Case study: endometriosis and infertility
A case study by Dr Geoffrey D Reid, Director, Gynaecological Endoscopy, Liverpool Hospital, Genea (City, Liverpool); Dr Michael JW Cooper, Head, Gynaecological Surgery, Royal Prince Alfred Hospital, Genea (City); and Ms Hannah Wills, Medical Student, University of NSW (research project: outcomes following surgical management of colorectal endometriosis).
Suzanne and William*
Suzanne 39 years: generally healthy; BMI 22.1; attempting to conceive for 8 years; slightly irregular menses with a 21-35 day cycle; William 42 years: healthy; normal seminal parameters; continuing reproductive difficulties.
Presentation and history
Suzanne 33 years: 2-year history of infertility, mild dysmenorrhoea and pre-menstrual spotting.
Laparotomy performed for removal of bilateral endometriomas (6cm & 3cm): ~ 50% left ovary and 80% right ovary retained. Post-operative Synarel (nafarelin acetate) nasal spray recommended.
NOTE: Medical treatments (progestogen or GnRH analogues) will not improve fertility when given either pre-operatively or post-operatively. Medical treatment can be used pre-operatively to quieten endometriosis in preparation for surgery.
Suzanne 35 years: advanced laparoscopic procedure performed, including removal of recurrent ovarian endometriomas, removal of extensive peritoneal endometriosis and tubal adhesiolysis. Deep rectal and rectovaginal endometriosis identified, but not removed. Both Fallopian tubes were patent. Referred to an IVF unit for a stimulated IVF cycle: 6 oocytes retrieved, leading to transfer of 2 embryos as blastocysts on day 5, but no pregnancy.
NOTE: Surgical removal of endometriosis will improve spontaneous fertility, and might improve IVF fertility in some circumstances. Laparoscopic removal of an endometrioma is aimed at minimising loss of normal ovarian tissue and function.
Suzanne 38 years: referred to Genea with continued infertility. Menstrual hip pain and pre-menstrual spotting were the only symptoms.
Ultrasound: no evidence of recurrent ovarian endometriomas. Hysterosalpingocontrast sonography: Fallopian tubes appeared patent. Day 2 follicle-stimulating hormone (FSH): 9 IU/L and oestradiol (E2) < 100. A repeat seminal analysis for William again showed normal parameters.
NOTE: Pre-menstrual spotting is reported by about 60% of patients with endometriosis. Severe endometriosis can be found in asymptomatic infertility patients. Ultrasound is a sensitive predictor of ovarian endometriosis, but a poor predictor of peritoneal or recto-vaginal disease. If ovarian disease is present, the large majority of patients will have coexisting peritoneal disease, and many have colorectal disease.
Suzanne 39 years: long down-regulated IVF cycle with FSH 275 units ? day 8 E2 < 100 ? cycle cancelled.
GnRH antagonist cycle commenced after day 1 FSH was measured at 11 IU/L and E2 < 100 ? stimulated with FSH 300 units ? E2 failed to rise ? cycle cancelled.
A day 1 FSH was measured at 18 IU/L, demonstrating a significant decline in egg numbers. Suzanne met with Genea counsellors to discuss a donor oocyte cycle. Her donor was 34 years old and had 2 children. She proceeded through the screening and counselling process established at Genea.
NOTE: Oocyte donation is a very personal choice, but has a high success rate when oocytes are derived from a young fertile donor. The process is altruistic and couples must source their own donor, often a family member or friend. Poor ovarian reserve is sometimes observed in patients who have undergone recurrent ovarian endometriosis surgery. It is therefore important to use surgical techniques that minimise the risk of ovarian recurrence while minimising collateral damage to adjacent ovarian tissue. The lowest risk of recurrence occurs with laparoscopic excisional surgery (Cochrane Database).
