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A chocolate cyst of the ovary ( also known as an endometrioma, endometrioid cyst, or endometrial cyst) is found in some infertile women who have endometriosis. In this disease, the inner lining of the uterus ( called the endometrium ) grows in various abnormal locations within the pelvis . One of the commonest sites this aberrant endometrial tissue can be found in is the ovary. With every menstrual period, this tissue grows, enlarges , bleeds, and sloughs off . Here it forms a cyst; and because the contents of this cyst are black, tarry and thick, they resemble dark chocolate , hence the name ! ( I feel that sometimes doctors can have a perverse sense of humor . For most women, the word chocolate produces happy feelings, because chocolates are a woman’s favourite treat. To label a disease condition after a dessert is something which only an unfeeling man would do ! )

How is the diagnosis made ? While an alert doctor will often suspect the diagnosis in infertile women with progressively painful periods, often women with chocolate cysts may have no symptoms at all. This means this diagnosis is made during a regular infertility workup ; or even during a routine pelvic examination. While some cysts are large enough to be felt on pelvic examination, many are small and cannot be detected on clinical examination.

Ultrasound scanning is an excellent way of diagnosing chocolate cysts and can pick up cysts which are very small. On scanning, chocolate cysts are complex masses ( which have both solid and cystic components); and are often tender. They have a typical ground glass appearance because they contain old blood. They can vary in size from a few mm to over 10 cm; and can be bilateral. However, it’s not possible to make a definitive diagnosis of endometriosis on ultrasound scanning, as many other conditions can also produce cysts in the ovary. The diagnosis can be confirmed either by aspirating the cyst under ultrasound guidance ( and finding the typical dark old blood which is diagnostic of endometriosis); or by doing a laparoscopy.

In the past, a laparoscopy was the gold standard for making the diagnosis of endometriosis, as this allowed the doctor to actually inspect the pelvic contents. However, because it involves surgery, many infertility specialists no longer do a laparoscopy for their patients.

There are 3 key factors which doctors need to evaluate when making a decision as to how to treat chocolate cysts in infertile women.

1. Whether the patient has any symptoms
2. The size of the cyst
3. The AMH level

Thus, when a small chocolate cyst is picked up when doing a routine vaginal ultrasound scan in a young asymptomatic infertile woman , the best course of action maybe masterly inactivity. This is because this is an incidental finding which is best documented and left alone. Remember that doctors do not treat ultrasound images - we treat patients ! Many fertile young women also have endometriotic cysts which they live with happily for all their lives ( and because they have enough sense not to go to a doctor, they often do not even know that they have a chocolate cyst !) Unfortunately, many doctors tend to be trigger-happy, and when they find a cyst on a pelvic ultrasound scan, they reflexly perform laparoscopic surgery – both to confirm the diagnosis; and to treat the cyst ! The danger is that this unnecessary surgery can actually reduce your fertility , as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.


Small cysts ( less than 3 cm in size) can be happily left alone . If they are larger, they can be monitored by serial scans, before making a decision as to what the definitive treatment should be.

As regards treatment choices, the options include medical therapy or surgery. Medical therapy consists of medicines such as danazol or GnRH analogs to suppress the endometriosis; and while this is very effective in providing temporary symptom relief , it is not very effective in treating the cyst, which tends to remain inspite of the treatment.

The definitive solution is surgical; and this usually consists of operative laparoscopy . Very few doctors will now do open surgery ( laparotomy) to treat a cyst, no matter how large it is.
There are many controversies regarding the optimal surgical management of chocolate cyst s in an infertile woman, which is why it is important that you go to an expert. In the past , doctors would try to excise ( completely remove) the entire cyst , to reduce the risk of its recurring . However, because this meant that they needed to also sacrifice normal ovarian tissue during this process, they often ended up pushing infertile patients from the frying pan into the fire by reducing their ovarian reserve and worsening their infertility ! This is why most doctors today prefer to be far more conservative in infertile women with chocolate cysts ; and will usually just create an opening in the cyst wall ( marsupialisation) to drain the contents. This often provides dramatic temporary relief. During the operative laparoscopy, the doctor also has an opportunity to remove the adhesions (scar tissue) and the other endometrial implants which are often found in women with chocolate cysts and treating these can also help to enhance their fertility for a few months. The chances of achieving a pregnancy are maximal within a few months after the surgery. However, if a patient has failed to conceive within one year of the surgery, then the chances of success with repeat surgery are quite poor; and it’s better to consider assisted reproduction.

