Many top doctors came and presented at last month’s Endometriosis Foundation of America‘s annual Medical Conference titled, Pursuing Precision with Passion. Experts in the field discussed at length the controversies and challenges of treating endometriomas.
What are endometriomas?
Dr. Kristin Patzkowsky, Assistant Professor of Gynecology and Obstetrics at Johns Hopkins Medicine, describes endometriomas as an endometriosis cyst of the ovary. Also called chocolate cysts, these can occur on one ovary or both. They affect between 20-40% of patients with endometriosis, many of whom also have stage III-IV disease. A knowledgeable doctor can tell the difference between a cyst and an endometrioma on an ultrasound. Some patients may have endometriomas and be asymptomatic. But many patients experience symptoms similar to those of endometriosis. These may include painful periods, pelvic pain outside of periods, painful intercourse, and in some cases, infertility.
How do endometriomas affect fertility?
Not all patients with endometriosis will experience infertility. But, 30% of patients with infertility have endometriosis. Endometriosis can cause infertility in many ways. Scarring and adhesions caused by the disease can distort the physical anatomy of the patient, making ovulation and fertilization difficult. Dr. Patzkowsky talks about how endometriotic lesions can produce inflammatory agents, causing a toxic environment in the body. This can lead to damage to the egg and uterine lining and adversely affect the ability of the embryo to implant.
Patients with endometriosis who have endometriomas have even greater challenges when it comes to fertility. Dr. Patzkowsky discusses how women with endometriomas, compared to women without, have fewer eggs in the ovarian tissue surrounding the endometrioma, impaired egg maturation, and lower AFC and AMH. Women with endometriomas also tend to have a higher FSH level.
Dr. Pinar Kodaman, Director of Reproductive Endocrinology at Yale Fertility Center, shares how the content of endometriomas is toxic in many ways, causing fibrosis, inflammation, and mechanical disruption of the ovary. The presence of endometriomas on both ovaries has a significant effect on ovarian reserve.
IVF and endometriomas
For patients with endometriomas, IVF is an option, although there are risks to consider. Dr. Kodaman discusses how some patients with endometriomas experience a decreased response to gonadotropins, which can lead to a greater IVF cycle cancellation rate. Depending on the size and location of the endometriomas, retrieval of the oocytes can be difficult. There is also a risk that the endometrioma can be punctured during retrieval causing leakage or a rupture, which can lead to infection. Finally, follicular fluid contamination with endometrioma fluid may contribute to decreased blastocyst hatching and also lower pregnancy rates.
Endometriomas and surgical intervention
If endometriomas are so toxic, it seems like an easy decision to just have them removed. Unfortunately, the solution is not that easy, especially for those who are looking to preserve their fertility. Dr. Kodaman warns that when surgically removing endometriomas, patients run the risk of a significant decline in AMH, inadvertent removal of ovarian cortex with cyst wall, and injury from inflammation, cautery or vascular disruption. These risks increase when removing endometriomas from both ovaries. Patients may even run the risk of ovarian failure and go into early menopause.
The importance of the experience of the surgeon
When thinking about surgically removing endometriomas, Dr. Kodaman stresses that the surgical experience of the doctor is very important. When a careful surgical technique is applied there can be no difference in the number of oocytes and embryos obtained following cystectomy. She also states that laparoscopic cystectomy is the gold standard of treatment. It is associated with the lowest recurrence rate of endometriomas and the highest spontaneous pregnancy rate. While researchers have not conducted studies in older patients, younger patients may initially have a drop in AMH levels after surgical intervention, but levels are back up after a year. Draining an endometrioma is associated with a 30-90% recurrence rate and is not recommended.
Even in the most experienced surgical hands, carefully removing endometriomas can be challenging. Dr. Tamer Seckin, the co-founder of the Endometriosis Foundation of America, agrees that draining an endometrioma is not the proper treatment for a patient. He stresses that the most challenging part of removing endometriomas is removing the cyst entirely without disturbing the ovarian tissue underneath.
Following the removal of endometrioma
After removing the endometrioma, some doctors will try to control the bleeding of the ovarian tissue with electrosurgery. But Dr. Seckin warns that it is important not to use this technique as heating the ovarian tissue can cause damage to the eggs. Instead, Dr. Seckin uses fine sutures to piece back the disrupted ovary. Most importantly, patients with endometriomas often have a deeply invasive disease affecting their pelvic sidewall. They also often can have leg and back pain due to the disease affecting the nerves. Simply, removing or draining the endometrioma will not bring pain relief to these patients. Meticulous excision, removing adhesions, scar tissue, and invasive disease throughout the pelvic cavity, is the best way for patients to get relief.
What to do?
For patients with endometriomas who are struggling with infertility, the path to treatment is not clear. Dr. Patzkowsky reports that results of conception are similar in patients who had surgery and those who did not. ASRM and ESHRE recommend surgery as the gold standard for systematic endometriomas and asymptomatic endometriomas that are 4 cm in diameter or larger. They also recommend that endometriomas with a mean diameter below 4 cm should not be systematically removed before IVF. The age of the patient and their baseline AMH levels should be considered before surgically removing the endometriomas. Both Dr. Patzkowsky and Dr. Kodaman believe that if the patient has significant pelvic pain and/or if the endometrioma appears to be large or malignant in nature, removal is the best practice.
Egg freezing as an option
Dr. Tomer Singer, director of the Egg Freezing Program at North Shore LIJ, stresses that early detection is key for patients with endometriosis. He believes patients should be referred to an endometriosis excision specialist and a reproductive endocrinologist to assess their fertility as soon as possible. Singer wants all gynecologists to assess endometriosis patients’ AMH levels from the start. They should then retest their levels every six months so that patients can make informed decisions about their fertility and maybe choose egg freezing as an option, Singer says. He feels one hurdle to getting excellent care is that it can be hard to find an excellent endometriosis surgeon and a reproductive endocrinologist that will do egg freezing, especially outside of major cities.
Conversation is key
Dr. Patzkowsky stresses that overall thoughtful and thorough conversations need to happen between a patient, their fertility doctor, and an endometriosis excision specialist. What is important to note is that many patients with endometriomas also have disease throughout their entire pelvic cavity. IVF may be able to help the patient achieve their pregnancy goals, despite the endometriomas. However, it is still worth talking to an excision specialist if the patient is having other symptoms of endometriosis. The patient and the excision specialist may decide not to touch the endometrioma. But the disease can be removed throughout the rest of the pelvis, reducing symptoms, improving quality of life, and reducing toxic inflammatory agents in the body, which can help reproductive efforts. Patients are their own best advocates in terms of doing what is right for their bodies.