For women who have endometriosis, the two most common symptoms are pelvic pain and infertility. Specialists at the Fertility & Reproductive Medicine Center have decades of experience in diagnosing and successfully treating women with endometriosis to preserve or restore fertility. Our advanced tests and treatment options have helped innumerable women increase their chances of conceiving.
Once diagnosed with endometriosis, and depending on the severity of the condition, treatment may include medication, hormonal therapy, and surgery. For fertility success, it might also include assisted reproductive technology. Washington University infertility specialist at Barnes-Jewish Hospital, Dr. Dan Lebovic specializes in fertility and reproductive medicine and has spent 27 years researching and treating endometriosis in the context of infertility.
Watch Dr. Lebovic’s Grand Round presentation,
Endometriosis and Infertility: Sundry Treatment Aspects, to learn more about past studies and how outcomes varied based on treatment. When I was putting together this talk, what I'm aiming to do is try to pick out some topics of endometriosis that I've really tried to pay attention to over the years. Um And actually in publications that have come up, it's vacillated in terms of what the ultimate viewpoint may be. And I wanted to kind of go through that with you. Um My fellowship in San Francisco, Doctor Taylor was uh primarily on endometriosis. So my research has been on that throughout the years and that's what I've concentrated on. Um And, you know, it's a mysterious disorder that we have yet to get a firm grasp on. Um But today I'm kind of centering on just endometriosis and the infertility proponents that uh some of these that I'm gonna to dissect out for you to try to go through. Let me grab a highlighter. Yeah. OK. So up to date is just a disclosure or chapter and up to date, start with this case presentation that I'll revisit near the end. So it's just something to keep in mind as we're going through. Let's say you have a 32 year old woman who recently read that Marilyn Monroe suffered from severe endometriosis. True fact, she has been trying to conceive for the past two years and believes she too suffers from endometriosis. How would you cancel her regarding her fertility options? So, I just recently ran across this quote from Doctor Grun at the Northwestern University School of Medicine. This was in 1987 where he wrote until the 14th century. It was widely believed that the human uterus was multi chambered and could wander about the body causing hysteria. Yeah, kind of outrageous. Uh Although in this publication, you can see that there was this small lesion on the lower eyelid. So this was a 57 year old post menopausal woman with a history of endometriosis on estrogen hormonal therapy. She had this bothersome papilloma lesion on her right. I'm sorry, her left lower eyelid and eventually, when it was excised, it was found to be in the metic tissue. So how did it get there? One wonders. But maybe I misogynous uh spread could be one possible a route that I got there but really remarkable to see an endometrium on the lower eyelid. Here's another just kind of fun fact of publication showing nasal lacrimal endometriosis. And this was in a 13 year old with cyclic bleeding from the left inferior punctum with each menstruation. Now, they never did biopsy lesion, but they did an MRI and found what seemed to be an endometriotic lesion further down in the nasal larita really pretty wild. But again, just I think they are, I know of at least two case reports of this sort of ectopic lesion of endometriosis. There's a publication back in 2003 that just goes over in general epidemiology of endometriosis in terms of incidents, maybe 5 to 10% in those who have proven fertility in sub fertile women, incidence may be as high as 50% that were refined endometriosis. I still think this is a bit high in our field. But again, this is a fertility clinic. So there were potential and endometriosis um centric type a clinic in Belgium where doctor Dua practiced. So it may have biased the data outcome but just goes to show there is seem seemingly a higher percentage of women with endometriosis suffering from infertility. This study by in 1998 looked at stage 1 to 2 endometriosis patients and how did their fertility compare over time to those with unexplained infertility? And they looked at all the way up to 36 weeks after laparoscopy and their main conclusion was no significant difference. Um So the percentages turned out to be about 24% pregnancy rate for those with unexplained and about 16% with those with minimal to mild endometriosis, that's kind of a significant difference. But again, maybe not enough patients. Um there were 100 and 68 patients that underwent laparoscopy for their study. And nevertheless, if you do the statistics and take this study for what it's worth, didn't seem to show a difference. And this is typically what we go by these days when we're counseling patients as to the effect on their fertility, women with endometriosis, at least stage 1 to 2. How did they react in terms of their fecundity? Similar to those with unexplained infertility? We put them in the same group in a way in terms of prognosis. Do they suffer in fertility? This has been long debated, but these are just some theories that I've listed here. There could be an altered hostile peritoneal