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Female Infertility

Female infertility is as important as male infertility. There are many aspects in female infertility. Here are some main ones that you need to know.

  1. Anovulation
  2. Polycystic Ovarian Disease - PCOD
  3. Endometriosis : Symptoms, Diagnosis & Medication
  4. Genital Tuberclosis


Anovulation means 'not ovulating', and is one of the common reasons of infertility. Women who fail to ovulate or who have abnormal ovulation usually have a disturbance of their menstrual pattern - either a complete lack of periods (amenorrhoea), irregular or delayed periods (oligomenorrhoea) or occasionally a shortened cycle. It can be treated successfully by a variety of treatments like clomiphene citrate, human menopausal gonadotrophin (HMG) and follicle stimulating hormone (FSH), HCG (human chorionic gonadotropin), bromocriptine, GnRH (gonadotropin releasing hormone) and GnRH analogue.

Anovulation (not ovulating) is one of the common reasons of infertility. Normally, one of the ovaries releases a single mature egg every month, and this is called ovulation. Egg maturation and ovulation is stimulated by two hormones secreted by the pituitary - follicle stimulating hormone (FSH) and luteinizing hormone (LH) . These two hormones must be produced in appropriate amounts throughout the monthly cycle for normal ovulation to occur. Every month, at the start of the menstrual cycle, in response to the FSH produced by the pituitary gland, about 30-40 primordial follicles start to grow. Of these, only one matures to form a large fluid-filled structure, called a Graafian follicle which contains a mature egg, while the others die ( a process called atresia). The mature egg is released from the follicle when the follicle ruptures in response to a surge of LH produced by the pituitary.After ovulation has occured, the follicle from which the egg has been released forms a cystic structure called the corpus luteum. This is responsible for progesterone production in the second half of the cycle.

Most women who have regular periods have ovulatory cycles. Women who fail to ovulate or who have abnormal ovulation usually have a disturbance of their menstrual pattern. This may take the form of complete lack of periods (amenorrhoea), irregular or delayed periods (oligomenorrhoea) or occasionally a shortened cycle due to a defect in the second part (luteal phase) of the cycle.

Abnormal ovulation

Abnormalities of ovulation ( anovulation) may appear in several ways. Menstrual cycles shorter than 21 days or longer than 35 days are often associated with anovulation. In addition, patients may skip menstrual periods for time intervals of three months or more and this is called oligomenorrhea (infrequent periods) . If the periods stop entirely, this is called amenorrhea.

Many hormonal systems work together to produce regular menstrual periods, and the blood levels of the hormones that make up these systems need to be tested in order to determine the reason for the ovulatory disorders.

The hormone blood tests, which are usually done on the third day of your cycle, test for the levels of the following key reproductive hormones :

The FSH level: The FSH level gives a good idea of the number of eggs remaining in the ovaries. A high FSH level suggests that the ovary has either failed or has started to fail. If the FSH level is very high (in the menopausal range) then the diagnosis is ovarian failure. If the level is borderline, then some doctors will do a clomiphene stimulated FSH level, which allows for an earlier diagnosis of failing ovaries. On the other hand, a low FSH level suggests hypogonadotropic hypogonadism. This seemingly verbose term simply means that the ovary in these patients is not working properly because of inadequate production of FSH by the pituitary gland. However, in most anovulatory patients, the FSH level will be in the normal range, and this can be reassuring.

The LH level: This is the other gonadotropin hormone produced by the pituitary; and provides much the same information the FSH level does. Another useful test is the LH:FSH ratio which is normally 1:1.

If, however, the LH level is much higher than the FSH level,this suggests a diagnosis of polycystic ovarian disease.

Thyroxine and TSH: These tests for thyroid function. The thyroxine level is high in patients with overactive thyroid glands (hyperthyroidism). In patients with decreased thyroid function (hypothyroidism), the TSH level is increased.

Prolactin: Prolactin is a hormone produced by the pituitary gland that induces lactation or milk formation.. High prolactin levels (hyperprolactinemia) can interfere with ovulation . A milky discharge from the breast nipple , not related to pregnancy or nursing , is called galactorrhea, and this is a telltale symptom of high prolactin levels and needs to be investigated. If the prolactin level is elevated, the doctor will need to recheck it to confirm it is persistently high. There are many reasons for an elevated prolactin level, including certain drugs as well as stress. In some women, the reason for a high prolactin level can be a small tumour in the pituitary gland. This is called a prolactinoma or microadenoma, and the doctor may advise you have an X-ray of the skull ( or even a CT scan or MRI scan) to rule out this possibility. However, most infertile women with hyperprolactinemia can be easily treated with a medicine called bromocryptine, which is a dopamine agonist medication . Another medication which can be used to treat hyperprolactinemia is oral cabergoline, which is usually taken twice a week. Only if the pituitary tumour is very large ( microadenoma) is surgical removal needed, and this is very uncommon.