Significant colorectal endometriosis remained present. While this had caused no marked symptoms, Suzanne wondered about its contribution to her infertility and concluded that she wished to have this disease removed before proceeding through a donor-recipient IVF cycle. The surgery was discussed in detail and Suzanne was aware that there were some risks in that the bowel would be operated on and extensive dissection and resection of tissue would be necessary.
The bowel was thoroughly prepared pre-operatively. Laparoscopic anterior segmental bowel resection for removal of deep-rectal endometriosis was performed. Suzanne recovered well and was discharged on the third postoperative day.
While not wanting to delay her egg donation cycle too long, Suzanne was also able to resume intercourse relatively early post-operatively and she became pregnant naturally. An early ultrasound showed a fetal heartbeat to be present. Unfortunately, fetal heartbeat motion was not present on a repeat scan and, miscarriage being inevitable, evacuation of the uterus was undertaken when Suzanne felt she was ready for this to be carried out. Suzanne remains confident she will achieve an ongoing pregnancy, if necessary with the assistance of her oocyte donor.
NOTE: Active cooperative management between laparoscopic surgery and IVF is the best way to avoid losing months or years of time - time that is vital when one considers the impact of female age and declining ovarian reserve upon fertility.
Endometriosis and infertility: take-home messages
GP advice to patients
It is difficult for GPs to advise patients with suspected or confirmed endometriosis and infertility because there appears to be great variation in specialist opinion on the topic of what form of treatment, medical or surgical, is most appropriate. Medical therapy necessarily stops ovulation, though, and is thus contraceptive. However, the European Society for Human Reproduction & Embryology (ESHRE) has published evidence-based guidelines confirming that suppressive medical therapy has no place in treating infertility per se, whereas the place of surgery and assisted reproductive technology (ART) is well established and comprehensively discussed.1
The more extensive the endometriosis is, the greater the improvement of fertility can be following its removal (provided the surgery does not cause significant adhesions).2 The duration of "watchful waiting" is therefore determined by disease severity and patient age. Older patients with minimal disease should proceed fairly rapidly to ART, whereas younger patients with more severe disease should be given a longer "trial of pregnancy". Some patients with suspected endometriosis may wish to try 1-2 cycles of IVF, proceeding to laparoscopy if this should fail. Management is therefore individualized to the patient's particular circumstances and preferences. The survival of sperm in the female reproductive tract is compromised even with mild endometriosis and this is not overcome by assisted insemination.3
IVF in patients with endometriosis
In general, patients with endometriosis should choose an approach that gives the highest pregnancy rate with the shortest period of ovarian stimulation. This favours IVF or intracytoplasmic sperm injection (ICSI), rather than various forms of ovulation induction and artificial insemination
Infertile patients with severe colorectal endometriosis
Management is a highly controversial area with little published data. Pregnancy rates of 45.5% have been quoted following laparoscopic anterior segmental bowel resection, and 39.5-52% following bowel resection at laparotomy.4 More recently, a pregnancy rate of 66.7% (with and without IVF) has been reported in 24 patients undergoing laparoscopic bowel resection for infertility.5
1. European Society for Human Reproduction & Embryology. The ESHRE guideline for the diagnosis and treatment of endometriosis page. Available at http://guidelines.endometriosis.org/ Accessed February 4, 2008.
2. Jansen RPS. Relative infertility: modeling clinical paradoxes. Fertil Steril 1993;59:1041-45.
3. Jansen RPS. Minimal endometriosis and reduced fecundability: prospective evidence from an artificial insemination by donor program. Fertil Steril 1986;46:141-43.
4. Darai E et al. Laparoscopic segmental colorectal resection for endometriosis: limits and complications. Surg Endosc 2007;21(9):1572-77.
5. Reid G et al. Fertility following laparoscopic colorectal surgery for endometriosis. Abstract submitted: World Congress on Endometriosis. Melbourne, Australia. March 2008.
Further reading Jansen RPS. Getting pregnant 2nd ed. Allen & Unwin, Sydney 2003 (chapter 15-16).
* personal details have been changed for privacy reasons