environment with adverse effects on the o site on the sperm, maybe increasing DNA fragmentation of the sperm effects on the embryo, uh on the endometrium, altered expression of a 10 and Muin one, maybe alpha five beta three as well. Is there fallopian tube dysfunction potentially with contractions that are irregular or simply blockage of the fallopian tube due to the severity of disease and it needs and that gets to the distorted pelvic anatomy, which is a pretty obvious reason why you'd have infertility getting into more detail. This study looked at simply the granulosa cells and found that there was a higher incidence of apoptotic granulosa cells in endometriosis patients shown here in the red bar at about 17% compared to maybe 12%. Um for those with tubal factor in so interesting. But is this really a difference that is significant enough to have an impact potentially. But it's just not not an interesting study to bring up. This wasn't the uh best foot forward by our journal fertility and sterility. Now, about 10 years ago, published this article led by Doctor Vir on attractiveness of women with rectovaginal endometriosis. A case control study pretty outrageous when I saw this in the journal, when it came out, the first thing that came to mind was how did it ever get through the peer review process? Um And sure enough, this article thankfully was retracted, although they've subsequently published even other articles that are um in a similar vein. Um But I think it just goes to show, be careful what you read and we'll get back to this theme in a bit. Look at this article, I compared the rates of success for women undergoing I VA that have endometriosis. So this was a, a nice large study from the University of Pennsylvania um where Doctor Bart Hart, who's currently the in chief of fertility and sterility was a senior author using the S A RT Database Society for Assisted Reproductive Technologies and tried to compare and see it was there really any difference and presumably lower rate of success in women undergoing I V with endometriosis? Well, I just wanna highlight kind of the last sentence here of their conclusions, the minority of women. So this was the smallest group that they could end up dissecting out who have endometriosis in isolation. Meaning there was no other fertility issue, no male factor, no diminished reserve, checked off just endometriosis and isolation. The live birth rate was similar or maybe slightly higher compared with other infertility diagnoses. And this is a theme that I think has really remained when you look at subsequent studies that are looking to see whether or not there really is a difference. However, Doctor Grimes has come out with a beautiful article in 2010 where he showed that epidemiological research using administrative databases. He says it's garbage in garbage out. So be wary of what you conclude by using these databases. And that last study I mentioned did happen to use one of these administrative large databases, but some articles have drilled down a bit more. And so I wanna bring up this study. It's a retrospective cohort study assessing I V F outcome endometriosis patients versus tubal factor looking at birth or ongoing pregnancy rate divided by either tubal factor stage 1 to 2. So early endometriosis stage 3 to 4 and then further dissecting out the stage 3 to 4 of those without an endometrioma and those with an endometrioma. As you can see, there seemed to be equivalent pregnancy rates until you got to the group that had severe severe disease including having an endometrioma. And that pregnancy rate was around 20% compared to 25 to 30%. So maybe there's a subset who truly have a lower rate of success with I V F. And uh as I go through my talk, I am going to try to emphasize whether that study was looking at I V F outcomes or, you know, technology to help patients conceive versus natural or using ovulation induction. This was I V F. There's another study, meta analysis of 36 retrospective studies assessing the I B F outcome or endometriosis patients compared to tubal factor as the reason for undergoing I V F. And again, for the lower stages, stage 1 to 2, there was no difference. Whereas with stage 3 to 4 pregnancy rate was lower, um a little bit different than the previous study because here it's not divided up by endometrioma or no endometrioma. But again, just to give you a flavor that there may be a cohort that does have a lower rate of success. But in general, it's not what we quote the patient. So throughout the rest of the talk, I'm gonna be giving you a kind of a summary statement just to make it clear what my point is. Although I wouldn't take it for granted that this is the absolute answer, but I gotta come up with some position. And so I'm gonna state that and then give you some supportive evidence if you will. Although I think some astute participants here or listeners can probably find an article that says the exact opposite. But this is my best assessment of the literature. And you know, they always say you only come away from a talk, remembering maybe one at top three things. So perhaps some of these you will remember, I just want to emphasize them. The first one is surgery is of no assist prior to a RT or I B M. And this is a study with um stage 1 to 4 endometriosis patients undergoing surgical resection, all stages. It was retrospective, there was no control group and it was not prospective. So some faults there, endometrioma is greater than three centimeters if a patient had that, they were excluded. But this group under 19 cycles, um they assessed their outcome within the first six months after surgery compared to greater than six months interval. For the other group. 