Endometriosis is a condition affecting 30-50 % of women with infertility.Dr. Bozdogan is the specialist endometriosis and infertility NYC. The medical “literature” is a very busy, on-going and growing collection of medical information. It is made up of on-going studies and subsequent reviews of those studies. Its purpose is to inform doctors and other health care professionals of the latest valid information of the science behind what causes disease and the rationale and evidence for treating their patients. Once a study, article, or review is “peer-reviewed” (reviewed by professional authorities on a subject for accuracy), it is further judged by others as to its relevance to a particular journal. For example, does it add to our knowledge on a particular subject? Does it belong in a particular journal? Is its evidence solid or theoretical? There is an important place for theoretical conjecture, since all “solid” evidence-based information starts out as theoretical; thus, there is a place in the medical literature for experimentally exploring different ideas.
What is CERM?
CERM is a journal for Clinical and Experimental Reproductive Medicine. It is from here and in journals like this that the most advanced and up-to-date doctors—such as Dr. Bozdogan, for endometriosis—gather their state-of-the-art expertise.
Why is CERM important?
Since infertility due to endometriosis is considered a time-urgent emergency, a patient is best served going to a doctor who has his or her eyes on the latest in the medical literature. From time to time, there are journal articles that are too important to merely wait for the follow-up studies—studies that could take years before becoming “textbook” material. When this happens, Dr. Bozdogan likes to issue a “Medical Literature Alert” for his patients. One such article is the review article in the CERM journal entitled, “Management of endometriosis-related infertility: Considerations and treatment options,” by Lee, Kim, et al., published just this year, 2020.1 Nearly a hundred (actually, 99) studies and journal articles were used in the writing of this article.
Endometriosis is a condition in which tissue similar to that lining of the womb which disintegrates and falls away during a menstrual “period” is—instead—trapped inside a woman’s pelvis; that is, it isn’t discarded into the outside world (i.e., onto a tampon or pad), but remains to hormonally react to the menstrual cycle. This is a site of irritation, inflammation, and destruction of the tissue it occupies internally.
The result is pelvic pain from inflammation and normally free-floating structures adhering to each other and the obstruction to the conception process by scarring of the tubes and ovaries. In severe cases, it can even cause a solid occupation of normal pelvic spaces, like that between the uterus (womb) and rectum or between the bladder and uterus, resulting in abnormalities of—and pain with—having bowel movements and urination, respectively. Endometriosis can impact the normal operation of the urinary system, the gastrointestinal system, and in rare cases can even implant upon other systems, such as the respiratory, skin, and brain.
What causes endometriosis?
Most feel it is a reverse transmission (called “retrograde”) of this lining tissue, backwards into the pelvis. Others feel these cells can get into the bloodstream or the lymphatic fluid and be carried anywhere in the body, which would explain the distant places it is sometimes seen—nose, lungs, brain, etc. Another theory is that during development of the embryo, the normal migration of what will become reproductive tissue leaves “nests” of this tissue along the route of migration, only to awaken with puberty and the cycling of the hormones that comes with it. Probably no one explanation is the final one and that all of these have taken place to explain all cases of endometriosis.
Why this article is important: “ovarian reserve”
The article, “Management of endometriosis-related infertility: Considerations and treatment options,” is important because functioning ovaries are important for pregnancy; they must ovulate eggs for conception and contribute to the menstrual cycle. What this article discusses is the actual survival of the ovary’s function when endometriosis is present.
The ability of the ovary to function normally is what is called “ovarian reserve.”
This is an important concept in that seeking the best outcome for the most ovarian reserve should be highest on the priority wish list for infertility patients with endometriosis.
The article also reviews the data on using medication alone to treat endometriosis. This is done via hormone manipulation, and the conclusion by this review is that it just doesn’t help for infertility. Even when medication is added to surgical removal of endometriosis, it is the surgery alone and not the added medication that results in fertility when successfully achieved.
What this article explains
The lowering of the ovaries’ reserve (to function, i.e., ovulate) is what is at stake from endometriosis and its related treatment, setting a patient up for a double infertility whammy:
- Endometriosis itself poisons the ovary with an inflammatory reaction that causes an increased attack by inflammatory cells trying to fight it. This is a “drive-by shooting” of sorts on the normal ovarian tissue that gets caught in this crossfire.
- Surgery to remove endometriosis (certainly superior to just taking medicine for it), unfortunately can result in damage to the ovary, thus lowering the ovarian reserve by mechanically decreasing the amount of normal ovarian tissue.
