Surgery may improve endometriosis-related sub-fertility

June 2006

IVF can be perceived as the last hope in achieving pregnancy, yet researchers at Stanford University have looked at patients with previous IVF failures who conceived following laparoscopic treatment for endometriosis.

Out of 29 patients with prior IVF failures, 22 (76%) conceived following laparoscopic treatment of endometriosis, including non-IVF pregnancies and seven IVF pregnancies [1].

“In some cases IVF can still be successful despite the presence of untreated endometriosis,” said Camran Nezhat MD, president of the Society of Laparoscopic Surgeons and a fertility specialist at Stanford University Medical Center who helped lead the study. “However, this research shows that one should not bypass the pelvic area, instead, the option of a thorough laparoscopic evaluation and surgical technique may give the patient a greater rate of success.”

Whereas the number of women enrolled in this study is relatively small, the authors conclude that complete and thorough microsurgical eradication of endometriosis allows many patients to conceive without further IVF therapy and may help optimize success for those who require subsequent IVF cycles.

A previous study in 1997, by Marcoux et al, showed that when endometrioc implants in women with minimal-mild endometriosis were removed there was a significantly higher monthly fecundity rate in the treated compared to the control group [2].

According to Kutluk Oktay MD,Head of The Program for Fertility Preservation Research at Weill Medical College of Cornell University:”Recent studies have showed that endometriosis may be associated with alteration in the genes that play role in embryo implantation. While performing laparoscopy on women who failed to get pregnant on IVF is different than the current practice, it is only by challenging the “norm” that science and medicine can progress.”

Part of the reduction in pregnancy rates to begin with may be due to the inability of the fertilized egg to properly implant into the lining tissue when a woman has endometriosis. Several studies have examined the association of endometriosis and implantation failure on a molecular level. These basic studies suggest that endometriosis may be involved in the deregulation of select genes that play critical roles in the process of implantation.Therefore, in addition to decreasing inflammation in the pelvis and associated toxicity to embryos and gametes, surgical treatment of disease may result in enhanced uterine receptivity.

According to Dr Nezhat there is hope for many couples who have experienced failed IVF: “Whereas women are commonly in their mid-30s or older when they seek infertility therapy. This, combined with the risks of undergoing a surgical procedure, often leads patients who disregard other methods and go straight to IVF without thorough evaluation or therapy of potential endometriosis. Furthermore, when initial IVF cycles fail, patients and physicians tend to choose additional IVF treatment and some may even elect oocyte donation after multiple failures. Many couples and physicians believe that since the ultimate therapy, IVF, failed to result in a pregnancy, further infertility investigation and treatment are likely to be futile”.

“This research is important for couples who have become anxious after trying to achieve pregnancy after many years. I hope that this study will influence the methods of treatment so we can achieve much more success in this area of medicine”, concludes Dr. Nezhat.

Sources

1. Littman E, Giudice L, Lathi R, Berker B, Milki A, Nezhat C. Role of laparoscopic treatment of endometriosis in patients with failed in vitro fertilization cycles. Fertil Steril 2005;84(6):1574-8.

2. Marcoux S, Maheux R and Berube S. Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis. N Engl J Med 1997;337:217-222.