Endometriosis Conquering the Silent Invader Surgical Treatment for Endometriosis When Is Surgery Indicated? The severity of the disease, the woman's history of infertility, the intensity of her desire for pregnancy, and her age all play a role in determining whether or not to do conservative surgery to restore reproductive structures or to perform a hysterectomy. Unfortunately, even hysterectomy is not a guaranteed cure for the disease as up to 30% of women have persistent pain. In women with distorted tubal-ovarian anatomy due to endometriosis, the first surgery is the most effective. Repeat surgical interventions are less effective at restoring fertility, than the initial attempt, which is best performed by a skilled endoscopist. The most common surgical procedures performed with the laparoscope are the cutting and removal (lysis) of pelvic adhesions surrounding the ovaries, tubes, and uterus, excision or surgical removal of endometriotic implants and removal of ovarian endometriomas. Surgical treatment of endometriosis consists of cautery, coagulation, excision or vaporization. As most cul-de-sac endometriosis is generally deeper than it may at first appear, excision should be the treatment of choice. Vaporization of adhesions on the ovarian surface, bladder flap, and uterine peritoneum may be beneficial. Uterosacral nerve ablation (LUNA) Since sensory nerves from the uterus run inside the uterosacral ligament, sometimes I will sever the ligament to relieve the pain associated with endometriosis. This procedure relieves discomfort related in menstrual cramps in up to 85% of patients. Unfortunately LUNA does not relieve pain associated with adhesions, endometriomas and pelvic sidewall endometriosis. For more severe pain, a pre-sacral neurectomy (PSN) can be performed. In this operation, the the bundle of sensory nerves are cut as they enter the pelvis. As the nerves are surrounded by large veins, bleeding can occasionally complicate this operation. Treatment of ovarian endometriomas has included removal of the ovary, simple drainage, destruction of the cyst-lining with laser, bipolar electrosurgery, monopolar electrosurgery, and excision of the ovarian cyst. Although in many cases the cyst-lining can be stripped from inside the ovary during laparoscopy, in approximately 30% of the cases, this cannot be performed. In these cases, unless destruction of the lining is carried out, the endometrioma will likely recur. Use of an Argon beam coagulator, C02 laser or bipolar electrocautery are the methods of choice in this situation. Monopolar cautery must be used with caution as deeper penetration with this method may destroy normal ovarian tissue and cause premature ovarian failure. Success Rate with Surgery Pregnancy rates following surgery generally range between 35-40% for severe endometriosis to 55-65% with milder disease. Of those who become pregnant, 30 percent conceive within three months, 50 percent within six months, and 86 percent within fifteen months. There appears to be no difference in pregnancy rates with laparoscopy or laparotomy with laser or electrosurgical techniques. While long term pregnancy rates may approach 65%, surgical studies that look at fecundity show monthly pregnancy rates as low as 3-6% per month following surgical treatment of this disease (versus 20% per month in fertile women). Usually, normal monthly pregnancy rates can be achieved with ovulation induction and intrauterine insemination. Postoperative pregnancy rates appear best for those with infertility of short duration of one to two years of 68%. Those who have been trying between three and seven years have a 43% pregnancy rate, while those with eight or more years of infertility demonstrate a pregnancy rate of less than 10%. Table 17-4 indicates the pregnancy rates following surgery for endometriosis. Table 17-4 Pregnancies Within 15 Months of Surgery for Endometriosis Severity of the Disease % Pregnancy Rate Mild 70-80 Moderate 55-60 Severe 40-45 Overall 55-65 When Hysterectomy May Be Appropriate Complete hysterectomy-including removal of the ovaries-is the treatment of choice for women past their reproductive age. With this procedure the recurrence rate is only 1 to 3 percent. However, the use of estrogen-only hormone replacement or leaving an ovary behind significantly increase your risk that pain will recur. Up to 30% or more will experience recurrent endometriosis symptoms if both ovaries are not removed. For this reason I often recommend a hormone-free period before initiating hormone replacement therapy with a combination of