Early Endometriosis – Surgical Treatment Leads to Unexplained Fertility Outcomes

Fortunately for those who have experienced difficulty conceiving, many significant advances have been made in reproductive diagnosis, treatment and technology. These advances have helped fertility treatment centers to determine the individual causes of infertility and develop an optimum treatment strategy for many couples.

Endometriosis and Unexplained Infertility
However, even in light of these advances, some causes and contributing factors in infertility remain elusive or disputed. Endometriosis, for example, remains a source of controversy. While it is widely accepted that advanced stage endometriosis causes a significant disturbance of the pelvic anatomy which can cause infertility. The impact of early endometriosis is not as clear.

What Is Endometriosis
Endometriosis is a common gynecological disease which occurs in  3-10% of women of reproductive age. In women experiencing infertility, the rate increases to between 20 and 40% of that population. It is defined by the American Medical Association, as the presence of endometrial cells outside of the uterus that may result in pain and infertility.

How Does Endometriosis Develop?
Although not fully not understood, it is thought that the disease develops as a result of the drainage of menstrual debris, cells and blood, back into the abdomen and pelvis through the fallopian tubes. Genetics are likely to also play a contributing role, as women with close relatives suffering from the disease are nearly 7 times more likely to develop the disease.

Clinical Diagnosis
There are several possible ways of diagnosing endometriosis, with varying levels of accuracy. A fertility treatment center may base a diagnosis on the presence of pelvic pain, excessive menstrual pain, and painful intercourse. However, not all patients, even with advanced cases experience pain. A physical examination confirm the presence of the disease, but also may not be reliable or conclusive. Frequently, a diagnosis is reached based on the exclusion of possibilities. The most reliable form of diagnosis is surgical.

Does Surgical Treatment of Endometriosis Improve Fertility?
Many studies have been done to determine the pregnancy rate between women who were surgically treated for endometriosis and those using controlled ovarian hyperstimulation and intrauterine insemination, and the verdict is still out. Part of the problem is that a clear understanding of the association has yet to be determined.

However, it has been established that the management of the disease through medications alone does not positively impact a person’s ability to become pregnant. The question then becomes, which is more effective; surgical treatment or COH- IUI? In many randomized trials, fertility treatment centers found that women with early stage endometriosis and surgically treated did see an increased rate of pregnancy, as did those using COH-IUI.

Fertility Treatment Centers Help Develop Treatment Strategy
There is much data to support that ablative therapy is as effective as surgical therapies but must be considered on a case by case basis. Most fertility treatment centers agree that management plans for couples experiencing unexplained infertility and endometriosis must be individualized based on many clinical factors, such as:

• The stage of endometriosis
• The age of patient
• The anatomy
• The duration of infertility
• Other contributing factors

Based on your individual clinical profile, your fertility treatment center will develop a plan that is most likely to yield positive results. Discuss your options with your physician.

For many couples experiencing fertility problems, in-vitro fertilization can seem like the one last hope at having the baby that they so desire. Already they have endured months of quenched hopes when they come to the fertility treatment center and embark on an emotional journey of treatment. Most people do expect fertility treatments to be a hard and emotional process-but few are aware of the true magnitude. The process is grueling, both physically and psychologically, and there is little way to prepare for it except through experience.

The Emotional Process of IVF
Since IVF has the highest success rates, and often considered the last course of action, it  is difficult to leave room for the possibility of failure. Seemingly endless trips to the fertility treatment center, shots, date checking, temperature taking, and scheduling all take the forefront of the relationship leaving little room for much else. The days are filled with expectation, and the relationship is consumed with this one goal.

Financial Factors
In addition to the monthly cycle of high hopes and deep disappointments, the couple often begins to feel financial pressures mounting. No doubt most couples would give up anything to have a child, but it does not mean that it will come without difficulty, or that other unexpected expenses will not arise.

After Failed IVF
Many couples experience a wide range of feelings after an IVF failure. There are likely strong feelings of grief, disappointment, and even guilt. The woman may not only feel a deep loss for herself, but also a terrible guilt in not being able to conceive and carry a child her partner so longs for. There may be some secret resentments, however unreal, unreasonable or unfair.  There may be some regret in investing so much of their  time, money and energy into something, only to be so terribly let down.

Grief
As hard as the in-vitro fertilization process can be, while in it, there is always at least the hope of future success. If the IVF process has not been successful, the emotions can range from deep disappointment to a deep depression. Initially, the hopelessness can be overwhelming. Grief has as a schedule unique to each person that can not be forced, hurried or ignored. The good news is; grief does have an end. The time spent in the fertility treatment process with all the hopes and dreams, will remain important and vivid, but the emotions will eventually become bearable.

The Good News
While experiencing depression is a real and reasonable reaction, it does have an end. Studies show that even though infertility can shake the foundations of a relationship, most develop a core strength that others, not experiencing the hardship, do not have. One study notes that an overwhelming majority of couples successfully take an alternate path to parenthood.
Getting on Track
The key to getting through the most difficult times is getting the right help. After  and unsuccessful procedure, the fertility treatment center is like to be able to connect you to professionals that deal specifically with the issues you are facing. Most fertility treatment centers also have support groups to offer the unconditional support of common experience.

