The choice of treatment for endometriosis depends on whether the patient desires fertility or not
When determining appropriate treatment of endometriosis, it is necessary to determine what is most important to each patient: Improving pain or improving fertility. Sometimes both cannot be accomplished using the same treatment. As this is a progressive, ongoing, long term disorder, patients will do best to establish an ongoing relationship with a physician who can provide appropriate care.
Infertility due to endometriosis often is difficult to treat. Many of the medications used to relieve the symptoms of endometriosis may decrease your chances of becoming pregnant. Your doctor may recommend that you have surgical treatment with laparoscopy. During this procedure, your doctor may burn away small areas of endometriosis or use a laser to vaporize them. Your doctor may also remove adhesions or scarred tissues that might be blocking your pelvic organs or twisting them out of their normal position. These procedures may be done during the same laparoscopy session that your doctor performs to diagnose your endometriosis. Your doctor may then treat you with fertility drugs to help induce ovulation or recommend an assisted reproductive technology, such as in vitro fertilization (IVF).
It is also important to know if there are other fertility factors involved, such as low sperm count or ovulation abnormalities. If a patient is infertile, the standard workup for infertility is warranted (which includes evaluation of her ovarian reserve, semen analysis and if her tubes are open). Though every case is different, a basic idea of how treatment options are decided is listed below.
Pain with periods, intercourse and /or bowel movements (i.e. suspected endometriosis):
No other fertility factors are present (i.e. normal sperm, tubes are open and ovarian reserve is normal): It is reasonable to proceed with ovulation induction and IUI to maximize the chance of pregnancy. If pain is not well controlled with NSAIDS (motrin type medication) then it is reasonable to attempt a laparoscopy if pregnancy is not achieved in the first three months of treatment.
Other fertility factors present: It is recommended to address all other fertility factors at the same time, making sure that all issues are addressed prior to any surgery. Sometimes it is more critical to address the pain first rather than a low sperm count for example. (hence the reason for individualized plans with each patient)
No pain, but documented endometriosis with prior laparoscopy:
- It is reasonable that as long as both tubes are patent and the sperm count is normal, ovulation induction and IUI is the first treatment option to improve the chances of conception. If conception does not occur in the first 3-4 months, IVF is a reasonable options.
- If there are ovarian endometriomas present (“chocolate cysts”), it is reasonable to remove these surgically, but acknowledging that this may also diminish fertility if normal ovarian tissue is removed at the time of surgery.
Pain is present, but fertility is not desired in the immediate future (but may desire pregnancy in the distant future):
- OCP (Oral contraceptive pills) and NSAIDS (Motrin®, Advil ®etc)
- GnRH-agonist (Depo-leuprolide acetate, or Lupron®)
- Other options (Danazol®, letrozole, acupuncture. . . )
- Laparoscopy and removal of all visible implants, but not removing ovaries or uterus
- Combination of medical management and surgery
Pain is present, but patient has completed or is not interested in child-bearing:
- Hysterectomy and oophorectomy: This is what is known as definitive therapy and in theory will eliminate the pain associated with endometriosis. There are rare patients who continue to have other implants in other locations which can cause pain and requires more individualized approaches to discerning the best treatment.
- Laparoscopy: Sometimes definitive therapy is not warranted even if she has completed child bearing. If a patient has suspected early disease and is <40 years old, it is advantageous to opt for more conservative surgery or medical management. Removal of just the implants, but not a hysterectomy /oophorectomy may offer long term success and prevent the need for possible future hormone replacement therapy.