76 cycles underwent I V F, assess the number of sites and the pregnancy rate. As you see, neither of them were significant, an average of 17 0 sites for both groups, pregnancy rates were equivalent just about 60% concluding that surgical management of endometriosis does not enhance a RT cycle outcome. What about what about for just stages? 1 to 2, maybe, maybe there's a benefit and let's break that up for I V F or non I V F. This was surgical resection. Stage 1 to 2, endometriosis undergoing I V F. So you had the diagnostic group compared to the group, good number of patients in each group. So almost 400 for the diagnostic and 262 cycles for the group underwent ID F looked at the live birth rate for retrieval, turned out to be 21% versus 28% for those with ablation. And they had enough numbers that this 7% difference did come out to a statistically significant difference to play this. I think we have the time. Is it just an example of excision of an implant um described potentially by the big surgeons? But I wanted to at least show this for those that are listening to their students or the residents and how we tried to undermine the lesion with a relatively larger margin because there can be satellite lesions of enemy Joses that can't be seen with laparoscopy just on a microscope. When you analyze, it could appear up to about 25 millimeters outside of the lesion is cutting the Perini and the underlying tissue to separate the implant. Come on for the next few slides are some classic studies trying to answer the question of whether or not surgery for stage 1 to 2, endometriosis was of any benefit with subsequent fertility. And this study is the first one that came out being a randomized trial. Um And this was a Canadian study by Marco et cetera in 1997 published in the New England Journal of Medicine with 341 women with stage 1 to 2 endometriosis. 100 and 72 underwent laparoscopic ablation. 169 underwent simply surgery, diagnostic laparoscopic surgery where they identified the lesions and they looked at the outcome to 36 month cumulative pregnancy greater than 20 weeks along. What was the probability? And it was found that the laparoscopic ablation group seemed greater 31% compared to 18%. Well, let's dig deeper into this article. Um If you look at the details, they actually had to operate on twice the number of patients to get patients that had endometriosis. So half their patients that went to surgery did not have endometriosis. Um just looking at the data points, 31% in 18, you would need eight surgeries to obtain one pregnancy. That's not counting those extra patients that underwent surgery where there was no endometriosis scene at all. So based on that, you may actually need 16 surgeries to get the one extra pregnancy. So all number needed to treat was eight. But is it really a also clear and pink vesicular lesions were not considered as endometriosis? And there is some thinking that these clear and pink lesions are the more active endometriosis and maybe have more of a deleterious effect on someone's fertility and they weren't included in that endometriosis group. Overall, the monthly fecundity for the laparoscopic ablation group was 6.1% and that's far less than the typical, maybe 15 to 20% fertility rate per month study followed this. Similarly, it was prospective randomized. It was from an Italian group published in 1999 fewer patients 96 with stage 1 to 2, endometriosis, again, divided up between ablation and diagnostic laparoscopy. Only looking now at a 12 month cumulative conception rate, they actually did not find a difference, you know, it was maybe 5%. But with their numbers wasn't powered enough to show any significance regarding that. Um For this study, the women that had stage two endometriosis comprised 60% of this study compared to 30% for the Marco Canadian group that I had mentioned earlier. Also, the power was inadequate, inadequate to detect it between group difference and pregnancy rate observed in the Marco study, if you put these two landmark studies together kind of a mini meta analysis of surgery versus no treatment still comes out slightly ahead, does not cross one barely. Um And so the conclusion is there's a modest efficacy of endometriosis ablation in increasing the pregnancy rate in such in internal women and putting these studies together, the overall number needed to treat is 12. But again, is it really 12 when we're never 100% sure that a woman has endometriosis when she undergoes laparoscopy to begin with? So that number may be 20 the number needed to treat. So just as a practical matter, uh these days, I don't recommend patients undergo surgery for endometriosis, infertility is their primary outcome. Now, if they're suffering from pain, I think it's perfectly reasonable to address that and perhaps get this slight benefit if you will from the surgery on their fertility. I want to play for you some short quotes or, or interviews with doctor who is from the uh Canadian study that I just mentioned the new England journal. That was the first one published in 1997. And then also doctor Donna who's published