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Endometriosis: Fertility Options are Clear

Endometriosis: Fertility Options are Clear

Endometriosis: Fertility Options are Clear

Endometriosis means tissue of the lining of the uterus is present outside the its normal boundaries. It can involve the pelvic lining, the ovaries (endometrioma), the fallopian tubes, the intestine and the muscle of the uterus (adenomyosis). As menstruation takes place in the uterus, these deposits menstruate into itself, become distended and causes pain (pain with menstruation, chronic pelvic pain, pain with intercourse, urination or defecation). Moreover, because of its chemical effects or associated pelvic scarring endometriosis may cause infertility.

Accurate diagnosis of endometriosis requires laparoscopy and biopsy of the areas suspicious because of its appearance. If you are suspect you have endometriosis (usually because of pelvic pain) and want to get pregnant or having difficulty becoming pregnant you face a small dilemma. You are usually given different recommendations from different headquarters, depending on their expertise and biases. Examples of such recommendations:

‘Lets do laparoscopy to diagnose endometriosis, remove any endometriosis we find as well as remove any scarring’

‘Lets give you medications for endometriosis’

The questions is which recommendation is “good for your specific case”.

Few basic principals about endometriosis treatment

These are not disputed principals, just facts related to the treatment of endometriosis in general.

1. Accurate diagnosis of endometriosis requires a laparoscopy and pathological examination of tissue biopsies obtained.

2. Medical treatment of endometriosis does not allow you to get pregnant while you are using it: oral contraceptive pills, synthetic progesteron, danazol and GnRH agonists (lupron) prevent ovulation. While you are taking these medications you will mostly not ovulate so you will not get pregnant.

3. Endometriomas (endometriotic cysts of the ovary) do not respond to medical treatment. Moreover their removal mostly require removal of a part of the ovary, because they are firmly attached. Thus their removal can lower the number of eggs remaining in the ovaries (ovarian reserve).

Treatment of infertility associated with endometriosis

Though each specific situation may require a different course of action as recommended by your physician, there are general guiding principals for treatment of infertility when endometriosis is suspected.

1. Infertility investigation: do not make any treatment decisions without a full fertility workup. Do not proceed unless you know your partner sperm analysis, obtained the results of ovarian reserve tests, tested if your fallopian tubes are open or not via an HSG as well as general preconception lab tests. Why? if you undergo surgical treatment for endometriosis and later discovered that your partner has very low sperm count requiring IVF and ICSI, then surgery had no potential to help you get pregnant.

2. What is your priority treating infertility or treating pain? This is important because medical treatment, although effective in treating pain cannot help you with infertility because it mostly prevents ovulation. Please note that the best treatment for pain associated with infertility is pregnancy. The large amounts of progesterone produced during pregnancy suppresses endometriosis, sometimes for years after delivery.

3. Resection of endometrioma; If a cyst consistent with endometriosis is seen on ultrasound be very careful with a recommendation to resect that cyst. Resection requires surgery. it reduces ovarian reserve because of removal of ovarian tissue. Unless the cyst is suspicious of malignancy or complication they are better left alone with observation while proceeding directly to fertility treatment e.g IVF. There is no evidence that removal of the cyst improves IVF success. On the contrary, removal of the cyst is associated with low response in that ovary.

4. Laparoscopis surgery for mild and minimal endometriosis: There are two studies that showed an improvement in pregnancy rate after laparoscopy for mild endometriosis. To put this in perspective, yes laparoscopy for infertility and mild endometriosis and infertility is an option but the magnitude of benefit in this case is limited at best. You first have to undergo surgery (with its possible complications). If endometriosis is found and ablated you would get a small bump in pregnancy rate in the year following surgery. The surgery may also help you with pain. On the contrary, endometriosis may not be found and you still have to try after surgery. Considering all the risks and benefits, the odds for pregnancy is not dramatically improved.

5. An alternative approach to mild and minimal endometriosis: The general thinking about infertility associated with minimal and mild endometriosis is that it is unexplained infertility. In these cases there is no mechanical distortion of pelvic organs and fallopian tubes are open. If sperm analysis is within normal enhancing fertility could be achieved through stimulation of the ovary to produce multiple eggs followed by IUI or IVF. This approach avoids surgery with its potential complication. IVF carries approximately three times the odds of pregnancy and can control the risk for multiple pregnancy, compared to IUI.

6. Moderate to severe endometriosis: These cause distortion or blocking of the fallopian tubes. Surgery is an option but its much more complicated than mild cases and has the risk of injury to the intestine, ureter, fallopian tubes, oavries..Scarring also may recur after surgery. An alternative approach is to proceed to IVF. It avoids major surgery and can address tubal, male and ovulatory factors. IVF success is not reduced in women with endometriosis.

7. Adenomysis (endometriosis of the uterus): MRI is sometimes needed for accurate diagnosis of adenomyosis. Adenomyosis is a surgical disease and its cure require removal of the whole uterus. This is because it cannot be shelled out of the uterus like a fibroid. Better ignored and proceed with fertility treatment.

Do not make any decisions related to infertility before a complete workup; sperm analysis, ovarian reserve tests and fallopian tube patency test. Avoid surgery in the ovary as it may reduce ovarian reserve. There is no established evidence that the chance for successful fertility treatment is reduced in women with endometriosis. Laparoscopic surgery is an option but is associated with surgical complications.