Ovarian failure

Ovarian failure is a disease in which the ovaries fail to produce eggs. This disease is uncommon, occurring in only about 10% of women whose periods do not occur at all, a condition called amenorrhea (absence of periods). Ovarian failure may be genetic (for example, in girls with Turner's syndrome, a chromosomal disorder) or may be acquired (for example, following radiation or chemotherapy for cancers; surgery to remove the ovaries for treating ovarian cancer or severe endometriosis; autoimmune ovarian failure; or for unexplained reasons.) Ovarian failure is diagnosed by finding a high FSH level. In such patients it is usually not possible to stimulate ovulation and they have any eggs, and they suffer a premature menopause. The only effective medical treatment for these patients is the use of egg donation for IVF or GIFT. However, in a very small proportion of these patients, ovulation can resume spontaneously.

Induction of ovulation

What forms of treatments are available for inducing ovulation?

The most commonly prescribed medicines for induction of ovulation include the following: clomiphene citrate, human menopausal gonadotrophin (HMG) and follicle stimulating hormone (FSH), HCG (human chorionic gonadotropin), bromocriptine, GnRH (gonadotropin releasing hormone) and GnRH analogue.

For women with hypogonadotropic hypogonadism (low FSH and LH levels), the treatment of first choice is HMG. This is effective replacement therapy; and excellent pregnancy rates can be achieved in these women.

For women affected by hyperprolactinemia, the drug of first choice is bromocriptine.

For most other women, the drug of first choice is clomiphene - the "workhorse" of ovulation induction. If this does not work, then HMG is resorted to.

Poor responders to HMG can be treated with GnRH analogues in conjunction with the HMG; or by adding a hormone called the human growth hormone.(HGH).

HCG (human chorionic gonadotropin) is given to trigger off the release of the egg.

In patients with high androgen levels (high blood levels of male hormones), dexamethasone can be used as an adjunct, since this suppresses androgen production.

Often ovulation induction requires an investment of time, money, energy and emotion before a satisfactory response is achieved. After all, every woman is different and there can be no standard "formulae". Careful monitoring of the response to ovulation induction is the key to therapy - and this usually involves daily ultrasound scans and/or blood tests. It is often a tedious process - which may involve "trial and error" to tailor the therapy to the individual patient's ovulatory response. With the treatments available today, however, correcting ovulatory dysfunction is one of the most rewarding and successful of infertility treatments.


Polycystic Ovarian Disease - PCOD

Polycystic ovarian syndrome ( PCOS), also known as PCOD ( polycystic ovarian disease) is one of the commonest causes of infertility. Patients have multiple small cysts in their ovaries that occur when the regular changes of a normal menstrual cycle are disrupted. The ovary is enlarged; and it produces excessive amounts of androgen and estrogenic hormones. This condition is also called Polycystic Ovarian Syndrome (PCOS) or the Stein-Leventhal Syndrome.

Polycystic ovarian syndrome ( PCOS), also known as PCOD ( polycystic ovarian disease) is one of the commonest causes of infertility.

Patients suffering from polycystic ovarian disease ( PCOD ) have multiple small cysts in their ovaries ( the word poly means many). These cysts occur when the regular changes of a normal menstrual cycle are disrupted. The ovary is enlarged; and it produces excessive amounts of androgen and estrogenic hormones. This excess, along with the absence of ovulation, may cause infertility. Other names for PCOD are polycystic ovarian syndrome (PCOS) or the Stein-Leventhal syndrome.


PCOD can be easy to diagnose in some patients. The typical medical history is that of irregular menstrual cycles, which are unpredictable and can be very heavy, and the need to take hormonal tablets (progestins) to induce a period. Patients suffering from PCOD are often obese and may have hirsutism, (excessive facial and body hair) as a result of the high androgen levels. However, remember the "sin of diagnostic greed " ! Not all patients with PCOD will have all or any of these symptoms. We see many patients who have what I call "occult PCOD". They have regular cycles, but when they are superovulated, they grow lots of eggs, which is typical of patients who have PCOD.Most gynecologists ( and even infertility specialists !) often overlook this diagnosis, because they do not think of it.