a lot on endometriosis. I think it's interesting to hear their viewpoints and then I'll make a brief comment about that. I have a take home message here and it is that management of endometriosis oriented, we don't treat endometriosis. We treat Mrs Smith with a problem of pelvic pain or a problem of infertility. We don't know what cause endometriosis. We don't know the natural history of this disease. We have a lot of recurrence after surgical or medical treatment. So we should orient our treatment on symptoms. I believe that for treatment of pain, medical treatment should be the first option. And for treatment of infertility as a seed with endometriosis, laparoscopic surgery should be our first option. So his last comment about surgery being the first option for these patients. As I just mentioned, I don't really feel the same and I think some follow up studies would uh tamper that conclusion a little bit. Uh I would also just want to mention doctor Ma who is really a fantastic person. He, he passed away unfortunately, soon thereafter from this interview, uh quite suddenly at the age of 57 I'm sure he would have been even more productive with further studies that you um have been planning. But he, he did a lot for us. There was no question. Sometimes there is a medical approach for the first line if the patient is consulting for pain. But in the group of a general or in my group, we are more in favor of the laparoscopic diagnosis and description of all side of endometriosis. Because even in a young woman, an adolescent suffering from pelvic pain, I think that it's very important to have the right diagnosis of endometriosis because probably we have in this young woman to propose a medical therapy, a long term medical therapy in order to try to decrease the recurrence rate of the disease of to decrease the severity of the disease, which will appear with years and years of non therapy. You're able to hear that. And I know that it's because of the accident may be a little bit hard to understand, but it brings up a lot of important points, not all of which I I can't address at this time. But the big one I want to just mention is this whole idea of doing surgery to at least have a diagnosis because he and and I do, I I similarly agree that there is long term treatment that I believe is the best for the patient going forward. And do you want to put them on it if you don't know that they truly have endometriosis. I would say that most recently, the European Society for uh reproduction has concluded that no longer is laparoscopy mandated to make the diagnosis. So, um it may be putting this into a bit of a doubt that you would have to have surgery. If you are convinced based on the history that they have endometriosis or imaging, then uh you could subject a person to hormonal therapy or treatment long term to try to keep the disease at bay if you will. Yeah. How about removing endometriomas prior to doing I V F? No known benefit or detriment. So neutral on whether or not to remove endometriomas. Let's talk about this for a little bit. This was a study problem formed by uh viral in 2006 where patients had an endometrioma seen on an ultrasound and they were randomized to no surgery simply aspiration of the um endometrioma versus cystectomy. And each group was about 50 patients. Initially, the aspiration group, 63 cycles of I V F. Whereas the ones with cystectomy underwent 100 and 47 cycles I V F. Number of O sites, one outcome parameter looked at and the pregnancy rates, number of sites pretty similar pregnancy rates again, pretty similar. Um surgery for endometrioma does not impair or improve I V F success rate. But I wanna just introduce this concept that there may be a quantitative, not qualitative impact. And by that, I mean. Yes, the pregnancy rate for that initial cycle on embryo transfer, the first embryo transfer doesn't seem to be different. Um for endometriosis patients in general, for those that have had a cystectomy. But maybe those with endometrioma, endometriomas that have been resected or in general, those with endometriosis, they may have fewer embryos frozen what we call super numerary embryos. That may be a consequence that's negative of having endometriosis. However, the initial transfer in pregnancy rates theme here has seemed to be equivalent. There's a systematic review and meta analysis on surgical treatment for endometrioma on I V F outcomes. And again, showing overall no great difference between no treatment or treatment of the endometrioma. And basically, if A RT is going to be done, there's insufficient evidence to favor cystectomy over aspiration, some pros and cons for endometrioma surgery. These are things we think of. I mean, it's not a clear cut endometrioma, removed end, keep it in. We look at a, a number of different factors. Um One advantage to removing endometrium is you get a histological diagnosis. There is a slight increased risk of malignancy in the ovary in women with endometriomas. So instead of the quoted 1% lifetime risk of ovarian cancer with endometriosis, that's believed to be 1.5%. Um and you don't know until they remove the endometrioma. Obviously, um you could have improved a RT monitoring to access the follicles by removing the endometrioma. So, really large endometriomas where you can't get to the other follicles very easily. At the time of a retrieval may be an indication for surgery because we