Endometriomas: What You Need to Know

Endometriomas: What You Need to Know

Many top doctors came and presented at last month's Endometriosis Foundation of America's annual Medical Conference titled, Pursuing Precision with Passion. The controversies and challenges of treating endometriomas were discussed at length by experts in the field.

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. Endometriomas, which are also sometimes known as chocolate cysts, can occur on one ovary or both. They are known to occur 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. While some patients have endometriomas and are asymptomatic, many patients experience symptoms similar to that of endometriosis, such as painful periods, pelvic pain outside of periods, painful intercourse and for some, 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 that can cause damage to the egg, 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, as compared to women without, are shown to 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 for those looking to become pregnant, although there are risks to consider. Dr. Kodaman discusses how some patients with endometriomas experience a decreased response to gonadotropins (somigliana et al 2006) 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 and patients may even run the risk of ovarian failure and go into early menopause.

When thinking about surgically removing endometriomas, Dr. Kodaman stresses that surgical experience of the doctor is very important. When careful surgical technique is applied there can be no difference in number of oocytes and embryos obtained following cystectomy. She also states that laparoscopic cystectomy is the gold standard of treatment that is associated with the lowest recurrence rate of endometriomas and the highest spontaneous pregnancy rate. While studies have not been done in older patients, studies are finding that 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 of surgical hands, carefully removing endometriomas can be challenging. Dr. Tamer Seckin, 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. 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 together the disrupted ovary. Most importantly to note is that patients with endometriomas often have deeply invasive disease affecting their pelvic sidewall. They also often can have leg and back pain related to 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 for patients who undergo IVF, results of conception are similar in patients who had surgery and in those patients who did not have surgery. ASRM and ESHRE recommend surgery as the gold standard for systematic endometriomas and asymptomatic endometriomas >/= 4 cm. They also recommend that endometriomas with a mean diameter below 4 cm should not be systematically removed before IVF. Age of the patient and 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 best practice.

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 also to a reproductive endocrinologist to assess fertility as soon as possible. He wants all gynecologists to assess endometriosis patients AMH levels from the start and then retest their levels every 6 months so that patients can make informed decisions about their fertility and maybe choose egg freezing as an option. 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.

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 as stated above, many patients with endometriomas also have disease throughout their entire pelvic cavity. While IVF may be able to help the patient achieve their pregnancy goals, despite the endometriomas, it is still worth talking to an excision specialist if the patient is having other symptoms of endometriosis. While the patient and the excision specialist may decide not to touch the endometrioma, disease can be removed throughout the rest of the pelvis, reducing symptoms, improving quality of life and also 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 body.



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Patient Reviews

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  • Angela Aro

    I have struggled with endometriosis and adenomyosis since first starting my period at 13. I was diagnosed at 21 and what followed was a series of unsuccessful surgeries and treatments. My case was very aggressive and involved my urinary tract system and my intestines. After exhausting all of my local doctors I was lucky enough to find Dr. Seckin. We…

  • Emi O

    Seckin and Dr. Goldstein changed my life!

  • Kristin Sands

    Like so many women who have tirelessly sought a correct diagnosis and proper, thorough medical treatment for endometriosis, I found myself 26 years into this unwanted journey without clear answers or help from four previous gynecological doctors and two emergency laparoscopic surgeries. I desperately wanted to avoid the ER again; a CT scan for appendicitis also revealed a likely endometrioma…

  • Wilfredo Reyes

    Dr. Seckin literally gave my wife her life back. I am eternally grateful to him for his generous, determined spirit to see that Melanie finally live free from the prison bonds of Endometriosis.

  • Carla

    I am so grateful to Dr Seckin and Dr. Goldstein. My experience was nothing short of amazing. I was misdiagnosed with the location of my fibroids and have had a history of endometriosis. Dr. Seckin was the one who accurately diagnosed me. Dr Seckin and Dr. Goldstein really care about their patients and it shows. They listened to my concerns,…

  • Melissa Boudreau

    When I think of Dr. Seckin these are the words that come to mind. Gratitude, grateful, life-changing, a heart of gold. I feel compelled to give you a bit of background so you can understand the significance of this surgery for me. I am passionate about Endometriosis because it has affected me most of my life and I have a…

  • Jaclyn Harte

    Dr. Seckin and Dr. Goldstein radically changed my quality of life. They treat their patients with dignity & respect that I've personally never seen in the literally 25+ doctors I've seen for endometriosis. This summer, I had a surgery with Dr. Seckin & Goldstein. It was my first with them, but my 5th endo surgery. I couldn't believe the difference,…

  • Megan Rafael Moreno

    I was in pain for 2 years. I was getting no answers, and because dr Goldstein and dr seckins were willing to see and treat me I'm finally feeling almost back to normal. They were very down to earth and helpful in my time of need. Dr Goldstein was easy to talk to and caring, she took care of me…

  • Nancy Costa

    Dr. Seckin is one of the best endometriosis surgeon. Every time I go to the office, he really listens to me and is always concerned about my issues. Dr Seckin's office staff are a delight and they always work with me. I feel I can leave everything to them and they will take care of it. Thank you to the…

  • Rebecca Black

    Fast forward 5 years to find out incidentally I had a failing kidney. My left kidney was only functioning at 18%. During this time, I was preparing all my documents to send to Dr. Seckin to review. However, with this new information I put everything on hold and went to a urologist. After a few months, no one could figure…

  • Monique Roberts

    I'll never stop praising Dr. Seckin and his team. He literally gave me back my life.

  • Erin Brehm

    I had a wonderful experience working with Dr. Seckin and his team before, during and after my surgery. I came to Dr. Seckin having already had laparoscopic surgery for endometriosis 5 years prior, with a different surgeon. My symptoms and pain had returned, making my life truly challenging and my menstrual cycle unbearable. Dr. Seckin was quick to validate my…

  • Anita Schillhorn

    I came to Dr. Seckin after years of dealing with endometriosis and doctors who didn't fully understand the disease. He quickly ascertained what needed to be done, laid out the options along with his recommendation and gave me the time to make the right decision for me. My surgery went without a hitch and I'm healing very well. He and…

  • Nicholette Sadé

    Dr. Seckin brought me back to life! I am now 3 weeks into my recovery after my laparoscopy surgery, and I feel like a new and improved woman! Being diagnosed with Endometriosis, then 25yrs old in 2015, and discovering the severity of my case being stage 4, made me devastated. Dr. Seckin's vast knowledge of the disease, sincere empathy, and…