Endometriosis and Tubal Surgery Before IVF

Endometriosis surgery before IVF is often advised when there are endometriotic (chocolate) cysts, ovaries stuck to the uterus, or adhesions that block the tubes or distort the pelvis; very mild endometriosis is usually left alone. Damaged fallopian tubes are treated according to where the damage lies: blocked ends can be opened, while badly damaged tubes are removed or clipped so that they do not lower IVF success.

Endometriosis and tubal disease share a setting, the pelvis outside the uterus, and a common surgical tool, the laparoscope. Dr. Shelly Singh, Senior Director Obstetrics & Gynaecology, Fortis La Femme, New Delhi, India, described both as areas where a well-judged operation before IVF improves the odds of the cycle, and where a poorly judged one can do lasting harm, above all to the ovaries. Uterine surgery for fibroids, polyps, adhesions and anomalies is covered separately in Fibroids, polyps and uterine surgery before IVF, and the whole pathway in the complete guide to pre-IVF workups and corrective surgeries.

What endometriosis is, and why it complicates fertility

Endometriosis is a condition in which endometrial tissue, the tissue that normally lines the uterus, grows outside the uterus. Dr. Singh described it as a lifelong condition, and a difficult one for physicians, surgeons and patients alike.

It runs along a spectrum:

• Mild endometriosis: scattered endometriotic spots on the pelvic surfaces.
• Ovarian endometriomas: cysts of endometriotic tissue in the ovary, known as chocolate cysts because of the thick, dark old blood they contain.
• Deep infiltrating endometriosis: the most severe form, in which the pelvic organs are stuck to one another and the pelvis is effectively frozen. The bowel, the bladder and the ureters (the tubes that carry urine from the kidneys) can all be involved, and the normal anatomy is completely distorted.

Endometriosis can also occur at distant sites, such as the lungs or even the brain, but these are uncommon. Endometriosis within the pelvis, by contrast, is a fairly common condition, and one Dr. Singh sees often in her practice.

When endometriosis needs surgery before IVF

Dr. Singh's approach is to correct endometriosis before IVF unless it is very mild. Very mild disease is better left alone, because operating on it can lead to more scarring. Surgery is indicated when:

• there are endometriotic cysts in the ovaries;
• the ovaries are stuck to the uterus;
• adhesions are blocking the tubes; or
• adhesions are distorting the anatomy of the pelvis.

Practice on endometriomas specifically varies between centres. The European Society of Human Reproduction and Embryology (ESHRE) 2022 endometriosis guideline does not recommend routinely removing an endometrioma before assisted reproduction solely to improve live birth rates; surgery before IVF is more clearly indicated for pain or for a cyst that would obstruct egg collection. The decision is therefore individual, and the risk to ovarian reserve described below is central to it.

How endometriosis surgery is performed

The operation is an operative laparoscopy, and it typically combines several steps.

Ovarian cystectomy that preserves ovarian reserve

Chocolate cysts are removed by ovarian cystectomy. The most important principle, in Dr. Singh's words, is to make sure that as much healthy ovarian tissue as possible is left behind. If normal ovarian tissue is destroyed along with the cyst, the result is a lower AMH (anti-Müllerian hormone, the blood marker of ovarian reserve) and a lower chance of IVF success. Her technique is to remove only the cyst and to use as little cautery (heat to stop bleeding) as possible, so that functional ovarian tissue survives the operation.

Egg freezing before surgery

Because removing an endometrioma can reduce ovarian reserve, some women benefit from having eggs frozen before the cysts are removed. Dr. Singh sometimes advises egg freezing first, so that the woman's fertility is protected whatever the effect of surgery on the ovary.

Adhesiolysis to restore the pelvic anatomy

Adhesions between the ovaries, tubes, uterus and bowel are divided, a procedure called adhesiolysis. The aim is to restore normal pelvic anatomy, which Dr. Singh regards as essential to the success of IVF.

Documenting the tubes and ablating remaining disease

During the same operation, the surgeon examines and records the condition of the fallopian tubes, including whether they are open or blocked. Any remaining endometriotic spots in the pelvis are ablated (destroyed), because these deposits release inflammatory chemicals that can interfere with the success of IVF.

Tubal surgery before IVF: five procedures

Tubal disease is one of the commonest reasons couples need IVF, but IVF does not always make the tubes irrelevant. Depending on the problem, a tube may need to be opened, repaired, removed or disconnected from the uterus. Dr. Singh described five procedures.

1. Reversal of tubal ligation

Some women have had their tubes tied (tubal ligation) after completing their family and later wish to conceive again, sometimes because of a problem affecting their children. Tubal reanastomosis rejoins the cut ends of the tube.

2. Salpingectomy for badly damaged tubes

When a tube is badly damaged, leaving it in place raises the risk of an ectopic pregnancy, a pregnancy that implants in the tube rather than the uterus. Such tubes may need to be removed, an operation called salpingectomy.

3. Tubal clipping for badly damaged tubes

When both tubes are badly damaged, an alternative is tubal clipping: the tubes are clipped at their uterine ends and disconnected from the uterus. The purpose, Dr. Singh explained, is to stop damaged tubes from passing toxic material into the uterus, which lowers the success of IVF. Fluid from a blocked, distended tube (a hydrosalpinx) is known to reduce implantation and pregnancy rates in IVF, and removing or proximally occluding such tubes before IVF improves the chance of pregnancy.

4. Fimbrioplasty

Sometimes only the fimbrial end of the tube, the fringed opening next to the ovary, is blocked. Fimbrioplasty reopens it and is, in Dr. Singh's description, a fairly simple procedure.

5. Hysteroscopic tubal cannulation

When the tube is blocked at its uterine (cornual) end, a fine cannula can be passed through a hysteroscope into the tube to open it. This hysteroscopic cannulation reaches the blockage from inside the uterus, without opening the tube from outside.

Choosing the right tubal operation

The choice of procedure follows from a diagnostic laparoscopy, which shows exactly which part of the tube is damaged. Dr. Singh's decision logic is:

• Blockage at the cornual end: attempt hysteroscopic cannulation.
• Blockage at the fimbrial end only: fimbrioplasty.
• The whole length of the tube badly damaged: keeping the tube serves no purpose and is counterproductive, so it is removed (salpingectomy) or clipped, so that IVF success rates improve.

When an HSG suggests both tubes are blocked

The diagnostic step is often prompted by a hysterosalpingogram (HSG) showing that both tubes are blocked near the uterus. Dr. Singh's view is that this finding is frequently a false positive caused by tubal spasm in a tense patient, and she reduces it by giving an antispasmodic and, where possible, light sedation before HSG. If both tubes still appear blocked, she moves directly to diagnostic hysterolaparoscopy with chromopertubation, in which dye is passed through the tubes under direct vision, rather than repeating an HSG that most patients find very painful. The tests themselves are described in Pre-IVF tests: ovarian reserve, tubal patency and semen analysis.

Why this surgery shapes the IVF that follows

The common thread in Dr. Singh's approach to endometriosis and tubal disease is that surgery before IVF is judged by its effect on the cycle that follows. Cystectomy is done in a way that protects AMH; adhesiolysis restores the anatomy the cycle depends on; residual endometriosis is ablated because it is inflammatory; and tubes that would leak toxic fluid into the uterus are removed or disconnected. Each step is a decision about the embryo's environment, made before the first injection of the IVF cycle.

Questions that attending doctors raised on these themes, including the choice between repeat HSG and hysterolaparoscopy, are collected in the Live Discussion from this masterclass. Indicative costs for laparoscopic and other gynaecological procedures are on the gynaecological treatment cost page.