estrogen and progesterone. Some women with a history of severe pain will request a hysterectomy. After fighting her endometriosis and Michael's retrograde ejaculation for years, Shelley T. decided to have a hysterectomy. "It felt so good for our fertility nightmare to end," Shelley said. "We could finally have sex for fun. And we didn't have to worry anymore about whether or not my period would start each month. I didn't realize how much pain I had each month until it was over. I wish I'd done it sooner." Medical Treatment for Endometriosis Historical Medical Approaches Multiple studies have reported a 4-5 times improvement in fecundity (monthly chance of conception) with empirical treatment, superovulation with either clomiphene or injectable gonadotropins (Humegon, Metrodin, Pergonal) combined with intrauterine insemination. A number of different types of medical regimens have been tried but discarded because of adverse side effects and questionable results: androgen, estrogen, progestin, and high-dose estrogen-progestin. The aim of all these therapies was to suppress ovulation and menses for a prolonged period of time in hopes that in an unstimulated environment (decidualization) the disease would regress. Birth Control Pills, Danazol, Lupron, Synarel, Zoladex, depot-Provera and Norplant have not been proven effective as either primary or adjunctive therapy (combined with surgery) for endometriosis related infertility. While the use of medical treatment may decrease inflammatory reactions making surgical correction easier and reduce endometriosis-related pain, use of these medications in patients with minimal disease is of no proven benefit in treating infertility. "Taking the Pill Decreases Pain but Won't Help You Get Pregnant" Because many women reported that their symptoms from endometriosis subsided when they were on birth control pills, doctors began using the Pill to control the disease. By suppressing their periods for nine months or more with very high-dose birth control pills, 80 to 90 percent of these women suffered less pain, and nearly half became pregnant when they discontinued the medication. However, endometriosis recurred in a third of these patients. Because of the adverse side effects from high-dose hormones and the marginal results, high-dose birth control pills are not used today to treat endometriosis. Today's low-dose birth control pill not only may reduce the risk of developing endometriosis, but for many it also seems to provide temporary relief from the symptoms. Some physicians suggest that their patients skip the placebo pills (pills 22-28) and start a new pack each 21 days. While this may be an effective method of treating pain related to endometriosis, the Pill is also very effective contraceptive. The Pill may also preserve the woman's fertility by temporarily containing the milder forms of the disease. For these reasons young women with endometriosis may wish to take the Pill until they decide to start their families. I should caution you, however, that if you suspect you have endometriosis, you should not delay treatment by taking birth control pills until you are thirty years old. By then the disease may already silently have invaded your reproductive organs and made restoring your fertility difficult. Danazol Therapy Initially popular after being introduced in 1975, because of unpleasant and often irreversible side-effects, Danazol is rarely the chosen for initial therapy. Danazol inhibits the release of FSH and LH by the pituitary gland. The endometrial implants will improve in 85 to 95 percent of the women taking the drug. Danazol seems to be most effective in women with mild or moderate endometriosis (stages I and II). Menses return four to six weeks after stopping the drug, and the best chances for pregnancy occur about two months after that. Pregnancy rates may be as high as 50 percent with Danazol therapy. Due to the side effects, however, about 5 to 10 percent of the women stop taking Danazol. Table 17-2 illustrates the astounding improvement this drug offers. Potential side effects are profiled in table 17-3. Table 17-2 Results of Danazol Therapy Result Incidence (%) Pain relief 75-100 Laparoscopic improvement 85-95 Regression of the disease       75-100 percent regression 33     50 percent regression 50     No improvement 10     Invasive ovarian disease Very low Pregnancy rate (up to twenty-four months after discontinuing Danazol) 41-51 Table 17-3 Potential Side Effects of Danazol Side effect Incidence (%) Weight gain (5 to 15 pounds) 85 Depression 32-62 Unexplained muscle