The major bugbear with chocolate cysts is that they tend to recur. This is why doctors will often combine medical suppression with surgical treatment. However, all these are temporizing measures, which help to buy the patient time – we really do not have any way of curing this enigmatic disease !

If the chocolate cyst recurs, patients are understandably upset, and feel that the doctor was incompetent and did not do a good job with the surgery. This is not always true, because endometriosis can be quite an aggressive disease in some women, and can recur even if the surgeon was very skilled. It’s important to ask for DVD documentation of all surgical intervention, so that the video can be reviewed later on, if needed.

If the cyst recurs, patients will often go to another surgeon ( who they feel is more expert) to try to correct the problem. The pelvis in some of these patients starts resembling a battle field, because they often end up having many laparoscopies done by many different surgeons, each of whom claims to be the best ! The surgery can be extremely challenging in these patients . The scarring , adhesions and previous surgery tend to distort the anatomy and the pelvis sometimes is completely frozen. Operative complications in these cases ( for example, inadvertently opening the bladder or rectum) are not uncommon.

The AMH level is a very important factor which many doctors tend to overlook in treating infertile women with endometriosis. The major danger with endometriosis is that the chocolate cyst replaces normal ovarian tissue, as a result of which many of these patients have little normal ovarian tissue and poor ovarian reserve as a result of their disease. This is why it’s important to assess your ovarian reserve by checking your AMH level and your antral follicle count before doing anything further ! If your AMH level is low, then it’s best to avoid surgery and to move on to IVF to maximize your chances of having a baby quickly ( before the disease becomes worse and eats away more of your precious reserve).

For young women with normal ovarian reserve, open fallopian tubes ( as proven on HSG) and small chocolate cysts who have no symptoms, it’s worth trying IUI before doing anything more aggressive. However , if the patient is symptomatic and the endometriosis is causing pain, then this become a trickier issue ! You need to set your priorities – is pain control more important ? Or is having a baby more important ? This is often a difficult decision to make, but you need to decide. It’s best to make a list of all your options so you can think through these logically.
If having a baby is key, then it’s best to manage your pain symptomatically and concentrate your energies on getting pregnant quickly. IVF is very effective , as it maximizes your chances of getting pregnant quickly . The beauty with IVF is that it allows you to kill 2 birds with one stone – not only do you get your deeply desired baby, you also have dramatic pain relief for at least 1 year ( because your periods will stop during your pregnancy and your postpartum period ). As an added bonus, the endometriosis will also get better as a result of the pregnancy in some women ! This is why many doctors advise that the best treatment for a young woman with endometriosis is a pregnancy. Of course, this is easier said than done, because endometriosis does affect your fertility !

Do you have a chocolate cyst and are unsure what to do ? Send me your medical details by filling in the free second opinion form and I'll be happy to help !

Blocked fallopian tubes are one of the commonest causes of infertility. The fallopian tubes project out from each side of the body of the uterus and form the passages through which the egg is conducted from the ovary into the uterus. The fallopian tubes are about 10 cms long and the outer end of each tube is funnel shaped, ending in long fringes called fimbriae. The fimbriae catch the mature egg and channel it down into the fallopian tube when released by the ovary .

The tube itself is a muscular highly movable structure capable of highly coordinated movement. The egg and sperm meet in the outer half of the fallopian tube, called the ampulla. Fertilization occurs here, after which the embryo continues down the tube toward the uterus. The uterine end of the tube, called the isthmus, acts like a sphincter, and prevents the embryo from being released into the uterus until just the right time for implantation, which is about 4 to 7 days after ovulation.The fallopian tube enters the uterus at its cornual end.

The tube is much more complex than a simple pipe, and the lining of the tube is folded and lined with microscopic hair like projections called cilia which push the egg and embryo along the tube. The tubal lining also produces a fluid that nourishes the egg and embryo during their journey in the tube.