This implies the following:
- In the quest for pregnancy, which is time-urgent due to the premenopausal “biological clock,” medical treatment alone simply wastes that precious time. These approaches include things like oral contraceptives (birth control pills), progesterone-related hormones, aromatase inhibitors (which are “anti-estrogen” drugs), and GnRH agonists (which work by stopping the hormonal feeding of endometriosis via exhausting the ovarian cycle with over-stimulation).
- Surgery, the superior way to remove endometriosis, includes the risk of more scarring and compromise to the ovary’s blood circulation.
- This means that the most delicate and exact surgical technique becomes of utmost importance, which necessitates surgery via advanced robotic surgery, the most sophisticated way to protect tissue.
Endometriosis causes damage to ovarian tissue due to the attack on it by inflammatory substances, resulting in scarring (scarred ovarian tissue does not function). Intervention via surgery can make things worse if not performed with minimally invasive techniques.
What this article recommends
Based on all of this, it turns out that different approaches to helping women with endometriosis conceive are based on the amount (level, or degree) of endometriosis that is present.
- Women with minimal to mild endometriosis should consider intrauterine insemination. Medication can be used to stimulate ovulation in conjunction with this. Since this relies on the normal pathway down the fallopian tube for a woman’s egg, the increased scarring that occurs with severe endometriosis does not show as good a result with insemination. Therefore…
- Women with moderate to severe endometriosis are advised to consider in vitro fertilization (what some call “test tube” pregnancy). This is because the severity of the endometriosis may reduce the ovarian reserve, thus diminishing normal function that ordinarily would make it possible for an egg to be released, upon which insemination relies; furthermore, the severe endometriosis would make it less likely the egg could travel unimpeded down a tube due to the scarring from the disease. Because of the reduced ovarian reserve (again, its ability to have normal ovary function) due to severe endometriosis, there is question as to whether surgery (and its mechanical damage to ovarian tissue) should be skipped and in vitro fertilization (IVF, or “test tube” pregnancy) tried first.
But this strategy can get tricky, because the pain that accompanies endometriosis may be unbearable and make the surgery necessary first, which could flip the order of the process above. If so, minimally invasive surgery, e.g., the da Vinci robotic surgery, would be the way to go, to avoid accidental damage to what ovarian tissue remains for normal functioning.
What this article concludes
Endometriosis is a terrible disease, causing two devastating effects—pain, in many cases unbearable, which sabotages relationships, employment, and a woman’s, couple’s, or family’s quality of life—and infertility, which impacts a woman’s or couple’s actualization and destiny for generations to come.
In a nutshell
The “abstract” of an article, placed first, tells of what is to come in the body of the writing. It is not designed to replace the longer text that explores the concepts more deeply, but serves as both an introduction as well as a concise summary. It also serves as a depository of “key words” through which search engines can sift for the purpose of scanning countless related articles in the literature. The abstract of “Management of endometriosis-related infertility: Considerations and treatment options” lists the following:
- Endometriosis causes a sustained reduction of ovarian reserve through both physical mechanisms and inflammatory reactions, which result in the production of reactive oxygen species and tissue fibrosis.
- The severity of endometriosis is related to ovarian reserve.
- With regard to infertility treatment, medical therapy as a neoadjuvant or adjuvant to surgical therapy has no definite beneficial effect.
- Surgical treatment of endometriosis can lead to ovarian injury during the resection of endometriotic tissue, which leads to the deterioration of ovarian reserve.
- Ovarian reserve can be reduced both due to endometriosis itself and by the process of removing endometriosis.
- In cases of mild- to moderate-stage endometriosis, intrauterine insemination with ovarian stimulation after surgical treatment may increase the likelihood of pregnancy.
- In cases of severe endometriosis, the characteristics of the patient should be considered in a multidisciplinary manner to determine the prioritization of treatment modalities, including surgical treatment and assisted re- production methods such as in vitro fertilization.
Medical literature alert
This is the first in a series of medical literature alerts. As the science progresses, it is Dr. Bozdogan’s intention to take his patients along the journey of discovery in hopes of making an impact on their conditions and recovery. Stay tuned.
- Lee, D, Kim, SK, Lee, JR, Jee, BC. Management of endometriosis-related infertility: Considerations and treatment options. Clin Exp Reprod Med February 24, 2020; https://ecerm.org/journal/view.php?doi=10.5653/cerm.2019.02971