This diagnosis can be confirmed by vaginal ultrasound, which shows that both the ovaries are enlarged, and the increased ovarian volume is suggestive of PCOD; the bright central stroma is increased, and there are multiple small cysts in the ovaries. These cysts are usually arranged in the form of a necklace along the periphery of the ovary. Typically, blood levels of hormones reveal elevated levels of androgens (a high dehydroepiandrosterone sulphate ( DHEA-S) level); a high LH level; and a normal FSH level. This reversal of the FSH:LH Ratio ( high LH levels with a normal FSH level) is typical of PCOD. Another new test which helps to confirm the diagnosis of PCOD is the blood level of AMH ( antiMullerian hormone). Patients with PCOD have high AMH levels. Many patients with PCOD will also have elevated insulin levels, because they have insulin resistance.

Fig 1. A schematic, comparing a polycystic ovary with a normal ovary.

We don't really understand what causes PCOD. However, we do know that the characteristic polycystic ovary emerges when a state of anovulation persists for a length of time. Patients with PCO have persistently elevated levels of androgens and estrogens, which set up a vicious cycle. Obesity can aggravate PCOD because fatty tissues are hormonally active and they produce estrogen which disrupts ovulation. Overactive adrenal glands can also produce excess androgens, and these may also contribute to PCOD.

Treatment of PCOD for the infertile patient will usually focus on inducing ovulation to help them conceive.

Weight loss:

For many patients with PCOD, weight loss is an effective treatment but, of course, this is easier said than done! Look for a permanent weight loss plan, and referral to a dietitian or a weight control clinic may be helpful. Crash diets are usually not effective.

Increasing physical activity is an important step in losing weight. Aerobic activities such as walking, jogging or swimming are advised. Try to find a partner to do this with, so that you can help each other to keep going.

Ovulation Induction:

The drug of first choice is clomiphene( clomid) ; this may be combined with low doses of dexamethasone, a steroid which suppresses androgen production from the adrenal glands. Just taking clomiphene is not enough , and you need to be monitored (usually with ultrasound scans) to determine if the clomiphene is helping you to ovulate or not. The doctor may have to progressively increase the dose till he finds the right dose for you.

We have now learned that many patients with PCOD also have insulin resistance - a condition similar to that found in diabetics, in that they have raised levels of insulin in their blood ( hyperinsulinemia) , and their response to insulin is blunted. This is why some patients with PCOD who do not respond to clomiphene are treated with antidiabetic drugs, such as metformin. Studies have shown that these drugs can help to improve their fertility by reversing their endocrine abnormality and thus improving their ovulatory response.

A recent alternative to clomid is the new drug called letrozole( Femara). Letrozole, an aromatase inhibitor, which is now being increasingly used as an alternative to clomid for inducing ovulation in patients with PCOD. The dose is 2.5 mg daily for 5 days, starting from Day 3. Aromatase is an enzyme which converts androstendione ( an androgen) to estradiol, and because this action is blocked by letrozole , the estradiol level in the blood drops. ( Incidentally, it is because letrozole is an antiestrogen and reduces the estradiol level that it is used for the treatment of patients with estrogen receptor positive breast cancer ) . The resulting lower estradiol will in turn stimulate the release of increased amounts of pituitary FSH and LH, and thus stimulate ovulation. It's safe and effective; and does not have the anti-estrogenic activity which clomid does, so that the uterine lining and cervical mucus with letrozole is often better than it is with clomid. The use of letrozole for ovulation induction would be considered an off-label use in the United States, as it is not officially approved for this purpose.

If clomiphene does not work, HMG( gonadotropins, Repronex, Follistim ) can be used. Some doctors prefer to use pure FSH for inducing ovulation in PCOD patients because they have abnormally high levels of LH. Ovulation induction can often be difficult in patients with PCOD , since there is the risk that the patient may over-respond to the drugs, and produce too many follicles, which is why the risk of ovarian hyperstimulation syndrome ( OHSS) and multiple pregnancy is often increased in patients with PCOD. The doctor has to find just the right dose of HMG ( called the threshold value ) in order to induce maturation and release of a single or only a few follicles , and this can sometimes be very tricky. Difficult patients may also need a combination of a GnRH analog (to stop the abnormal release of FSH and LH from the pituitary) and HMG to induce ovulation successfully.

