Wednesday, June 16, 2010

Woman With Stage 4 Endo Worries About Endometrioma: Will Not Interfere With IVF, Can Be Excised At A Later Date


I am 28 years old & TTC for a while. Diagnosed with stage 4 endo in Dec. 09. I was told to do 6 months of lupron, then another laparascopy from an ob-gyn. I got a second opinion from a fertility doctor in may 09 after not getting pregnant naturally with the assistance of acupuncture and herbs. He said I could do another lap, or start on fertility drugs. I chose to start on clomid 50 mg CD 5-9. I do have a 2mm cyst on my left ovary and am concerned about the cyst growing.

Is Clomid something recommended for someone with stage 4 endometriosis trying to conceive? I asked my doc if the cyst posed a problem and he said if it was larger then he would be concerned, but he said given the size it's not an issue. Well, if the clomid causes the cyst to grow, then that scares me. Not sure if I should consult another fertility doctor? K. from the U.S.


Hello K. from the U.S.,

In general, if a patient has stage 3 or 4 endometriosis, then the treatment of choice is IVF. The reason is because the endometriosis, despite the laparoscopy and Lupron, causes the pelvis to be inflamed and is hostile to the egg. Basically the egg gets destroyed before it can make it into the tube. This is not 100% of cases, however. I have had patients with stage 4 endometriosis that become pregnant naturally. How they did it, I cannot explain, but they are definitely the exceptions to the rule. In general, natural pregnancy is very, very difficulty with stage 4. Therefore, if you consulted me, I would recommend IVF to you.

The cyst you had (2 mms) is a normal follicle and technically NOT a cyst. We don't worry about cysts unless they are 2 cms (20mms) or more. The clomid will cause a follicle or follicles to grow. That is what it is supposed to do. Those follicles contain the eggs and they have to grow to 24 mms in order to ovulate and for the egg within to mature.

Because you are young, your doc is probably thinking that you could try something easier for a few tries to see if you might be one of the exceptions to the rule. That is why he is suggesting Clomid. Then if that doesn't work, he might suggest IVF. I would recommend that you talk with him/her again and ask if he/she thinks the Clomid has a good chance of working and what treatment would be the best treatment in light of the severe endometriosis. He/She might change their opinion then. I don't think you need to consult another fertility doctor because you just consulted me. I hope I gave you the information you needed.

Follow-Up Question:

Thank you Dr. Ramirez! You did clarify things for me. I'm sorry I meant to put 2cm cyst, I don't know why I put 2mm. I was told it was a chocolate cyst when I had my laparoscopy in Dec. The ob/gyn said he drained it. It was 4cm then, and now by June it has grown to 2cm again. I guess that is the reason I have been feeling the pain again. Can endometrial cysts dissolve on their own? If not, if it continues to grow does that pose any risk to getting pregnant if my tubes are open, and if I succeed in natural pregnancy could the cyst create a problem during pregnancy?

I just don't know if I should have another laparoscopy so soon. Is 6-7 months too soon? Thank you for any insight on this issue.

Follow-Up Answer:

Hello Again,

The cyst that you have is called an Endometrioma. It is an endometriotic cyst or tumor. Draining it is not sufficient because the endometriosis is still located within the cyst and it will refill as it has done in your case. It should have been excised (cystectomy) at the time of the laparoscopy. It will not interfere with your ovarian function and will not interfere with an IVF treatment. Its presence, however, means that endometriosis and scar tissue are still present and an issue, which reduces the chances of a natural pregnancy (as I explained previously).

If you were lucky enough to become pregnant naturally despite the endometriosis, then pregnancy is a good treatment for endometriosis, and the endometriosis will not complicate the pregnancy. Neither will the endometrioma as long as it does not get too big or does not twist on itself (torsion). If needed, it can be removed during pregnancy.

Six to seven months for another laparoscopy is not too soon. We usually will do a second-look laparoscopy within 4 weeks if we are worried about recurrent scar tissue formation. My advice would be either to have another laparoscopy and this time make sure the cyst is removed, then proceed to IVF or proceed to IVF directly without the laparoscopy. My wife had an endometrioma at the time that we did our IVF which they were able to drain at the time of egg retrieval. It did not interfere and her cycle was successful.