cramps 50-57 Decreased breast size, flushing, sweating 30-56 Mood changes 38-55 Change in appetite 28-54 Fatigue 25-54 Oily skin, acne, abnormal hair growth 25-51 Water retention 28-37 Decreased sex drive 20-35 Increased sex drive 8-35 Insomnia l0-32 Headache 17-31 Nausea 17-28 Deepening voice 7-17 Dizziness and weakness 7-12 GnRH agonists Can Provide Relief The pituitary hormone LH and FSH stimulate ovarian production of estrogen, the major stimulus for growth of endometriosis. By blocking the production and release of LH and FSH, GnRH agonist (Lupron, Synarel and Zoladex)lower estrogen to menopausal levels. The drug creates the pseudomenopausal state desirable for reducing the size and number of endometriotic lesions. Synarel, a daily nasal spray; Lupron, a monthly injection; and Zoladex, a monthly implant; appear to be equally effective. Side effects are most often due to the lowered estrogen levels. They include: hot flashes, vaginal dryness, headaches and sleep disturbances. Rarely, complications such as short term memory loss, muscle, bone and joint pains and decreased bone calcium. Soreness at the injection site may be seen with Lupron and Zoladex, while nasal stuffiness and burning have been reported with the use of Synarel. These medications are approved for six months of use, and many endometriosis sufferers report six months of blissful relief. Unfortunately, not all women respond and GnRH agonists are definitely not a cure for endometriosis. They merely suppress endometriosis during the course of therapy. Unfortunately, without aggressive surgical excision, endometriosis often returns within months of discontinuing any of these medications. So why use them if the endometriosis is going to return? GnRH agonists reduce endometriosis-related pain. If the diagnosis of endometriosis was made at a previous surgery, often a GnRH-agonist can effectively reduce your pain. After a three to six month course of therapy, you can either switch to the Pill, Depo-provera or Norplant as these often prolong the pain relief induced by a GnRH agonist. Others choose to continue agonist therapy with add-back. Add-back therapy involves the daily administration of a small dose of estrogen and progesterone. Given together in combination, these two medications will lessen the side effects due to low estrogen and minimize further bone loss. Further steps to prevent bone loss include monitoring bone turnover with NTX and insuring an adequate dietary calcium intake. GnRH agonists may facilitate surgical treatment. By reducing endometriosis related inflammation, surgery is easier. These is less raw surface area when endometriosis is resected and adhesions are separated. This may minimize subsequent adhesion reformation. GnRH agonists can be used as a diagnostic tool. You may wish to postpone costly diagnostic surgery. If you benefit from a short course of GnRH agonist, it is more likely that surgical excision will be of benefit than if you did not respond with a significant reduction of pain. GnRH agonists do not restore normal fertility in patients with endometriosis. While GnRH agonists can benefit patients undergoing ovulation induction or in vitro fertilization, their use after surgery in patients with minimal or moderate disease that has been excised does not improve pregnancy rates. Medical Therapy Combined with Surgery In women with more severe endometriosis (stage III or IV), medical therapy may be combined with surgery to provide even better results. Frequently physicians prescribe the medication prior to surgery to reduce the number and size of the lesions. Surgery following medical treatment is much less likely to destroy healthy tissue and cause adhesions. To reduce inflammation and in an attempt to clear up any remaining endometriosis, medical treatment is also prescribed following surgery. Reportedly this approach increases the chances for women with severe endometriosis to become pregnant. Some physicians, however, feel that since the highest levels of fertility immediately follow surgery, postponing ovulation with postsurgical medical treatment may rob you of your best chances for pregnancy. Therapy for Mild Endometriosis (Stages I and II) Treatments for mild forms of the disease are controversial. Some physicians feel that since adhesions may not form at this stage,it's better to take a wait-and-see approach (expectant therapy)rather than prescribing heavy doses of medication. Although most studies have found no proven benefit of surgical treatment for minimal endometriosis, more recent studies suggest increased