In Vitro Fertilization:

If 3 cycles of IUI have failed, then In Vitro Fertilization is the best treatment option for patients with PCOD. However, many IVF clinics have little experience in superovulating these women, and they often mess up their superovulation. Because these women grow so many eggs in response to the HMG injections used for superovulation, and because doctors are very worried about the risk of ovarian hyperstimulation, they often end up triggering egg collection with HCG when the eggs are immature. They consequently get lots of eggs, but since most of these are immature, fertilization rates and pregnancy rates are very poor.

In our clinic, because we have extensive experience in dealing with women with PCOD ( which is much commoner in the Middle East and South India than in the West), we do a much better job at getting these women to grow many mature eggs. Also, because we carefully and meticulously flush each and every follicle at the time of egg collection, the risk of PCOD patients developing ovarian hyperstimulation in our clinic has been virtually zero in the last 8 years.


An alternative treatment option uses laparoscopy to treat patients with PCOD. During operative laparoscopy, a laser or cautery is used to drill multiple holes through the thickened ovarian capsule. This procedure is called laparoscopic ovarian cauterisation or ovarian drilling or LEOS (laparoscopic electrocauterisation of ovarian stroma) . Destroying the abnormal ovarian tissue helps to restore normal ovarian function and helps to induce ovulation. For selected young patients with PCO ovaries on ultrasound ( only those with large ovaries , many follicles and increased ovarian stroma ) , if clomiphene fails to achieve a pregnancy in 4 months' time, we tell them to consider laparoscopic surgery as the next treatment option. This is because LEOS helps us to correct the underlying problem, and about 80% of patients will have regular cycles after undergoing this surgery, of which 50% will conceive in a year's time, without having to take further medication or treatment. Having regular cycles without having to take medicines each month can be very reassuring for these patients ! The risk of this surgery is that it can induce adhesion formation, if not performed competently.Another major risk of this surgery is that if it is done for PCOS patients who do not have large ovaries, the destruction of ovarian tissue this surgery causes can end up causing infertility by reducing the ovarian reserve !

This is what the surgeon sees on the video screen when operating.

In the past, doctors used to perform ovarian surgery called wedge resection to help patients with PCOD to ovulate. The removal of the abnormal ovarian tissue in the wedge breaks the vicious cycle of PCOD, helping ovulation to occur . While wedge resection used to be a popular treatment option, the risk of inducing adhesions around the ovary as a result of this surgery has led to the operation being used as a last resort.

The good news is that with the currently available treatment options, successful treatment of the infertility is usually possible in the majority of patients with PCOD.



Endometriosis : Symptoms, Diagnosis & Medication

Endometriosis , commonly called 'endo', occurs when normal tissue lining of the uterus grows outside the uterus. This misplaced tissue may implant itself and grow anywhere within the abdominal cavity. It is labeled a 'career woman's disease' since it is more likely to be found in delayed pregnancy.

Endometriosis , commonly called endo, is commonly found in infertile women, though the relationship between endometriosis and infertility is complex. We will look at what the symptoms of endometriosis are ; how doctors use endometriosis stages for describing its spread; how it is treated; and how infertile women with endometriosis are often badly treated.

Endometriosis is an enigmatic disorder that affects women of reproductive age and occurs when normal endometrial tissue (the endometrium or lining of the uterus) grows outside the uterus. This misplaced tissue may implant itself and grow anywhere within the abdominal cavity.

Many specialists feel that severe endometriosis is more likely to be found in infertile women who have delayed pregnancy - and for this reason, the condition is sometimes labeled a "career woman's disease".

Endometrial tissue, whether it is inside or outside the uterus, responds to the rise and fall of estrogen and progesterone produced by the ovaries during the reproductive cycle. Under the influence of the hormones, the misplaced tissue swells; and when hormonal levels drop, the tissue may bleed. Unlike the normally situated endometrium, which is shed from the body as menstrual discharge, this blood and tissue has no outlet. It remains to irritate the surrounding tissue.

The disease is highly unpredictable. Some women may have just a few isolated implants that never spread or grow, while in others the disease may spread throughout the pelvis. Endometriosis irritates surrounding tissue and may produce web like growths of scar tissue called adhesions. The scar tissue can bind the pelvic organs and even cover them entirely. Many women who have endometriosis experience few or no symptoms. However, in some women, endometriosis may cause severe menstrual cramps, pain during intercourse, and infertility.

It is a disease which has been called an "enigma wrapped inside a mystery ", and there is a lot about it that we do not understand as yet.

What causes endometriosis?