Fig 1. Normal tube and ovary, as seen during laparoscopy

Remember that a doctor cannot judge if your fallopian tubes are open or closed either by an internal examination; or a vaginal ultrasound scan. Unfortunately, this is a very common mistake many patients make, and they assume that if the scan is normal, this means their tubes are open. This is not true. Sadly, many doctors also make the assumption that the fallopian tubes are open, without bothering to test them. Thus, some doctors will assume that a young woman with polycystic ovarian disease must have open tubes, and they start treating her with clomid, without bothering to test the tubal status. This can sometimes be a very expensive mistake ! Just because you have had no symptoms of a pelvic infection does not mean that your tubes cannot get blocked; and if the tubes are blocked, this means the eggs and sperm cannot meet, no matter what medicines you take. This is why it is essential that you ask the doctor to formally test your tubal status before starting any treatment.

The only reliable ways of testing if your tubes are open or closed is by doing either a HSG or a laparoscopy. Personally, I prefer a HSG, because it is much less expensive and provides hard copy documentation.

If a tubal block is found, then what are the next steps ?

The first question is - Are both the tubes blocked ? If only one tube is blocked, then there is no need to take any action at all ! One normal tube is enough for normal fertility. If one tube is open and your doctor advises you to have surgery to open the other tube, please do not agree !

The next question is - Where is the block ? The block could be at the terminal ( fimbrial) end of the fallopian tube. This often causes the tube to get swollen with fluid, and form a hydrosalpinx. In the past, doctors would perform tubal surgery to open this kind of blocked tubes. However, the results were very poor. The tube would usually close down again; or would never function properly, because its inner lining was damaged - damage which cannot be repaired by surgery. Some of these patients would then go on to have tubal ( ectopic) pregnancies.

If the tube is blocked at the cornual end, it's sometimes possible to repair these tubes. Sometimes the block is not a real block, but just an apparent block because of tubal spasm . Sometimes the block is because of a mucus plug or debris, and this can sometimes be cleared with the help of FTR ( fluoroscopic tubal recanalisation). This is a bit like doing an " angioplasty " for the fallopian tube ! ?

Remember that it's impossible for a doctor to judge tubal function. While we know that a blocked tube will not work, it does not follow that an open tube ( which may look perfectly normal anatomically on the HSG or the laparoscopy) is in fact capable of functioning normally ! Sometimes the doctor says the spill of dye is "sluggish"; or that "the tubes filled slowly"; or that they have a beaded appearance. These are just descriptive terms, and often cause more confusion rather than clarity !

Finding out your tubes are blocked can be quite a blow. Because tubal disease is often silent, there is no way of suspecting tubal blockade prior to doing the tests. Blocked tubes will not affect your menstrual cycle, your health or your sexual life, but they will prevent you from having a baby !

While the results of tubal surgery to repair blocked tubes is poor, the good news is that it is possible to offer very effective treatment for this problem today, thanks to IVF, which allows us to bypass the problem completely ! In IVF, the test tube in the IVF lab performs the role the fallopian tube would normally perform in the bedroom !

If you have a hydrosalpinx , some doctors will want to surgically remove this prior to performing IVF. I do not think this is a good idea at all !

I just got this email from a patient.

I am a patient with azoospermia. My wife's reports are perfect with no fertility problems.

We are undergoing TESE- ICSI in a fertility clinic in Bangalore. My wife was superovulated with RECAGAN 100IU which she has been taking for the last 10
days . Today's scan result shows 14 mature follicles . The sizes are:

Right ovary
2.1*1.7
1.8*1.4
1.7*1.3
1.9*1.2
1.6*1.5
1.6*1.4
1.6*1.4

Left ovary
1.8*2.2
1.9*1.6
1.6*1.5
1.8*1.4
1.4*1.3
1.7*1.2
1.5*0.9

According to the original plan , we were supposes to take HCG tonight (11th day of the period) and the egg retrival was planned for Wednesday . However, due to non-availability of " TESA Specialist " they are postponing the egg retrival by 3 days and HCG injection by 2 days. We have been asked to continue injection RECAGON 100IU for 2 more days. The doctor gave me harsh reply , saying he can't help this and there is no choice.