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Asian Women & Fertility Problems

Asian Women & Fertility Problems

Asian Women & Fertility Problems

Majority of Asian Women and Men agree that it is very important for them to have children. Unfortunately, many Asian couples face challenge trying to conceive naturally or using fertility treatment. The decline in natural fertility and the lower success of IUI and IVF in Asian women is documented in The US, UK, China, Japan, Korea and other Asian countries.

Fertility in Asian countries has declined to the population replacement rate 2.1 or lower. Many factors contribute to decline in natural fertility in Asian women;

Ovarian Reserve in Asian Women

When compared to Caucasian women, Asian women undergoing IVF significantly produce less eggs at all Anti-Mullerian hormone (AMH) levels, even in women with high AMH. AMH is the most accurate marker for ovarian reserve.

Gynecologic and medical disorders that impairs fertility: PCOS, endometriosis and Systemic lupus (SLE) are more common in Asian women.

Vaginismus : may interfere with regular intercourse in some Asian women.

Environmental Factors: Asian women has more exposure to methyl Mercury and vitamin D deficiency.

Culture : surveys of Asian women and men indicate that they are less likely to consent to be contacted for fertility research, are fatalistic about failure to conceive, less informed about fertility issues, only 36 percent knew that chances of getting pregnant declined with age, and are less likely to suspect a male factor.

Asian women are commonly late at seeking care for infertility and overestimate the chance for getting pregnant.

Genetics : Many genes are likely involved. FMR1 is a gene on X chromosome responsible for Fragile X syndrome and its variants. High repeats at this gene may reduce ovarian reserve.

Fertility Treatment Outcomes in Asian Couples

  1. Pregnancy and delivery rates are lower in Asian women following ovarian stimulation and IUI compared to white women
  2. IVF: when compared to white women in the US,  31 per cent of the Asian women gave birth successfully compared to 48 per cent of the white women. Asian women were also less likely to become pregnant; 43 percent against 59 per cent even after control for many fertility factors. Enodmetrial lining was thinner in Asian women compared to Caucasian women.

Asian women should be aware that fertility treatment may be less successful and seek care of a reproductive endocrinologist and fertility specialist as early as possible.

In addition there are other factors that require attention in Asian women during fertility treatment especially the higher prevalence of chronic hepatitis B infection.

After conception, asian women at are a higher risk for gestational diabetes.

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Frozen Embryo Transfers (FET)

Frozen Embryo Transfer

Following IVF, excess embryos are frozen for use with second attempts if no pregnancy takes place or to conceive a second child. With improvement of the freezing and thaw techniques: the majority of frozen embryos survive thawing, the implantation potential of a thawed embryo is comparable to a fresh embryo, less embryos or single embryo can be transferred in the fresh cycle and selection of the best embryo for fresh transfer became less important.

Frozen embryo transfer: blastocysts and cleavage embryos can be vitrified after IVF

Frozen embryo transfer (FET)

Freezing of embryos allow ample time for genetic testing of embryos if needed, transferring embryos to a different locale, delaying transfer due to medical problem, the emergence of an abnormality in the lining of the uterus e.g thin  endometrium, polyp, fluid.. or till a gestational carrier is found.

Benefits of Frozen Embryo Transfer

1. Pregnancy rate after frozen embryo transfer is comparable to fresh transfer and may even be higher than fresh transfer in some studies. More work is needed to confirm higher live birth rate.

2. Complications: frozen embryo transfer minimize some of the complications related to IVF. Ovarian hyperstimulation syndrome (OHSS) and possibly ectopic pregnancy (pregnancy in the fallopian tube)

3. Lower risk for pregnancy complications and better quality baby: frozen transfer appear to reduce the risk for preterm delivery, bleeding in pregnancy and low birth weight, possibly due to better placental function.

How is the lining of the uterus prepared for frozen embryo transfer?

1. Natural cycle: in ovulating women, the follicle in the ovary is monitored till the point of ovulation is accurately identified. The follicle will internally produce the estrogen required to build the lining. When ovulation takes place, the embryos are thawed and transferred in a day comparable to its age e.g a day 5 embryo is transferred 5 days after ovulation. This process require only ultrasound and blood work monitoring

2. Estrogen replacement cycle: ovulation is stopped and estrogen is supplemented externally (patches,oral or vaginal) till the desired thickness and pattern of the uterine lining. Progesterone is then started (injection or vaginal) then embryos are transferred.

Timing of thaw and transfer is a complicated question and it depends on the type of cycle and age of embryos. Sometimes embryos are thawed and cultured for few days before transfer

All method for endometrium preparation yield similar pregnancy rate. At NYCIVF we prefer natural cycle with luteal phase support using vaginal estrogen.

What makes a frozen embryo transfer cycle successful?

Embryo quality: one or more top quality embryo morphology observed at any stage of culture improves the outcome even if high-quality characteristics disappeared before transfer. Transferring more than one embryo increases the pregnancy rate but also multiple pregnancy.

Conclusion: should you intentionally delay transfer to frozen cycle? no but if you need to freeze the embryos, expect similar pregnancy rate as in the fresh cycle.

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