Stolen Laptop Returned...Medical Treatment of Endometriosis

Hello again to all those (including my Mother) who were wondering where I have been and what I have been doing. The answer is pretty much working and trying to keep up with a number of projects that drain my energy and time. A pretty lame excuse, I know, but it is the truth.

Here is a housekeeping point. I usually fail to respond to posts on this blog as quickly as I respond to posts on the INCIID website. Shame on me but just remember that free advice is worth what you pay for it..

For those who have read this blog since last summer here is an update on the great stolen laptop trauma….I now have it back in my possession. The guy who sold it to the pawn shop was let off as there was no physical evidence linking him to the act of stealing the laptop: “I was just walking down the street when suddenly this MacBook Pro fell out of the sky and almost killed me…so I immediately took it to a pawn shop.” Oh well, that’s the way it goes. So in any case I have it back. Unfortunately, all of my family photos were deleted and my iPhoto application was filled with downloaded photos of Beyonce (without many clothes covering her ample assets) and additional other photos from www.bigbooty.com…not a site that I regularly visit as I explained to my wife.

So picking up where we were last time… we were discussing endometriosis and the impact of endometriomas on IVF success. Not all endometriosis treatment is surgical but if the goal is fertility then medical treatment makes little sense as all of the medical treatments prevent ovulation and therefore, prevent pregnancy. Here is the Question of the Day (?week, ?month) from the book that all of you lurking out there have yet to review on Amazon.com…100 Questions & Answers about Infertility.

38. Are there medical treatments for endometriosis?

Several medications exist to treat endometriosis. All of them are designed to suppress the endometriotic implants by sup- pressing ovulation and causing a hypoestrogenic state. Unfortunately, suppressing ovulation also prevents pregnancy from occurring. In patients who are not trying to conceive, medical treatment of endometriosis can be very beneficial and relieve symptoms of dysmenorrhea and pelvic pain.

One common medical treatment involves oral contraceptive pills taken on a daily basis. Although each of these pills contains estrogen, the progestin (progesterone-like component) in the pill overrides the estrogen effect, resulting in suppression of the endometriotic lesions. Oral contraceptive pills are effective in 30% to 60% of patients with endometriosis-related pain.

Many physicians prescribe gonadotropin-releasing hormone (GnRH) analogs (such as Lupron), which reduce estrogen levels to postmenopausal levels for their patients with endometriosis. These medications suppress estrogen production, prevent ovulation, and cause atrophy of the endometriosis in 70% to 90% patients.

Unfortunately, GnRH analogs are expensive and must be given as injections either once a month or every 3 months. GnRH agonists can cause side effects including headaches, hot flashes, moodiness, insomnia, and vaginal dryness. To counteract these problems, physicians often prescribe oral contraceptive pills or supplemental progestin therapy such as norethindrone along with the GnRH analogs. This combined therapy has many advantages, including improved treatment acceptance and alleviation of the many side effects associated with the use of the GnRH analogs as single therapy. Patients tolerate this combination very well and achieve maximal benefits in suppressing the disease and its symptoms.

For patients with endometriosis who are actively trying to conceive,medical therapy is not indicated, because all of these treatments will suppress ovulation. Instead, for these patients, the goal should be to promptly establish pregnancy before the endometriosis causes any further damage to the reproductive organs. Generally, these women should seek treatment from a fertility expert to maximize their chances for successful pregnancy.

Endometriosis and IVF

Sorry for the large gap between posts but I actually took some vacation and have been paying for it ever since. Usually it takes at least a week to catch up and handle all the questions that have been raised over the previous week. This torture explains why my vacation schedule is pretty sparse!

Once back here at Dominion I was interested in the Grand Rounds lecture given at Inova Fairfax Hospital this past Monday. The topic was the surgical treatment of endometriosis and infertility. Specifically the question of removal of endometriomas was raised and discussed. Basically, there are no good randomized studies so one is left with the choice of doing IVF with an endometrioma just sitting there, or taking a patient to the operating room before IVF. There may be an increased risk of infection after egg collections where an endomtrioma is pierced. However, the absolute risk of infection after egg collection remains very low. Removing the endometrioma removes this risk but may further damage the ovary reducing the egg count… Decisions, decisions…

Ultimately, there is no clear cut answer here so I try to individualize based upon the patient and her history. Hopefully, your RE will do the same.

So after much delay here is today’s Question of the Day from the book that we shamelessly promoted on the Kane Show (click here to hear us on the air) on 99.5 FM here on Tuesday .

37. Does surgery for endometriosis improve pregnancy rates?

Well-designed medical studies clearly show that destroying even small amounts of endometriotic tissue can improve fertility by as much as 50%. In a large Canadian study, the monthly pregnancy rate following surgical treatment of minimal endometriosis rose from 3% to 4.5%. Although this finding represented a 50% improvement in the patients’ monthly chance of pregnancy, it does not compare very favorably with IVF pregnancy rates, which average around 30% for a single treatment cycle.

Nevertheless, because treatment of endometriosis at the time of surgery does improve pregnancy rates, most doctors will destroy the abnormal endometriotic tissue at the time of the diagnostic laparoscopy by using either laser or coagulation techniques. In addition to improving fertility, surgery may often eliminate or improve symptoms of dysmenorrhea and pelvic pain. Ovarian cysts that contain endometriotic tissue may grow quite large. They are often called “chocolate cysts” because of the dark brown fluid found within them, although endometriosis cysts are more correctly referred to as endometriomas.

If left untreated, these growths may destroy part or all of the normal ovarian tissue, including the eggs. Endometriomas must be surgically removed, usually via laparoscopy. Sometimes, however, laparotomy is required. The ultimate choice of which surgery is performed depends on the operative findings and the skill and experience of the surgeon. Medical treatment of endometriomas is insufficient and will not cause these cysts to resolve.