Several theories exist as to how endometriosis begins. One possibility is retrograde menstruation, the backward flow of the menstrual discharge through the fallopian tubes into the pelvis. According to this theory, the endometrial cells may implant on the ovaries or elsewhere in the pelvic cavity.

What does it look like?

Early implants look like small, flat dark patches or flecks of blue or black paint ( "powder-burns" ) sprinkled on the pelvic surfaces. The small patches may remain unchanged, become scar tissue or spontaneously disappear over a period of months. Endometriosis may invade the ovary, producing blood filled cysts called endometriomas. With time, the blood darkens to a deep, reddish brown or tarry color, giving rise to the description "chocolate cyst." These may be smaller than a pea or larger than a grapefruit.

In some cases, bands of fibrous tissue called adhesions may bind the uterus, tubes, ovaries, and nearby intestines together. The endometrial tissue may also grow into the walls of the intestine - but although it may invade neighboring tissue, endometriosis is not a cancer.

Doctors often use the ASRM staging system to stage the severity of spread of endometriosis. Like other diseases, it is categorized into four stages -- the higher the number, the more severe the endometriosis. Stage I is when endometriosis is minimal and still very thin and "filmy," hence easier to treat. Stage II is mild endometriosis; the endometriosis is still on the thin side but invades more deeply into surrounding tissues. Stage III is moderate endometriosis; while Stage IV means severe endometriosis, which is dense and deep.

Fig 1. Schematic, showing a chocolate cyst (endometrioma) in the right ovary; and peritubal adhesions because of endometriosis

Fig 2. Laparoscopy, showing minimal endometriosis, in the form of " powder-burn" deposits.

Fig 3. Laparoscopy, showing a small chocolate cyst in the left ovary. This can be very easy to miss, so a careful multiple puncture laparoscopy is essential to make an accurate diagnosis of endometriosis.

What are the symptoms?

Progressively increasing dysmenorrhea (periods pains or menstrual cramping) may be a symptom of endometriosis. These are caused by contractions of uterine muscle initiated by prostaglandins released from the endometrial tissue. A puzzling feature of endometriosis is that the degree of pain it causes is not related to the extent of the disease. Some women with extensive disease feel no pain at all. A woman with endometriosis may notice that as the disease progresses her periods become more painful or that the pain begins earlier or lasts longer.

Endometriosis can cause pain during intercourse, a condition known as dyspareunia. The thrusting motion of the penis can produce pain in an ovary bound by scar tissue to the top of the vagina or in a tender nodule of endometriosis. Most women who have endometriosis report no bleeding irregularities. Occasionally, however, the disease is accompanied by vaginal bleeding at irregular intervals; or by premenstrual spotting.

How does endometriosis cause infertility? The relationship between mild (early) endometriosis and infertility is controversial. The most recent theories regarding the endometriosis-infertility link focus on the fact that endometriosis may lead to a form of mild inflammation within the pelvis. In some women with mild endometriosis, the levels of certain chemicals called cytokines ( released in response to inflammation) are increased in the abdominal cavity, and these hormones may have a negative effect on follicle and egg development, egg-sperm binding and fertilization, normal tubal function, and even implantation. Sometimes, the endometriosis may be coincidental and unrelated to the fertility problem. In these patients, other factors may be involved in a couple's infertility, such as poor quality sperm or ovulation disorders- and the endometriosis is a "red herring". Some women who have the condition are able to conceive, while others may be infertile due to endometriosis or a combination of factors.

The disease may hinder conception in various ways - especially when it is severe. Endometriosis may inflame surrounding tissue and spur the growth of scar tissue or adhesions. Bands of scar tissue may bind the ovaries, fallopian tubes, and intestines together and thus interfere with the release of eggs from the ovaries or the ability of the tube to pick up the egg. Rarely, severe endometriosis may cause the tubes to become blocked. The presence of chocolate cysts in the ovary may also impair ovulation.


Endometriosis can often be suspected on the basis of your symptoms. Your doctor may make a tentative diagnosis if you complain of progressively severe menstrual cramps or pain with intercourse. For many patients , making the diagnosis is a big relief - the pain I feel is not all in my head - I have a disease which is causing me to be miserable ! However, this diagnosis can come like a blow as well - especially when you read on the net about all the possible complications which endo can cause ! The good news is that endometriosis does not lead to cancer; and we have may very effective treatment options to manage this.