A couple experiencing infertility faces an emotional journey filled with many questions and considerations. After choosing a reputable fertility treatment center, it is important to discuss those concerns with the reproductive endocrinologist in the development of a treatment plan.

One of the most common concerns about fertility treatment is whether or not there is a connection between fertility medications and ovarian cancer. Early reports suggested a strong link, but those reports have since been challenged. This concern has been at the center of debate and research for over a decade with experts falling on both sides of the argument.

Recent Studies in ovarian Cancer and Fertility Medications
One of the most in depth studies to date exploring the possible link between fertility medications and ovarian cancer found no convincing association between the two. The study, which was published in the February 2009 British medical Journal followed a group of women under the care of a fertility treatment center and given either gonadotropins, clomiphene citrate, human chorionic gonadotropin, or gonadotropin-releasing hormones, and were compared with women who were not given the drugs.

The study, which is consistent with other recent studies, did calm some fears but did not completely rule out a possible cancer link. The study did note a slight elevation in the instances ovarian cancer and the use of clomiphene, but so low that it cold be a statistical aberration.

The Early Data
One of the major flaws in 1990s research was that it compared statistics from the general population of mostly fertile women with data collected from women being treated at fertility treatment centers, which makes the data skewed. Conversely, critics also note that the study did not follow women long enough and many cases of ovarian cancer occur past the age of 45 where the study ended.

Most Resent Studies
Another recent study suggested that there may be an increased risk of ovarian cancer for those who took clomiphene citrate for more than 12 cycles, compared to those who took the medication for less than 12 cycles. Though the results are unclear and the actual incidence of ovarian cancer very low, it is recommended that individuals considering fertility treatments consult their physician and ask about the fertility treatment center’s practice regarding clomiphine citrate.

Understanding Ovarian Cancer
The risk for developing ovarian cancer in a woman’s lifetime is between 1-2%. Women with certain conditions that may cause them to seek the help of a fertility treatment center such as endometriosis or “unknown infertility” are at a higher risk of developing the disease.
The known causes are multifactorial and include:

• Early onset of menses
• Irregular cycles
• History of untreated infertility
• Never having children

The study also notes that some factors may help reduce a woman’s risk of developing ovarian cancer. Some of those factors include:

• Use of oral contraceptives
• Removal of ovaries
• Late onset of Menses
• Early onset of menopause
• Repeated pregnancies
• Prolonged lactation

Though most studies either find no link, or the incidence is low and the connection unclear, most fertility treatment centers will suggest each patient weigh the desire of having a child against any possible risks.

Surgical Reversal of Tubal Ligation Versus IVF
As one of the results of divorce and subsequent remarriage, a common question posed to fertility treatment centers is whether microsurgical tubal reversal (MTR) or IVF is a better option to attain pregnancy when no other factors contribute to infertility. Both options are clinically reasonable and each woman should become educated about the advantages and disadvantages of each before making a decision.

About Tubal Ligation Reversal Surgery
Tubal ligation reversal is a procedure that rejoins the segments of the fallopian tubes so that eggs can become fertilized. It was once primarily performed in an inpatient situation, requiring 3 hours of surgery, several day hospital stay and month long recovery though things have vastly improved. Fertility treatment centers now perform tubal reversals as an outpatient procedure, frequently using laparoscopy technology; greatly reducing pain, recovery time and procedure expense.

Pregnancy Success Rates After Tubal Ligation Reversal
It is difficult to get specific estimates on the success rates for pregnancy after tubal ligation reversal because not as many studies have been done and, like in IVF, success varies between fertility treatment centers. While studies do suggest that IVF has a higher immediate success rate, it is limited to the amount of procedures a patient can afford, should it not be successful or more children are wanted. The opportunity to conceive after a reversal of tubal ligation is limited only by the couple’s individual contributing fertility factors.

Contributing Factors
As in any course of fertility treatment, it is difficult to know the exact possibility of success or failure. Whether it is success or failure, for the patient experiencing it; it is 100%. It is however possible to know the facts and weigh the possibilities in the balance.

• Before making a decision, it is advisable to know the male partner’s sperm quality. If it is poor and either low in count or motility, it may necessitate and IVF procedure.
• Age of the patient in any fertility treatment is always a consideration. The chances of pregnancy significantly decrease at age 43.
• The status of the tubes also plays an important part. The length of the remaining stumps can determine increase the patients chances if they are longer or decrease the chances if they are shorter. The condition of the fimbria at the end of the tube which essentially pick up the egg upon release, also determines the chances of success.
• Current pelvic conditions. The amount, extent and location of scar tissue can impact the successful outcome after a reversal.

Advantages of Tubal Reversal
There are two main advantages to a surgical reversal of a tubal ligation. One is that because no fertility medication is used, the multiple pregnancy rate is only 2% compared with 25% for IVF treatment. The second major advantage is that there is no need to have another procedure to try to achieve another pregnancy.

When weighing the options, it is important to discuss the options with the reproductive endocrinologist and know the preference of the fertility treatment center, as well as their expertise in tubal reversals.