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endometrioma, fibroid and IVF
I'm 40 and was diagnosed with a 5cm uterine fibroid subserosally
and a 5cm endometrioma 5 months ago. My gynecologist performed laparoscopy and "drained" my endometrioma, but didn't do anything to the fibroid because the uterus & cavity were not disturbed by the fibroid. But when I was referred to an IVF clinic, my IVF consultant found a 6cm ovarian endometrioma once again and told me to deal with the endometrioma as well as the fibroid now measured 6.6cm prior to proceeding with IVF treatment.
Q1)Is it normal for my endometrioma once "drained" to recur over 5 months to a larger size? Q2)Should my gynecologist have treated my endometrioma with laser or excised it instead? Q3)Is it strange that there is no port position scars on the right for my RIGHT-sided endometrioma operative laparoscopy? I have 3 scars: navel for laparoscopic entry, left and middle suprapubic punctures. Q4)What is the best treatment of my endometrioma? Do I need to go through another laparoscopy? Q5)Do I need to go through myomectomy for the fiboid before IVF treatment?
Thank you so much.
and a 5cm endometrioma 5 months ago. My gynecologist performed laparoscopy and "drained" my endometrioma, but didn't do anything to the fibroid because the uterus & cavity were not disturbed by the fibroid. But when I was referred to an IVF clinic, my IVF consultant found a 6cm ovarian endometrioma once again and told me to deal with the endometrioma as well as the fibroid now measured 6.6cm prior to proceeding with IVF treatment.
Q1)Is it normal for my endometrioma once "drained" to recur over 5 months to a larger size? Q2)Should my gynecologist have treated my endometrioma with laser or excised it instead? Q3)Is it strange that there is no port position scars on the right for my RIGHT-sided endometrioma operative laparoscopy? I have 3 scars: navel for laparoscopic entry, left and middle suprapubic punctures. Q4)What is the best treatment of my endometrioma? Do I need to go through another laparoscopy? Q5)Do I need to go through myomectomy for the fiboid before IVF treatment?
Thank you so much.
You are asking great questions, and at age 40 need to move pretty quickly. Here are my thoughts:
1) It is not unusual for the endometrioma to reaccumulate after being drained
2) excision of the endometrioma would have been preferable, but this is not always possible, or safe. There can sometimes be quite a bit of scar tissue, risk of bowel injury, etc. Furthermore, sometimes removing the endometrioma can result in inadvertant removal of valuable ovarian tissue, thereby accelerating decline in ovarian function, particularly in someone your age. Despite all of this, it would have been preferable to excise rather than drain. Use of laser is not an issue - laser is just another surgical tool that is not better or worse than cautery or scissors. It is not a question of whether or not to use the laser, but rather whether or not the endometrioma could have been safely excised.
3) If you have two punctures, one in the belly button and one in the lower abdomen, your surgeon could have drained the endometrioma. To remove the endometrioma, you would have had more incisions, perhaps one in the belly button and up to three small incisions in the lower abdomen
4) A 5cm fibroid and a 6 cm fibroid are probably the same - ultrasound is only so accurrate in measuring fibroid size. Whether or not to remove fibroids as part of infertility treatment is a somewhat complex question. Most REIs are in agreement that any fibroid distorting the cavity should be removed. Most REIs are in agreement that any fibroid that is truly serosal does not need to be removed to promote fertility. The controversy lies with large fibroids that are intramural (i.e. within the wall of the uterus) - some believe that large intramural fibroids (cutoff for some > 3 cm, for others > 5 cm) affect infertility and should be removed whereas others are not so sure. In your situation, the question is whether the fibroid is serosal or intramural. If serosal, it does not need to come out.
5) The question of the endometrioma is also complex. Our scientific literature on this issue suggests that treating moderate or severe endometriosis (which you have) improves the likelihood of getting pregnant on your own - i.e. removal of the endometrioma. However, if you are undertaking IVF, our literature suggests that there is no benefit to removing the endometrioma before doing IVF.
Putting all of this together, here are my suggestions:
1) Be absolutely certain that the fibroid is serosal, without a significant intraumural component.