I am really worried ! Will this affect our ICSI success chances ? Will it affect my wife's ovaries , because the follicles would have grown even more in 3 more days !

This patient has got a really raw deal. After spending so much time, money and energy, the egg collection is being re-scheduled because the specialist is not available.

This is sad ! This reduces the chances of pregnancy; and also increases the risk of OHSS ( ovarian hyperstimulation syndrome) , because the follicles will get too big !

It's very disappointing that the IVF clinic did not know when the “ TESA specialist “ was coming in advance !

This is why we tell patients that they should always select a full-service clinic which provides all the services themselves and operates around the year and is not dependent upon "visiting specialists" !

A vaginal ultrasound scan has now become a routine part of the work of an infertile woman, because it provide so much useful information. Unfortunately, many IVF specialists misuse this simple technique.

I have seen patients who have been advised donor eggs by IVF doctors, because their "ovaries looked small" on the vaginal scan done at the time of the consultation . Even worse, is the fact that some doctors advise surrogacy because " the uterine lining is thin".

They do not bother to provide any documentation of their scans - or to explain options and alternatives to their patients. Most patients are quite easily initimidated; and since the IVF doctor is seen to be the "court of last resort", many follow the doctor's advise blindly or get disheartened and give up.In fact, some clueless patients are very impressed by how skillful the doctor must be, that he ( or she) could come to the correct diagnosis so quickly - a diagnosis which had eluded all their earlier doctors ( because it is wrong !)

This is a guest post from Dr. Sai, Senior Embryologist, Malpani Infertility Clinic Pvt. Ltd.

Mrs. Bhatt had very poor ovarian reserve. Her AMH level was 0.3 ng/ml and she had reached the oopause . We advised her to use donor eggs but she was quite certain she wanted to have a baby with her own eggs. We explained to her that her prognosis was bleak, but she was determined, and requested us to do our best to help her to have a baby with her own eggs.

We superovulated her aggressively using a letrozole – antagon protocol, with 750 IU of HMG daily. She had a very poor ovarian response as expected, and grew only one follicle. We advised her to cancel the cycle, but she was very keen on getting pregnant and requested us to proceed with the treatment. Dr. Anjali did the egg collection and retrieved one oocycte cumulus complex from the follicle after flushing it multiple times. When I stripped the oocyte, it unfortunately turned out to be immature – it was a germinal vesicle stage egg.

We decided to keep the egg for In vitro Maturation ( IVM) .The egg matured exactly after 20 hours. I performed ICSI on that egg. It fertilized and we transferred the embryo back into the uterus on day 2. It was a gorgeous 4-Cell Embryo.

Even though we got only one embryo, the patient was very happy that at least we had helped her to reach this stage. She had been mentally prepared to get zero eggs and zero embryos, so this was quite a positive development from her point of view. Thanks to the technique of In vitro Maturation, they got a beautiful embryo to transfer.

We kept our fingers crossed – and 14 days after the transfer, she was on top of the moon when the HCG result was positive, confirming that she was pregnant ! Her pregnancy is now progressing well !

So what is in vitro maturation ? and how do we do it ?

In vitro maturation, as the name suggests, refers to the process of maturing immature oocytes outside human ovaries, in the IVF lab.

Applications of In vitro maturationof oocytes :

• Oocyte donors, to preserve their eggs in egg bank.
• Fertility preservation for women with cancer who are undergoing gonadotoxic chemotherapy.
• Fertility preservation for young women without partners needing IVF treatment.
• Poor responders to ovarian stimulation.
• Patients with lots of immature eggs after egg collection.
• Patients with PCOS syndrome, leading to retrieval of lots of immature eggs, after being hyperstimulated.

Mature Oocyte Immature oocytes

In vitro Maturation medium is now commercially available.

At our centre we use "SAGE In vitro Maturation medium”

It is not a ready to use medium. One has to prepare it.

Maturation media is usually supplemented with recombinant FSH and hCG.

