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.
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.
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.