Good Luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
Twitter with me at @montereybayivf and follow me on Facebook at


  1. Dear Dr,
    I am a 25 year old living in the US with regular cycles and ovulation. I was recently diagnosed with hydrosalpinx in my left Fallopian tube with a diameter of 1.2 cm and its 5.2 cm in length. My Dr says it is completely blocked and useless and needs to be removed. Me and my husband are actively trying for baby but as the doctor says my hydrosalpinx are working against it. Please help me. will the removal help or not. I am extremely stressed about the whole situation. Another thing they found in my ultrasound was that I have endometriomas in both the ovaries. As written on the report "within both ovaries there are similar appearing complex cysts with low-level somewhat heterogenous internal echoes and no internal color flow, on the right measuring 2.9cm and on the left 2.1cm, 1.1cm and 0.7cm. their appearance is consistent with hemorrhagic cysts or endometriomas.
    And I also do have pendunculated fibroid. The ultrasound says there are several fine linear echoes present adjacent to the fibroid which could represent adhesions.
    Please help me. Our first most priority is to have a baby! Would be a good decision to get the tube removed? Will I be able conceive naturally? I have gone through any kind of surgery/laproscopy. Would it help?

    -Worried girl

    1. Hello Worried,

      Your doctor is correct that they hydrosalpinx needs to be either removed or cut away from the uterus. But this another significance as well. Hydrosalpinx occurs when there is blockage of the tube. Most often, this blockage is due to an inflammatory event, such as a tubal infection, that occurred in the past. That could mean that the other tube is similarly damaged internally but not enough to completely block the tube. That means that the tube may not be functional, which would prevent pregnancy. In general, IVf would be the treatment of choice.

      The second issue is the possible endometriomas. The presence of endometriomas signifies pelvic endometriosis and is consistent with stage IV endometriosis. It can cause severe scar tissue formation within the pelvis. This level of endometriosis will cause infertility and again, IVF is the treatment of choice.

      The pedunculated fibroid is not a signficant finding.

      In all likelihood, you need to do IVf but prior to that, you will need laparoscopic surgery to treat the endometriosis, endometriomas and hydrosalpinx.

      Good Luck

  2. Hi Doctor,

    I recently had a failed IVF in July. During the egg retrieval my doctor drained an 3cm old cyst (was previously 6cm a year ago - I took vitamins and exercised to help reduce it). She has suspected that I have endometriosis. She said that when she drained the cyst it was thick and jelly-like with old blood. Based on this she "confirmed" that I have endometriosis. My doctor, husband, and I do not want to go the surgery route. I am 29 years old with only the left ovary functioning. My concern is that surgery would accidentally damage parts of my ovary and the eggs. The right ovary does not stim with the IVF drugs and the tube is blocked (HSG).

    I hope you don't mind, I have a few questions.

    1) Since the doctor punctured the ovarian cyst to drain it, could some of the contents may have spilled and spread the endo further?

    2) Does the presence of a single endometrioma mean that I have stage IV endometriosis? Your previous comment to "Worried Girl" was "The presence of endometriomas signifies pelvic endometriosis and is consistent with stage IV endometriosis."

    3) What are your thoughts on us proceeding with a frozen embryo transfer rather than surgery?

    Thank you so much for you time and knowledge!!!


  3. What you had is called an "endometrioma" or endometriotic cyst. Yes, some contents could have spilled leading to additional endometriosis but I don't think that will affect or change your fertility prospects.

    The presence of an endometrioma makes the endometriosis stage 4. The treatment of choice for this level of endometriosis is IVF, as you are doing.

    There is no reason that you cannot proceed with a frozen embryo transfer, and your chances should not be decreased. However, some specialists will recommend a course of Lupron depot therapy for 3 months to try to reduce the effects of any endometriosis, before proceeding further. There are some studies that show benefit and some that don't. I don't generally recommend this in terms of IVF treatments. I only recommend it for patients desiring to try some natural form of treatment such as IUI. I only mention it to you because it is an option, of you want to cover all your bases.