The protocol for preparation of In vitro maturation medium is as follows :

Solution A = 1 ml IVF culture medium

Solution B = We use Menogon ( HMG). This powder contains a mixture of 75 IU
FSH and 75 IU LH. Dissolve this in 1 ml of IVF culture medium (A).

Solution C = 1 ml of Fresh Oocyte Maturation Medium in a test tube.

Solution D = Add 10 ul Solution B into Solution C

Solution D is now prepared Oocyte Maturation Medium.

In Vitro Maturation of Oocytes :
In Vitro Maturation on cumulus-enclosed oocytes :

• Done on oocytes retrieved from small sized follicles.
• Done on oocytes with apparently compact cumulus complexes

Immature oocyte cumulus complex

• Immediately after retrieval, cumulus-enclosed immature oocytes are placed in a specialized IVM medium for 24–48 hours.
• Generally germinal vesicle–stage oocytes that matured within 30 hours of culture are developmentally more competent than are oocytes necessitating longer time to mature.
• After IVM, mature oocytes are transferred to traditional IVF media for insemination and embryo culture.
• Insemination of IVM-Mature oocytes can be done by either Conventional IVF technique or ICSI. ICSI has been our preferred method as oocytes are frequently denuded of granulosa cells for evaluation of maturational status. ICSI has been used to increase the chances of fertilization whether or not a male factor has been detected.

In Vitro Maturation on Stripped oocytes :

• Done on Germinal Vesicle stage oocytes (confirmed after denuding them of the surrounding cumulus cells)
• All Germinal Vesicle Stage oocytes are kept in Specialized IVM medium for 24-48 hours.
• After IVM, Mature ( metaphase II) oocytes are transferred to traditional IVF Medium for ICSI.

Germinal Vesicle Stage oocyte. The germinal vesicle is the clear vacuole within the cytoplasm.

Photo of the egg after IVM. It has now become mature ( metaphase II – MII) . You can see that the germinal vesicle has dissolved and the polar body can be seen at 12 o'clock.

IVM is not a panacea for all problems – and not all immature eggs will mature in vitro using this technique. However, it does allow us an additional option, and can be very helpful when treating poor ovarian responders !

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I had just advised a young woman who had oopause ( poor ovarian reserve) to try empirical therapy, with DHEA, wheat germ , yoga and acupuncture , before we started her IVF treatment.

She wanted to know the rationale behind my advise. " Doctor, on one hand you are saying that I have poor ovarian reserve, which means that I only have few eggs left in my ovaries. Women are born with all the eggs they will ever have and I cannot make any new eggs any more. In that case, how will taking all these medicines help me to grow more eggs during my IVF cycle ? "

This was my reply.

" Yes, it is true that we cannot make you grow new eggs. Your ovary contains all the eggs you will ever have. These eggs are in a resting phase, and are contained in primordial follicles. Each month some of these these follicles are selected and start growing. This group is called a cohort, and this is a response to the high FSH levels during the follicular phase. Of these follicles , only one will mature, while the others will die ( a process called atresia). It is our hypothesis that yoga and acupuncture will help us to recruit more of your follicles , so that if the cohort is larger, hopefully more follicles will mature when we superovulate you during your IVF treatment."

I enjoy being a doctor because my patients keep me on my toes !

I just saw a young woman who was sobbing as if her heart would break. She had had irregular cycles for many years, and I had just informed her that the reason for her irregular cycles was the fact that her egg quality was very poor, and that the only way she could have a baby was by using donor eggs.

She was very upset - and was actually quite angry with me ! She had been going to a gynecologist for the last 3 years in order to try to have a baby. He had diagnosed her as having PCOD ( polycystic ovarian disease) and had told her that this was the reason for her irregular cycles. She was given Duphaston every month to induce a cycle - and had even had 2 IUI cycles done.

On reviewing her records, I pointed out to her that her FSH level on more than 2 occasions had been very high - and this confirmed the diagnosis of ovarian failure.

Now she was angry with her gynecologist ! Why hadn't he made the right diagnosis ?
How could he miss the significance of the high FSH level ?

It was not until she came to me for a second opinion did she realise that her high FSH meant she had entered the oopause. She was very bitter, because she had always been very worried about her irregular cycles. However, her gynec had always reassured her, saying - " Don't worry - you are young ! Your eggs are fine !"

