Endometriosis and Fertility: When Surgery Is Needed

There are now government of India guidelines on this. Strictly by those guidelines it is 50 for the woman and 55 for the man, though this used to be more liberal — we used to see people at 60–65 also getting IVF done, before the ethical question of who will care for the children led to the cutoff being tightened.

After adhesiolysis we give a combination of estrogen throughout the cycle and progesterone added in the last 14 days, and it takes about 3 months for regeneration, confirmed with transvaginal sonography for endometrial thickness before and after. Many patients start to show improvement even after about a month and a half, where the scarring and adhesions are not so severe that they have permanently damaged the endometrium.

A lot of times when an HSG is done without sedation, the patient tenses up so much that there is a tubal spasm, which can appear as a bilateral proximal tubal blockage. One good approach is to give the patient an anti-spasmodic before the procedure, or do it with a little sedation, which removes many of these false positives. But if it still appears to be a genuine proximal blockage in both tubes, it's better to go directly for a diagnostic hysterolaparoscopy with chromopertubation, since that lets you directly visualise the tubes — and most patients also find repeating an HSG very painful.

Success rates of IVF in good centres are now around 60%. Cost depends on the kind of IVF procedure required — sometimes an ICSI procedure, sometimes donor eggs are needed — but it would typically start around 3 to 4 lakh rupees, roughly $3,200 to $4,500 per cycle.

There isn't a specific size used as a strict benchmark — even small fibroids can require removal if they are causing a cornual blockage, and submucous fibroids or polyps will usually require removal regardless of size. But anything bigger than roughly the equivalent of a 12–14 week pregnant uterus is a very large fibroid that definitely requires removal. On medical management: GnRH antagonists such as elagolix are used to help shrink fibroids, as are GnRH analogues/injections like leuprolide, which reduce the size of the uterus. However, submucous fibroids — the main culprits behind infertility — often will not respond well to medical management.

In cases of very mild endometriosis, surgery is generally avoided because it can lead to more scarring, which may worsen fertility outcomes rather than improve them.

An operative laparoscopy for endometriosis typically involves a cystectomy to remove chocolate cysts while preserving as much healthy ovarian tissue as possible, along with adhesiolysis to restore pelvic anatomy and ablation of any remaining endometriotic spots.

Damaging normal ovarian tissue during cyst removal can decrease AMH levels and reduce the chances of IVF success, so surgeons work to preserve as much healthy tissue as possible.

In some cases, yes. Egg freezing may be recommended before removing endometriotic cysts as a precaution against any reduction in ovarian reserve from the surgery itself.