    I would not recommend surgery.

    Good Luck.

  4. Hello Doc,

    Please help me! I am new to your site and would like to thank you in advance for providing help to women who face infertility issues.
    Doc, would like to brief you with my medical history. i underwent laproscopy in dec 2011 for removal of dermoid cyst measuring 5 cm on my right ovary. my specialist removed scar tissues and cyst. i had infection on my belly button after the surgery. after getting better from the infection i was fortunate to concieve within one go in march 2012. unfortunately, in June 2012 i had miscarrage when was 17 weeks pregnant. the cause was placenta infection. specialist told me that she is not sure whether the infection caused cervix to open or whether it was incompetent cervix as a day before my miscarrage my cervix measured 27mm. anyways, for next time she recommends progestrone support in early months with stitch 12-13 weeks with anti-infection injections. mentally, i have suffered too much because of this loss. I had to see my parents and my uncle who is a gynac took another ultrasound and found chocolate cyst measuring 2.7 cm on my right ovary. he gave me lupron 11.25 mg injection, course for 3 months starting from 20 july. meanwhile i am trying my best to understand the issue and have started taking endo diet excluding items which are bad for endo, doing yoga and meditation, also trying to detox my liver and uterus. doc, i have following questions,
    1) my specialist says that my endo was not that bad when she did laproscopy....she says that i should ttc after my first cycle with lupron. do you think i have chance to conceive naturally whith cyst?
    2) can changing diet, de-tox help reducing chocolate cyst?
    3) how long should i ttc? should i go for another laproscopy or IVF in case of failing to concieve?

    i am 30 years old and will soon turn 31 in sept. I always took my career and education as priority and now I am very desperate to concieve as just lost my first child! i get very upset that i failed to carry my baby and hence want to know what would be best option next time.

    I thank you for your precious time and really hoping to seeing your response soon.

    best regards,
    parul sharma

    1. Hello Ms. Sharma,

      I think it is a good idea to try for pregnancy after the lupron treatment. You don't necessarily need to have surgery at this point. There is certainly a chance that you could become pregnant. If you are not successful after 6-12 months then you might want to consider removing that new cyst.

      Diet does not affect endometriosis.

      If you fail to conceive on your own after 12 months of trying, your choices are to either try to resolve the endometrioma with surgery or proceed to IVF. In the U.S., we consider an endometrioma as stage IV (advanced) endometriosis. The recommendation would be to proceed to IVF.

      Keep in mind that you were able to get pregnant previously and the loss had nothing to do with your fertility but rather was an obstetrical problem. It sounds like your OB doctor has a good handle on that to try to prevent the problem in another pregnancy. Be confident that you will eventually be successful.

      Good Luck,

      Dr. Edward J. Ramirez, M.D., FACOG
      Executive Medical Director
      The Fertility and Gynecology Center
      Monterey Bay IVF Program

      Monterey, California, U.S.A.

      for additional information check out my blog at check me out on twitter with me at @montereybayivf and facebook @montereybayivf. Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate.

    2. Hello Doc,

      this is Parul Sharma again, I wrote to you earlier in Aug 2012 and mentioned about going on with Lupron Depot 11.25 mg 3 months course.
      It is approx 6 months now and I have just completed my blood test to check the hormones. the readings are as follows, dated 3/01/2013:

      FSH: 6.9 U/L
      LH: 4.1 U/L
      Oestradiol: 288 pmol/L
      Progesterone: 14.0 nmol/L

      I have also completed my ultrasound, dated 21 dec 2012:
      choc cyst has reduced from 2.9 cm to 2.1 cm
      follicle on left ovary measuring 15 mm
      endometrium measures: 0.79 cm

      Doc, can you kindly tell me if I did ovulate? i am very confused with the units ng/ml and nmol/L. one doc said I have not ovulated and the other said I did!

      please let me know if the progesterone levels are normal?
      do you think I have come out of Lupron or you recommend and medication to come out and help ovulation if that has not happen.

      Waiting eagerly for your response,
      thanking you for all the support and guidance so far,

      best regards,
      parul sharma



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