try not to reverse the endometrioma. It has old blood. It's definitely not the greatest environment for an O site and some even change the needle after they go through the endy trauma and so on. So that subsequent aspirations do not have that contamination. So that's something we look for. Reduce the risk of rupture during pregnancy every now and then you'll see a case study that documents a rupture of an endy trauma during pregnancy, disadvantages of surgery, adverse effect on ovarian reserve. And we'll talk about that in a moment, delay in fertility treatment, arranging for surgery recovery, cost of surgery, risk of surgical complications even though they usually low. But with endometriomas, especially bilateral and so-called kissing endometriomas can have a lot of adhesions, scar tissue that can make surgical complications rise. In terms of surgical technique. I want to back away from I V F for a moment. This is just in general uh pregnancy rates not using I V F is one favorite over the other vaporization or coagulation of the lesion of the ey trama or excision in total of the cyst cystectomy. These two studies came out and if you look at the common odd ratio, there was a benefit from excision of the lesion. So, excisional group or endometrium almost greater than four centimeters in diameter reduce the recurrence rate after two years of pelvic pain. And there was a greater rate of spontaneous conception with the number needed to treat of 2.7, which is pretty good for a number needed to treat. Well. What's something to think about when you remove endometriomas or just having an enemy trema? Let's talk about both. So, ovarian reserve impact of an endometrioma, there does seem to be a damaging effect seen via an A MH, which is kind of the marker of ovarian reserve that we use anti malaria hormone. So this is a prospective cohort study published in 2013 and those with no ovarian cyst compared to those with an endometrioma greater than two centimeters, 30 patients in each group looked at baseline A MH no surgery 4.2 and those without a cyst 2.8, significantly lower. Those with a a larger endometrioma, six months post cystectomy that went further south to 1.8 for the A MH Valium. Um So there are other articles that talk about how those with bilateral exist having an either even further decline in the AM age by 63% compared to those with a unilateral. Um Yes, where it was down to 25%. Another study showed a drop of 57% for bilateral cystectomies compared to 39% for unilateral cystectomies. I think you get the theme here. This is one other study perspective, cross sectional study looking at those without endometriosis, 413 an intact endometrioma, 36 patients and those that had a cystectomy, 59 A MH values 4.1 to 3.9 that you again is not good. And those with a cystectomy, it was the lowest. Finally, uh those uh this is study prospective, studied benign cystectomy group compared to an endometrioma that was removed 32 patients and about 70 patients preop A MH 4.8 versus five post. Uh A MH three months later, the benign cystectomy group A MH got lower by 36% compared to 31% for those with an end drama. So surgery on cyst seems to affect an A MH value G N R H or Luli agonist pretreatment. Does this affect a RT outcome? The summary statement says generous pretreatment does not improve a RT outcome for many years. I too practiced based on the data and the summary articles showing that there seemed to be a benefit, but this did not turn out to be true. And this is a summary slide regarding that. So for I V F patients, is it worthwhile pretreating them for several weeks with the gonadotropin releasing hormone agonist? The 2006 Cochrane review of three randomized controlled trials found an increased benefit. 4.3. Um small number of participants in each study, it was a clinical pregnancy rate outcome, not life, birth rate, varied length of G N R H Agnes three months, 5 to 6 months, six months. Um And the only study of these that included whether or not there was endometriomas specified that was the Siri study. Um And I actually at one point tried to delve further into this data. So I tried to email those studies that didn't talk about whether or not there was enemy dramas involved. And in researching, I believe it was this study to try to find an email address. I happened to Google across the fact that this researcher was sanctioned um and couldn't do further research because of falsified data. And so it made me wonder what about this study? Could we really even trust it still? Uh it's still accused as part of these randomized trials. There's evidence that it may be a benefit. But in 2019, the Cochrane review now included some other randomized trials that had um they were better control and they concluded that there was no improved benefit of using the gene H agonist. The three most recent randomized controlled trials did not show even so they concluded at the subsequent review, we are uncertain whether this intervention impacts on the clinical pregnancy rate. And in 2022 Hera, which is the European equivalent of A S R M said that Jah Agnes pretreatment is not recommended, which is a very different conclusion than the initial Cochrane review. Again, preaching to the choir. I know but be careful what we read, you know, you can really find an article to support any opinion of yours, um, or to keep a watch on the literature. What is the consensus