Silent Endometriosis (diagnosis based on immune findings without typical symptoms): high incidence in patients with repetitive IVF failures and Miscarriage.

Posted By Dr. Braverman || 8-May-2015

Dr. Vidali responds to patient’s questions about endometriosis

Q: My doctor said that routine laparoscopy would show that most women have some endometriosis so there is no benefit in trying to diagnose and treat it.

Dr. Vidali: We hear this statement quite frequently. Although endometriosis is a common health problem in women, it only affects a minority of them. The incidence of endometriosis in the general population is somewhere between 10 to 15%. This was determined by looking for endometriosis in women who were having surgery for some unrelated condition. As endometriosis is one of the most common causes of infertility, the incidence in infertile women has been shown to be higher in the 20 to 30% range.

If endometriosis is present, treatment is beneficial. This is not a matter of debate any longer. But the study below is an example of how treating endometriosis improves outcomes. Many centers believe that simply performing IVF will overcome the problems associated with endometriosis. But there are many cases where treatment of the endometriosis is necessary both surgically as well as immunologically ( see our lecture on Silent Endometriosis). Failure to address this leads to not only failure of own egg IVF but also donor egg IVF. Notice the improvement in clinical pregnancy rates is almost double in the treated group. Also notice these are clinical pregnancy rates and does not include delivery rates. Many of these patients still require treatment of the underlying immune issues that are associated with endometriosis for successful completion of their pregnancies.

Endometriosis Pregnancy

Pregnancy and Endometriosis

Q: What is the incidence of endometriosis in the women who have laparoscopy with your center?

Dr. Vidali: Braverman Reproductive Immunology is in the process of compiling one of the largest series ever published of laparoscopic surgery in women with recurrent pregnancy loss, repetitive failed IVF cycles, and late pregnancy complications. What is relevant about this series of women is that the indication for the surgery was not based on the physical symptom of pain, but instead on the evaluation of their immune profiles performed by our center, their clinical histories, and sonographic evaluations that suggested the presence of endometriosis. Endometriosis is a symptom of underlying immune syndromes and these can be clearly identified in our immune profiles. The chart below summarizes some preliminary findings in a series of 70 of our patients who underwent laparoscopic evaluation and surgical excision based on our immunology findings.

What emerges from our data is that Braverman Reproductive Immunology has identified a subset of women with endometriosis as the probable cause of their infertility and pregnancy loss issues based mostly on our analysis of their immunologic profile, clinical history and sonographic findings(these patients did not have a prior diagnosis of endometriosis due to lack of typical symptoms). The graph below shows almost three quarters of those that had exploratory laparoscopy had biopsy proven endometriosis and another 20 percent had inflammatory changes on the biopsies of abnormal tissue showing “inflammation” that is also suggestive of endometriosis. This approximately 3 times the general incidence in the infertility population showing the unique and significant effectiveness of immunologic diagnosis.

Endometriosis Pregnancy Rates

Q: Why is the percentage of patients with endometriosis much higher in our patient population?

Dr. Vidali: I believe that this is related to the population of patients that self-refer to Braverman Reproductive Immunology.. This is likely related to the fact that endometriosis is a manifestation of an underlying immune disorder that allows for implantation and growth of endometriosis implants. We suspect that the endometrial cells in the uterine cavity undergo changes due to chronic exposure to an underlying inflammatory process that gives these endometrial cells the ability to implant and grow in locations outside the uterine cavity. Growth in the uterine muscle is ADENOMYOSIS (easily seen on sonogram) and growth in the abdominal cavity ENDOMETRIOSIS (diagnosed by laparoscopy). It appears the endometriosis has the most significant effect on egg quality and in our patients its removal shows significant improvement in outcome. There are many of our patients however that have previously failed donor egg cycles that also show improvement after the surgery when they first fail immune therapy alone.

Q: If I have endometriosis, is that the only cause of my infertility or miscarriages?

Dr. Vidali: In most cases endometriosis is not the only factor but it certainly can be regarded as a key contributing factor. Significant immunological abnormalities may still need to be addressed. The underlying immune issues associated with endometriosis interfere with the maternal immune response to the implanting embryo which can lead to failure to generate immune tolerance to the paternal genetics on the embryo through both innate and adaptive immune responses.