Some patients with the condition have no discomfort at all. This is why 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 and "stage" the severity of the disease. The mainstay of treatment also used to be laparoscopy. However, because it involves surgery, many infertility specialists no longer advise laparoscopy for their patients.

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 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.

Hormone medication

The goal of hormonal treatment is to simulate pregnancy or menopause, two natural conditions known to inhibit the disease. In each case, the normal endometrium is no longer stimulated to grow and regress with each monthly cycle, and menstruation ceases. The growth of misplaced endometrial tissue usually will suppressed as well.

To simulate the hormonal environment of pregnancy, birth control pills are prescribed. To be effective against endometriosis, the pills must be taken continuously without pausing for withdrawal bleeding. This state is sometimes called pseudopregnancy.

The hormone derivative danazol is the medication most frequently used to treat endometriosis. During treatment with danazol, estrogen levels are reduced to the low levels characteristic of natural menopause. This state is sometimes called pseudomenopause. Danazol is an expensive medication which is usually prescribed for six months or more. Unfortunately, large endometriotic cysts of the ovary are generally resistant to the drug.

Analogues of GnRH, the gonadotropin releasing hormone, are the newest class of hormones used for endometriosis treatment. These analogues switch off production of FSH and LH from the pituitary, thus inducing a menopausal state. These analogs can be given in the form of special injections called depot preparations, which release small quantities of the drug daily, allowing administration at monthly intervals.

Medical therapy used to be prescribed in the hope that it would cause the endometriosis to shrink sufficiently so that it would no longer interfere with conception after the treatment is stopped. However, since pregnancy cannot occur during the medical therapy of endometriosis, and because the treatment has been shown not to be helpful in improving fertility, medical therapy for endometriosis is no longer advised for infertile patients.


Treating endometriosis with medicines has definite limitations. Medication usually controls mild or moderate pain and may eliminate small patches of the disease. But large chocolate cysts in the ovary are less likely to respond, and drugs cannot remove scar tissue. This is why surgery may be needed to improve fertility by removing adhesions, lesions, nodules or endometriomas.

Laparoscopy can be used as a therapeutic tool. For example, fluid can be drained ; adhesions freed; and patches of endometriosis destroyed using a laser or electrical current. Even large endometriomas can be removed through the laparoscope by a skilled surgeon. Open surgery (laparotomy) is needed only very rarely and should be used only as a last resort.

Please remember that surgery is not always a good idea just because you have endometriosis. This is especially true if you are infertile. How useful operative laparoscopy is in improving the fertility of patients with endometriosis is still a controversial issue ! In fact, surgery can actually end up reducing your fertility. This is because normal ovarian tissue is also sacrificed when removing the endometriotic cyst wall and this can reduce your ovarian reserve.

In Vitro Fertilization (IVF)

Treatment cannot "cure" endometriosis - but it can control it. If an infertile woman with endometriosis fails to conceive , the next option is superovulation with intrauterine insemination, since the fallopian tubes in these patients are usually open. If this fails, then IVF ( in vitro fertilization ) can be very useful. However, the ovarian response in some of these patients can be poor, especially if they have large chocolate cysts, or have had surgery for these cysts. Fertilization rates in some patients with endometriosis can be a little lower than for other patients, perhaps because of an intrinsic oocyte abnormality.

Surgery versus IVF

This is still a vexed and controversial issue. While many gynecologists feel that operative laparoscopy should be the first choice, in reality there is little evidence to support this stance. While laparoscopy is useful for "treating" the endo lesions, whether this actually helps to improve fertility is still unproven ! In fact, overenthusiastic surgery can often push an infertile patient from the frying pan into the fire ! Unnecessary surgery reduces your fertility as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.

I suggest that patients always test their AMH level ( a simple blood test for checking their ovarian reserve ) before allowing a doctor to do an operative laparoscopy to treat their endometriosis. This is especially true for: older women; women who have had surgery earlier; women with recurrent cysts; and women with large ovarian cysts ( because they are at risk for having poor ovarian reserve, a silent condition called oopause.) If they do have poor ovarian reserve ( as suggested by a high FSH level and a low AMH level), then surgery is not a good idea and they should move onto IVF directly.

If there is a cyst, this can always be treated by aspirating it under vaginal ultrasound guidance, so that the ovarian reserve is not further impaired.

Endometriosis is a disease affecting millions of women throughout the world. For many, the condition goes unnoticed. But for others it demands professional attention, especially when fertility is impaired. The best strategy to maximize chances of conception is to select a specialist who is familiar with the latest developments in endometriosis management.