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I saw a patient who was at her wit's end. She had already had two laparoscopies for treating endometriosis. Since she was still not pregnant, she had gone to a third gynecologist. He did an ultrasound scan and found that the chocolate cyst had recurred; and was advising her to undergo a third surgery to "fix" the problem.

We find this is a very common tragedy which plays out frequently. The diagnosis of endometriosis is often done by the first doctor, while doing a diagnostic laparoscopy. He "treats" the problem by burning off the lesions, and dividing the adhesions. When the woman does not get pregnant after this, she gets a second opinion from an expert. This expert often pooh-poohs the surgical skills of the first doctor, and suggests that he needs to do another laparoscopy, in order to do a better job, to fix the problem once and for all ! The patient regrets having allowed the first doctor ( who appears to have not been very competent in hindsight !) to do the laparoscopy. She signs up for the second surgery and is now very hopeful. The doctor does the laparoscopy and "cleans" up everything - and shows her a beautiful video which demonstrates his surgical prowess. He then puts her on medications, and then tells her to "go forth and have babies " in her bedroom ! She is often quite happy for a few months, because her pain has now improved, and her symptoms are much better. However, when she still does not get pregnant, she goes back to him. Unfortunately, he has lost interest in her problem, because he is primarily a surgeon, and when you have a hammer, all you see are nails. He gives her some more medicines, and tells her to relax, go for a holiday and have more sex. When this also fails, she goes to a third doctor, who then finds the endometriosis has recurred; and suggests that he needs to do another laparoscopy, where he will compensate for the surgical shortcomings of the earlier surgeon, by using the " newest and latest " third generation laser and robotic equipment, which are available only in his clinic !

The sad truth is that endometriosis recurs, no matter how good the surgeon. We can never cure it - and even our treatment leaves a lot to be desired, because of our limitations ! This is hardly surprising, when you consider that we do not even know what causes this enigmatic disease ! While we are very good at suppressing this medically ( with GnRH analogs), this suppression is only temporary. Even worse, while these medicines are very effective as suppressing the endometriosis , they also suppress normal fertility ( because they stop ovulation). This medical treatment just wastes time and money ; and patients get fed up and lose confidence in doctors and in themselves !

What about laparoscopic surgery for removing the endometriosis ? While this is effective in some selected cases ( those patients with open tubes, good ovarian reserve, and anatomic distortion because of adhesions), it's not helpful for the majority. In fact, in some women, unnecessary surgery actually reduces fertility as normal ovarian tissue is also removed along with the wall of the chocolate cyst, thus reducing their ovarian reserve.

Unfortunately, patients believe that once the doctor has made a diagnosis of endometriosis, this disease is the cause of their infertility; and that once this is "treated", their fertility will be restored, and they will be able to get pregnant in their own bedroom. However, this is also a flawed assumption ! Endometriosis is a very common finding, even in fertile women; the endometriosis found on the laparoscopy in an infertile woman may just be a red herring, and not the cause of the infertility. This is why "treating" it may not help at all !

Let's go back to my patient.

" What do I do now , doctor ? I am completely fed up ! How do I manage my pain ? And what about having a baby ? "

I explained to her that she needed to set her priorities. " Which is more important right now ? managing the pain ? or having a baby ? We can't do both together - we need to do this one step at a time !"

" For me, having a baby is my first priority doctor".

" Fine, then let's focus on getting you pregnant. Let's forget about the pain and the endometriosis for now . The reason you are not getting pregnant is because your eggs and sperm are not meeting in your fallopian tubes. We need to get the eggs and sperm to do so; and we need to use assisted reproductive technology in order to do this."

The next step is to check the AMH level, to determine what the ovarian function . For young patients with a normal AMH level, the next step would be 3 cycles of superovulation with IUI. However, for older women; those with low AMH levels; and if the IUI fails, then the best course of action is IVF. After all, we need to find solutions , not waste time looking for problems !

Is there any need to surgically remove the endometriosis prior to doing IVF ? No ! The endometriosis is outside the uterus and will not affect embryo implantation, so it's best left alone.
If there is a chocolate cyst, we can always aspirate ( puncture) it under ultrasound guidance, when starting the IVF cycle.

The good news is that an additional bonus with this approach is that once you get pregnant, the endometriosis will also automatically improve !

Many infertile couples are very confused about how their treatment. Unfortunately, many gynecologists add to their confusion. Thus, if an infertile woman is found to have endometriosis, they will spend a lot of time, money and energy on "treating " the endometriosis with medicines. Similarly, the woman has irregular periods, they will concentrate on trying to "regularise the cycle" !

Why are these approaches flawed ?

The truth is that we really do not have any effective treatment for endometriosis. This is hardly surprising, when you consider that we do not even know what causes this enigmatic disease ! While we are very good at suppressing this medically ( with GnRH analogs), this suppression is only temporary. Even worse, while these medicines are very effective as suppressing the endometriosis , they also suppress normal fertility ( because they stop ovulation). This medical treatment just wastes time and money ; and patients get fed up and lose confidence in doctors and in themselves !

What about laparoscopic surgery for removing the endometriosis ? While this is effective in some selected cases ( those patients with open tubes, good ovarian reserve, and anatomic distortion because of adhesions), it's not helpful for the majority. In fact, in some women, unnecessary surgery actually reduces fertility as normal ovarian tissue is also removed along with the wall of the chocolate cyst, thus reducing their ovarian reserve.

Unfortunately, patients believe that once the doctor has made a diagnosis of endometriosis, this disease is the cause of their infertility; and that once this is "treated", their fertility will be restored, and they will be able to get pregnant in their own bedroom. However, this is also a flawed assumption ! Endometriosis is a very common finding, even in fertile women; the endometriosis found on the laparoscopy in an infertile woman may just be a red herring, and not the cause of the infertility. This is why "treating" it may not help at all !

Similarly, patients with irregular cycles are often very poorly managed. Many patients are unsure about the relationship between their irregular cycles and their fertility, and consider this as a chicken and egg problem. They naively believe that once the cycles are regularised, they will then get pregnant in their own bedroom ! After all, if the reason they are not getting pregnant is the fact that their periods are irregular, then surely fixing the irregularity problem will them to have a baby ! Many doctors also seem to subscribe to this belief, and will regularise the cycles by putting these infertile couples on birth control pills ! While this will regularise the cycle while they are taking the pills, this is hardly helping them to have a baby ! They obviously cannot get pregnant while taking the pill - and once they stop the pill, their cycles continue remaining irregular, because they are still not ovulating !

If you are infertile, how can you make sure your doctor is providing you with the most effective treatment ? The answer is surprisingly simple ! Remember, that the reason you are infertile ( no matter what your actual diagnosis is !) is the fact that your eggs and sperm are not being able to meet. The question you need to ask is - what is the doctor doing to increase the chances of the eggs and sperm meeting ?

Thus, if he is simply suppressing your endometriosis with drugs; or regularising your cycles with birth control pills, he is wasting your time and not doing a good job ! We need to look for solutions - not waste time in finding problems which maybe irrelevant . Fortunately, our technology for bypassing problems ( even without identifying them precisely ) is better than our technology for identifying problems !

Remember, the question should NOT be "Why am I not getting pregnant ? " Rather, it should be - What can I do in order to get pregnant ?" After all, no one cares about problems - we only care about results - about having a baby ! The quality of a doctor’s answers depend upon the quality of the patient’s questions !

Not sure if you are on the right track ? I'll be happy to provide a free second opinion ! Send me your medical details by filling in the second opinion form, and I'll be happy to help !