pregnancy rates after completely excising all endometriosis. Therefore, as endometriosis progresses in up to 60% of women if untreated, aggressive surgical management at the time of discovery leads to the long term best results. After excising all endometrial implants with the laparoscope, up to 75 percent of these women will become pregnant within twelve to eighteen months without additional medication. If no pregnancy occurs within six, the patient is older than 35 years of age or, has been attempting pregnancy for over two years, superovulation and intrauterine insemination is often successful. For those with extensive inflammatory endometriosis, I recommend a short course of GnRH agonist followed immediately by more agressive therapy. However, for most patients with minimal or mild disease who have undergone complete surgical excision, the use of GnRH agonists or danocrine are not likely to improve pregnancy rates or prevent recurrences. Therapy for Moderate and Severe Endometriosis (Stages III and IV) Stages III and IV endometriosis, however, often cause thicker and broader-based adhesions than early endometriosis and often cause the ovary to stick to the pelvic sidewall. Frequently the wall of the large bowel or rectum are involved and a portion of the bowel will also need to be removed. Since the removal of these types of adhesions and endometriosis of the bowel and rectum require more care than removing the filmy ones associated with earlier stages of the disease, this type of surgery is best performed by a well skilled endometriosis team. Prior to planning your surgery, I will have you consult with a bowel surgeon who may recommend a barium enema (x-ray) or an office procedure where the rectum and sigmoid colon are visualized with a flexible telescope. I will often recommend a GnRH agonist (Lupron, Synarel, Zoladex) prior to surgery to decrease inflammation. To safely perform bowel surgery it is necessary to perform a bowel prep a day or two before surgery (enemas, antibiotics and magnesium citrate or Golytely). But as I can never be sure when endometriosis of the bowel or rectum will be encountered and bowel surgery will become necessary, I order the bowel prep on all laparoscopy patients. Resolving Multiple Problems Is a Complex Task Because endometriosis may cause so many fertility problems-anovulation, luteal phase defect, adhesions, tubal blockage, ectopic pregnancies, and idiopathic (unknown) infertility-treating endometriosis can be very complex. I may have to decide if ovulation induction will work in the presence of the disease; or if the endometriosis must be treated before trying ovulation induction therapy. And before even attempting ovulation induction therapy, I must be relatively certain that adhesions will not interfere with fertilization or cause an ectopic pregnancy. If you are at risk for an ectopic pregnancy, medical and endoscopic surgical treatment may significantly reduce your risks for this complication. After I perform surgery to remove endometrial implants, clear adhesions, and perform tubal repairs, I must reassess your fertility potential. Together we can explore the post surgical treatment options below and develop a plan that best meets your needs. Expectant management (wait & see) Ovulation induction and intrauterine insemination In vitro fertilization Where to find help I strongly advise you to consult with a fellowship trained reproductive endocrinologist (RE) who can offer the full range of treatment infertility options as well as provide you with state of the art surgical treatment. By consulting with an RE, you may learn that in vitro fertilization or superovulation and intrauterine insemination will provide a better opportunity for success and than surgery. However, if surgery is necessary, your procedure will be performed by a skilled endoscopist best trained to protect your future fertility Fortunately there are many ways to solve these problems and get all of your systems working in perfect harmony so you will have your chance at making a baby-the greatest miracle of all. Click here to read Chapter 18, The Drama of Life Before Birth: Fertilization & Implantation or go to the Miracle Babies Online Table of Contents For more information on your initial visit to your physician read the INCIID Routine Fertility Workup or IVF.com Homepage. Miracle Babies and Other Happy Endings for Couples with Fertility Problems Copyright © 1986 Mark Perloe M.D., and Linda Gail Christie. Return to the IVF Homepage This page, and all contents, are Copyright © 2005 by IVF.com, Atlanta, GA, USA.