While in many situations surgery can improve fertility in patients with endometriosis, it has risks. In this section we will cover the most significant risks.

Risk To Ovarian Reserve

When women who have endometriosis on their ovary (known as an endometrioma) surgically treated, they experience a drop in AMH (a proxy for egg count). That’s because even the best surgeons will remove or damage some normal ovarian tissue with removal of endometriosis from the ovary.

While troubling, AMH itself is not a predictor of a woman’s ability to conceive naturally and so a degraded egg supply after surgery may not hurt a woman’s ability to have a baby.

But for patients with an already low ovarian reserve and/or those who will need IVF, such decline could hurt their chances to conceive. Also, studies have shown patients who had surgery on both ovaries went through menopause 4 - 5 years earlier.

If you are planning surgery to remove endometriosis from the ovaries and are starting with low ovarian reserve, it is worth considering freezing eggs or embryos before surgery.

Other Risks

Occasionally removal and repair of parts of the bowel, bladder or ureter (the tube that drains urine from the kidney to the bladder) are required to treat endometriosis. Not all gynecological surgeons are trained to perform these more complicated procedures.

While some report injury and complication rates as low as 0.09%, others report much higher complication rates from endometriosis surgery.

Therapeutic surgery to treat endometriosis is hard and potentially dangerous. A variety of doctors consider this their domain and they have an array of qualifications, namely:

• OBGYNs: Completed their residency which included training in gynecologic surgery
• Minimally Invasive Surgery Gynecologists: Completed their OBGYN residency and then a minimally invasive surgery fellowship
• Reproductive Endocrinologists: Completed their OBGYN residency and then a reproductive endocrinology and infertility fellowship

In pelvic surgery, experience clearly matters and there are two studies that bear this out. In one French study, increasing surgeon experience coincided with half the rates of complications, though complications were rare across both groups.

In another study, surgeons who had completed over 30 rectovaginal endometriosis surgeries recorded lower “incomplete surgery rates” (incomplete surgeries drive higher recurrence rates), shorter surgery times, and lower patient blood loss.

While complications from surgery are rare (single digits), they can be serious, inflicting injury to the bladder or bowel.

You must ask your surgeon if issues arise during surgery whether your doctor can treat it themselves or has adequate support from those who can nearby. If you’re being treated at a hospital, oftentimes assistance is close by.

If you are planning surgery for an endometrioma on your ovary, it is important to have discussed your ovarian reserve with your surgeon and whether fertility preservation is indicated before your surgery.

Additionally, you should discuss with your surgeon if they plan to “excise” the cyst wall or “drain it.” Excising the cyst wall decreases the recurrence risk by half but may have a higher risk of damaging normal ovarian tissue.

Finally, infection and pain can be common byproducts of endometriosis surgery. When a surgeon can remove or destroy endometriosis through minimally invasive surgery (using several small incisions instead of one large incision), the recovery times are shorter with less postoperative pain. Thus, it’s helpful if your doctor is comfortable with such an approach.

Again, if you’re considering therapeutic surgery, we recommend consulting the EFI (above) to chart the possible range of your scores based on your history to see if surgery makes sense.