Endometriosis Infertility : Understanding Fertility Issues


The G.O. Institute focuses on endo treatment including expert minimally-invasive robotic endometriosis excision surgery, which impacts endometriosis infertility.  This type of surgery gives you the best shot at preserving fertility when surgery is needed because the technique and tools allow for kinder, gentler surgery.  Dr. Steven Vasilev MD is a master robotic surgeon with decades of minimally invasive surgery experience, especially for situations where multiple surgeries have already failed.  But before surgery, one has to understand what endo does that can impact fertility.  This is a great review article our investigative team uncovered that might help you.

Endometriosis is defined as the presence of endometrial-like tissue outside the uterus that triggers a chronic, inflammatory response. Endometrium is the inner lining of the uterus that loosens each month and leads to menstruation (or periods). The same endometrium is also responsible for the implantation of the embryo and the formation of a pregnancy.

In endometriosis, this endometrium begins to grow in organs such as the ovaries and fallopian tubes, outer layers of the uterus, and sometimes the urinary bladder, intestines, lungs, etc. The incidence of endometriosis is two to 10 percent in the general population and up to 50 percent in couples with fertility problems.

The hormonal changes in the menstrual cycle affect the misplaced endometrial tissue, causing the area to become inflamed and painful. This means that the tissue grows, thickens and breaks down. Over time, the broken-down tissue has nowhere to go and becomes trapped in your pelvis, which can later lead to irritation, scarring, and adhesions where the tissue holds your pelvic organs together, causing severe pain during your period, and later fertility problems.

How It Is Diagnosed: Symptoms To Look For

Women who have endometriosis report to their gynecologist with one or more of the following most common symptoms: The 5 Ds:

Dysmenorrhea or painful periods. This can also include pain in the lower abdomen before and during menstruation.

Deep dyspareunia or painful intercourse.

Dysfunctional uterine bleeding – abnormal or heavy periods.

Difficulty conceiving – infertility.

Dyschezia – painful or difficult defecation.

Pain during periods, pelvic pain unrelated to periods, progressively worsening pelvic or period pain, and infertility are the main stress factors that severely affect the quality of life of patients with endometriosis.

Diagnosis: Clinical and radiological evaluation

The patient’s bimanual pelvic examination shows the gynecologist some signs that are confirmed with transvaginal ultrasound TVS. TVS can have a chocolate cyst (endometrioma) in one or both ovaries. The ovaries can be placed close together behind the uterus, or the uterus can be enlarged, especially its muscular layer if it is called adenomyosis, etc. In rare cases, an MRI may be needed to confirm pelvic endometriosis.

Role of laparoscopy and robotic surgery

Laparoscopy is a minimal access surgical technique in which vision is achieved with the help of a telescope. Laparoscopy is the gold standard for diagnosing endometriosis and has the advantage of treating the disease at the same time.  (At the GO Institute we favor robotics, which is super-laparoscopy with 3-D optics and instruments that are like tiny human hands, which is better than 2-D and straight instruments of laparoscopy.)

How endometriosis can cause fertility problems

There are four reasons for decreased fertility

Ovulatory infertility: Changes in follicle growth due to inflammation and thus changes in ovulation or obstruction to ovulation.

Tubal factor infertility: Endometriosis causes an inflammatory response that causes an abnormal fusion between the ovaries, tubes, uterus, and intestines. The tubes can become distorted, swollen, and unhealthy

Abnormality in the receptivity of the endometrium: The inner lining of the uterus does not provide a favorable environment for implantation.

Immunological Infertility: The inflammatory response in the pelvis caused by endometriosis releases many negative factors known as reactive oxidative species ROS, which cause oxidative stress for both the ova (eggs) and sperm. The gametes (eggs and sperm) are very sensitive to this oxidative stress and cannot function properly.


If the disease is minimal or mild, the tubes are open, the semen parameters are good, the partner is less than 32 years old, and the duration of infertility is less than three years, controlled ovarian stimulation in combination with intrauterine semen insemination ( IUI) the treatment of choice.

This treatment can be repeated for up to three to six cycles. The couple will not benefit from adding more IUI cycles and must continue for in vitro fertilization or IVF.

For moderate and severe diseases: the surgical resection of endometriomas (chocolate cysts) and the complete removal or “excision” of the endometriosis, should be the goal to improve the chances of conceiving.  (some “burn” the endo, but that we disagree with because there is good data now that shows that is an inferior approach)

The operation is followed by either an IUI or directly an IVF / ICSI (test tube conception) if it is found at the time of the operation that the tubes are damaged due to the disease.

Read more here…

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“I help and guide women to beat endometriosis and gynecologic cancers that are associated with endo, like ovarian cancer, using a unique combination of minimally invasive robotic surgery, precision medicine therapies and complementary holistic natural support towards thriving in survivorship." Dr. Vasilev is the only physician triple board certified in Ob-Gyn, Gynecologic Oncology and Integrative & Holistic Medicine in the United States. He is an accomplished advanced robotic master surgeon, and is internationally vetted by iCareBetter (https://icarebetter.com/doctor/dr-steven-vasilev/). He serves as Professor at the world-renowned Saint John's Cancer Institute in Santa Monica, California and is Clinical Professor at Loma Linda University School of Medicine. He is former faculty and professor at UC Irvine, UCLA, USC and City of Hope and was the founding Medical Director of Integrative Medicine at Providence Saint John's Health Center. He is an active member of multiple medical societies and has been nationally listed in "Best Doctors" for over 20 years.