It's important to differentiate between calendar age and ovarian age - and not all young women will have young ovaries ! Unfortunately, for many of these women, the diagnosis is not made in time. The eye only sees what the mind knows, and many gynecs do not even consider the possibility of premature ovarian failure when treating young women, because the majority of their patients are fertile !

It's even worse when they are misdiagnosed as having PCOD. The reason her periods were irregular is because she did not ovulate. This is called anovulation. Now while it is true that the commonest cause for anovulation is PCOD, the other common diagnosis which needs to be ruled out is premature ovarian failure. The high FSH level should have allowed the gynec to make the right diagnosis !

When patients have irregular periods, we advise them to do the following tests.

1. Blood tests for the following reproductive hormones - FSH ( follicle-stimulating hormone),LH ( luteinising hormone),PRL ( prolactin) , AMH ( anti-Mullerian hormone) and TSH ( thyroid stimulating hormone) on Day 3 of the cycle, ( to check the quality of their eggs).

Patients with PCOD have high AMH levels; high LH levels; and a normal FSH levels. Patients with ovarian failure, on the other hand, have high FSH levels and low AMH levels.

This diagnosis can be confirmed by doing a vaginal ultrasound scan which checks for ovarian volume and antral follicle count. Patients with PCOD have large ovaries, with an increased antral follicle count. Patients in the oopause have small ovaries and a reduced antral follicle count.

The worst tragedy occurs when a patient with anovulation because of poor ovarian reserve is misdiagnosed as having PCOD. Some doctors will do an ovarian drilling for these patients - and this destruction of their normal ovarian tissue will cause them to have iatrogenic ( produced by a physician) premature ovarian failure !

Conversely, we also to see patients with PCOD who have done IVF and have been told by their doctors that they have poor ovarian reserve, because the doctor did not do a good job superovulating them ! It's a pleasure to treat these patients, because with the right superovulation, they have very high pregnancy rates !

If you are unsure of your diagnosis, the single most important test you can do is to check your AMH level. This is a reliable test - and makes it very easy to differentiate between PCOD and oopause !

Many women these days are postponing having a baby in order to pursue a career. The good news is that while usually fertility does not decline too much until the age of 32, for some women the decision to postpone childbearing can prove to be one they bitterly regret later on. Fertility does decline as a woman grows older, and the problem is that it is not possible to predict the rate of decline for an individual woman. Most women are lulled into a false sense of security if they have regular period, because they assume that if their periods are regular, this automatically means that their egg quality if enough for them to make babies !

Unfortunately, this is not always true - and for some women, while their egg quality is enough for them to produce enough hormones to get regular periods, it may not be enough to make a baby ! Also, many women have very unrealistic expectations of IVF technology, thanks to all the stories of the over-40 celebs who have babies all the time ( often by using donor eggs, a fact which is very jealously guarded secret) !

How is an individual woman going to find out which category she falls into ?

Suppose you are 32 and want to postpone childbearing for another year because you have a very good chance of getting a promotion ? Is it safe to do so ? Or will this be something you will kick yourself for later on when your IVF doctor says - I wish you had come to me earlier ?

The bad news was that until now, there really was no very good test to check ovarian reserve. This often meant that most women had to just leave things upto destiny, which can be notoriously fickle.

The good news is that there is now a very good test to check your ovarian reserve !

The bad news is that most women are unaware of this test !

The good news is that this is a very simple blood test, which most labs now offer !

The bad news is that most family physicians and gynecologists are still unaware of this test and what it means !

So what's this test ?

This is a blood test for checking your AMH ( anti Mullerian hormone) levels. It can be done on any day of your cycle. The level correlates well with your ovarian reserve - the quantity and quality of eggs you have in your ovaries. Women with normal levels have good ovarian reserve; while those with low levels have poor ovarian reserve.

If you are more than 32 and want to postpone childbearing, I'd suggest you get this test done. If it's low, you might want to re-think your priorities. If it's normal, then it's fine to postpone childbearing, but do get the test repeated every year. If it starts dropping, this is a sign you might want to pay attention to your biological clock before it is too late !