2) Consider an IVF cycle without removing the endometrioma or the fibroid. The benefit of removing an endometrioma to improve upon IVF success is not proven, and there will be significant down time by the time you set up for another surgery, with no guarantees that the endometrioma will be removed, and time required to recover from the surgery. These are valuable months at your age.
3) If the IVF cycle fails, then re-evaluate the need for the surgery.
Here are some medical journal references for you to research:
Treatment of endometriosis; a review of the evidence. Ann N Y Acad Sciences. Authors D Olive and EA Pritts
Removal of endometriomas before in vitro fertilization does not improve infertility outcomes: a matched case-control study. Fertil Steril Volume 81, Issue 5, page 1194, year 2004
Good luck!
1) It is not unusual for the endometrioma to reaccumulate after being drained
2) excision of the endometrioma would have been preferable, but this is not always possible, or safe. There can sometimes be quite a bit of scar tissue, risk of bowel injury, etc. Furthermore, sometimes removing the endometrioma can result in inadvertant removal of valuable ovarian tissue, thereby accelerating decline in ovarian function, particularly in someone your age. Despite all of this, it would have been preferable to excise rather than drain. Use of laser is not an issue - laser is just another surgical tool that is not better or worse than cautery or scissors. It is not a question of whether or not to use the laser, but rather whether or not the endometrioma could have been safely excised.
3) If you have two punctures, one in the belly button and one in the lower abdomen, your surgeon could have drained the endometrioma. To remove the endometrioma, you would have had more incisions, perhaps one in the belly button and up to three small incisions in the lower abdomen
4) A 5cm fibroid and a 6 cm fibroid are probably the same - ultrasound is only so accurrate in measuring fibroid size. Whether or not to remove fibroids as part of infertility treatment is a somewhat complex question. Most REIs are in agreement that any fibroid distorting the cavity should be removed. Most REIs are in agreement that any fibroid that is truly serosal does not need to be removed to promote fertility. The controversy lies with large fibroids that are intramural (i.e. within the wall of the uterus) - some believe that large intramural fibroids (cutoff for some > 3 cm, for others > 5 cm) affect infertility and should be removed whereas others are not so sure. In your situation, the question is whether the fibroid is serosal or intramural. If serosal, it does not need to come out.
5) The question of the endometrioma is also complex. Our scientific literature on this issue suggests that treating moderate or severe endometriosis (which you have) improves the likelihood of getting pregnant on your own - i.e. removal of the endometrioma. However, if you are undertaking IVF, our literature suggests that there is no benefit to removing the endometrioma before doing IVF.
Putting all of this together, here are my suggestions:
1) Be absolutely certain that the fibroid is serosal, without a significant intraumural component.
2) Consider an IVF cycle without removing the endometrioma or the fibroid. The benefit of removing an endometrioma to improve upon IVF success is not proven, and there will be significant down time by the time you set up for another surgery, with no guarantees that the endometrioma will be removed, and time required to recover from the surgery. These are valuable months at your age.
3) If the IVF cycle fails, then re-evaluate the need for the surgery.
Here are some medical journal references for you to research:
Treatment of endometriosis; a review of the evidence. Ann N Y Acad Sciences. Authors D Olive and EA Pritts
Removal of endometriomas before in vitro fertilization does not improve infertility outcomes: a matched case-control study. Fertil Steril Volume 81, Issue 5, page 1194, year 2004
Good luck!
Hi,
I have a large fibroid but my doc(IVF doc) told me it would not get in the way of a pregnancy. In Sept I completed IVF and I am preg with twins.
The Doc told me I could wait until after birth to deal with the fibroid. I hope and pray it doesn't get in the way or cause complications.
Fibroids are common in fact a couple of women usually have them in a IVF cycle.
I have a large fibroid but my doc(IVF doc) told me it would not get in the way of a pregnancy. In Sept I completed IVF and I am preg with twins.
The Doc told me I could wait until after birth to deal with the fibroid. I hope and pray it doesn't get in the way or cause complications.
Fibroids are common in fact a couple of women usually have them in a IVF cycle.
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