Saturday, December 21, 2013

TTC After Surgery For Stage Four Endometriosis

Dear Readers,
As the year draws to a close I want to wish all my readers near and far the very best in their lives as you move forward into 2014. I hope that the blessings of health and peace are with you all and for those of you who continue to struggle with infertility, I can only wish with all my heart that the journey will come to a positive conclusion for you in 2014.
Thank you for following my blog and God Bless.
Edward J. Ramirez, M.D.

I was diagnosed with stage 4 endometriosis in 2011 (26 yrs old) after a laparoscopy found a large endometrioma. I've never had painful periods prior so that diagnosis was surprising to me.I then grew back another large endometrioma and had my 2nd lap in June 2013. I am now 29 and have been TTC (trying to conceive) since my surgery in June. I was told to try naturally for the 1st 6 months. I am now on my 7th cycle and beginning to look into other options. I have seen that with stage 4 endo the treatment of choice is IVF over trying clomid / IUI. Can you explain why?  I understand surgery can affect ovarian reserve but am looking for better understanding.
What would you recommend my next steps be? How aggressive should I be in getting pregnant right away since I only had a two years between surgeries was regrowth or large endometriomas?  Thank you.

C. from California

Hello C. from the U.S. (California),
Unfortunately, Stage 3 and 4 endometriosis have been found to significantly decrease fertility rates.  This is because endometriosis cause a chronic inflammation of the pelvis that recruits inflammatory cells and these cells attack and destroy the eggs when ovulation occurs (this of course is putting is very simply for ease of understanding).  In stage 4 endometriosis, severe adhesions or scar tissue formation occurs in the pelvis.  These adhesions are like spider webs so that when the egg exits the ovary and moves into the pelvis, prior to finding the tube, the eggs get caught in these spiker webs or the webs block the tubes so that the egg never gets into the tube where fertilization takes place.

Because of this, the only way to achieve pregnancy is to bypass the tubes, which you cannot do by natural means.  For that reason IVF is the only option.  Now, even I have had patients with stage 4 endometriosis get pregnant, and as a Catholic I believe in miracles, and so don't doubt that this can happen.  However, statistically speaking these cases are very, very few.
In terms of the recurrence of endometriosis or endometriomas, this is a chronic disease and new implants are continuously forming.  For that reason, you can form new endometriomas, despite the previous ones being removed.

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.


  1. Hello,

    I am 28 and I have been trying to conceive for 5 months. I came off a non-hormonal IUD in September. Before that, I was on the birth control pill. I started spotting mid-cycle about 5 years ago. None of my doctors thought it was cause for concern. Since getting off the pill my periods became irregular. My cycles vary between 28 and 40 days, most often they are around the 33 day mark and I still have spotting. My last couple periods have been extremely light. I have only had a 1 day period with a bit of spotting for the last couple months. I have tested for pregnancy with negative results. Are my irregular periods, spotting and light periods a cause for concern when it comes to conceiving? All the doctors I've seen just brush my concerns off.
    Thanks in advance for your response.

    1. In general, it takes the average woman under the age of 30, 8-12 months to achieve pregnancy. For that reason, we don't say a woman has "infertility" until she has been trying for at least 12 months. That being said, there is a problem based on the information you've given me and that is "irregular cycles." When the cycles are irregular, it means that the ovaries are not functioning correctly and this is the second step in the reproductive process. If the ovaries malfunction or dysfunction, then the subsequent steps required to get pregnant either don't happen or are thrown off. Irregular cycles also mean that you may not be ovulating, which is where the egg is given off.

      This is not to say that you can't get pregnant, but you have two choices at this point. You can continue trying on your own for a total of 12 months, then see an infertility specialist after that, or you can see an infertility specialist now and ask for medication that will help your ovaries to work properly called ovulation induction (this is what "fertility" drugs do).

      Good Luck



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