Q: My doctor does not believe in treating endometriosis that does not cause pain.

Dr. Vidali: It is an accepted medical fact that endometriosis is a leading contributing factor in affecting reproduction. It is also an accepted fact that treating endometriosis improves fertility. This is also stated by the recent (May 2015) Committee Opinions of the American College of Reproductive Medicine.

“Peritoneal factors such as endometriosis and pelvic or adnexal adhesions may cause or contribute to infertility. History and/or physical examination findings may raise suspicion but rarely are sufficient for diagnosis. Peritoneal factors also should be considered in women with otherwise unexplained infertility.”

“Given individual circumstances, there may be a place for diagnostic laparoscopy for young women with a long duration (>3 years) of infertility but no recognized abnormalities”

The committee opinion was formulated without the benefit or knowledge of our ability to make the diagnosis of endometriosis based on immunologic data. Clearly this gives us the opportunity to shorten the time interval to diagnostic laparoscopy to less than 3 years as well as move patients out of the category of “unexplained infertility” again allowing for shorter interval to surgical diagnosis and treatment of endometriosis.

One of the errors that doctor make in evaluating patients is that they wait for the patients to complain about the symptom of pain . But it is known that the relationship between pain and endometriosis is very misleading in infertility:

1) Many women with extensive endometriosis have no pain at all. In fact we have diagnosed very extensive endometriosis in completely asymptomatic women.

2) Some women have great pain tolerance and others are very stoic and they have been living with painful menstruation, painful intercourse and other problems and have not ever told anybody.

3) The doctors have never asked the right questions.

4) Even if symptoms are present, women are focused on their pregnancy losses or IVF failures and are ignoring everything else.

Q: I have heard that having surgery for endometriosis cysts (endometriomas) can reduce my egg counts. Is it true?

Dr. Vidali: There are a number of studies that have shown that women who have undergone removal of endometriomas appear to have smaller ovaries after the surgery. This is a very concerning matter to me. My opinion is that this finding is due to the fact that many doctors who treat endometriosis are not fertility specialists and are overly aggressive in the use of cautery. In the case of endometriomas , surgical technique is the most important factor at play for optimal outcome. Please also note that these studies relate to surgery on the ovaries, not surgery to excise peritoneal endometriosis which has not been shown to reduce ovarian reserve. I take great pride in the fact of being one of the few surgeons whose practice is primarily focused on the treatment of endometriosis who is also a reproductive endocrinologist.

Selected References

Opoien HK, Fedorcsak P, Byholm T, Tanbo T. Complete surgical removal of minimal and mild endometriosis improves outcome of subsequent IVF/ICSI treatment. Reprod Biomed Online 2011;23:389-395.

Nowroozi K, Chase JS, Check JH, Wu CH. The importance of laparoscopic coagulation of mild endometriosis in infertile women. Int J Fertil 1987;32:442-444.

Stilley JA, Birt JA, Sharpe-Timms KL. Cellular and molecular basis for endometriosis-associated infertility. Cell Tissue Res. 2012 Sep;349(3):849-62. Review. PubMed PMID: 22298022;

Yeung P Jr. The laparoscopic management of endometriosis in patients with pelvic pain. Obstet Gynecol Clin North Am. 2014 Sep;41(3):371-83. doi: 10.1016/j.ogc.2014.05.002.

Barri PN, Coroleu B, Tur R, Barri-Soldevila PN, Rodríguez I. Endometriosis-associated infertility: surgery and IVF, a comprehensive therapeutic approach. Reprod Biomed Online. 2010 Aug;21(2):179-85. doi: 10.1016/j.rbmo.2010.04.026

Hjordt Hansen MV, Dalsgaard T, Hartwell D, Skovlund CW, Lidegaard O. Reproductive prognosis in endometriosis. A national cohort study. Acta Obstet Gynecol Scand. 2014 May;93(5):483-9.

Practice Committee of the American Society for Reproductive Medicine.Diagnostic evaluation of the infertile female: a committee opinion. Fertil Steril. 2015 Apr 30. pii: S0015-0282(15)00224-1. doi:10.1016/j.fertnstert.2015.03.019.

Categories: Endometriosis
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