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.
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.
Q: Why is the percentage of patients with endometriosis much higher in
our patient population?
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
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
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
“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:
Many women with extensive endometriosis have no pain at all. In fact we
have diagnosed very extensive endometriosis in completely asymptomatic women.
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.
The doctors have never asked the right questions.
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.
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