view? Um, there's also some worry that with I V F is one's recurrence risk of endometriosis yet worse. The violin study looked at re pain recurrence, uh, at 36 months and by recurrence in their study, this was defined as the need to undergo surgery or hormonal treatment. And 24% was the incidence of that after 36 months, which I don't believe is that much different than in general, those who are not placed on hormonal therapy in terms of pain recurrence over time. This other study by Melia in 2010, looked at the number of cycles of I V F, 123 or four cycles of I V F and disease relapse. So, a proportion of recurrence free women and their general conclusion of this study was that there was no great difference. So it reassuring that undergoing I V F where the astro dial levels are increased by a great degree um that this does not worse than their pain necessarily. So, um this was welcome literature to support doing I V F without a detrimental effect to these patients. So, let's revisit this clinical scenario where we have a 32 year old ali woman who recently read that Marilyn Monroe suffered from severe endometriosis and she's been trying for the past two years to conceive and believe she too suffers from, from endometriosis. She has pelvic pain, heavy menstrual bleeding. Um You know, the classic symptoms of endometriosis. This peria, how would you counsel her regarding fertility specifically options? Well, given all the rage and chat GP T and chat bot, I just took this exact language and popped it into the chat GP T to see if they could help us. So I just wanted to read through what they come up, came up with, which isn't that far from uh what we actually do. So I would counsel her to seek out a fertility specialist to confirm if she does in fact have endometriosis. If she does, the fertility specialist would be able to discuss treatment options to help her concede depending on the severity of her endometriosis treatment could include medication surgery or I V F. Additionally, I would discuss the potential risk associated with each option as well as the potential success rates. I would also suggest that you consider lifestyle changes such as reducing stress levels, improving her diet and exercising regularly as these can help improve her chances of conceiving. Finally, I would suggest that she seek out emotional support from family, friends and other women in similar situations. All good advice. But I think it's really a case by case situation where you're discussing with the patient severity over pain. What is shown on any work up including imaging? Is there evidence of an endometrioma or not. Um So it's a more lengthy and personalized discussion with shared decision making, I believe. And to that extent I wanted to go through this with you. Um to kind of review what would be the um treatment options for someone who presents to our clinic, fertility clinic with presumed endometriosis based on history and no surgical confirmation in the past. I think it's reasonable if they're young enough to try ovulation induction or superovulation, something like Leros or Chlo along with I U I, you do have to add the I U I component to boost their chances. And that would do that for about three cycles. That's not successful. That's a good time to then have a discussion on I V F and potentially move on to do I V F or at that point, do laparoscopic surgery. And if you don't find any endometriosis and resort to I V F, if there is endometriosis and these lesions are removed or bladed, um if they're young following surgery, one can certainly, they just try naturally for the next few months. If that's then unsuccessful, move on to Superb I V F. If they're 35 or older, you know, time may be of the essence and after surgery confirming endometriosis, I'd probably move on to superovulation, do a few courses of that. And then I, yeah, um you know, there are certain things that may fast track someone to do I V F, for example, if there's a lower A mh um that may be an indication in terms of trying to bank embryos at their current age, at least because we never truly know the trajectory of an A mh, how soon will it get even lower? Um Also, if there's some male factor involved, clearly I V F could be of help. So this is at least one scheme. I'm happy to talk through this if anyone has questions as well. Thank you, Doctor Levick. I had a question about just how the field of R E I has changed. So remarkably, I mean, the R E I used to be the laparoscopic surgeons of um O B G Y N. And now uh it's entirely, you know, completely changed to medical care. And um and I V F and, and there's just, you know, in the context of endometriosis, do, do we still really go to R E I for endometriosis or who, where do those patients go to go to M I S? But they're the surgeons. So who provides the medical therapy for patients diagnosed with endometriosis? Yeah. No, I appreciate your thoughts on Doctor Taylor and uh your question in general. You're very right. And perhaps this applies to many other fields. It's just I'm focused on R E I as is your question. And from the days of my fellowship in the mid nineties there in San Francisco where I worked with some prominent surgeons like Doctor Adamson who became president of a S R M at one point, major, major surgeon in our field. And I never thought that that would not be something that I'd be doing on a weekly basis. But it is not something that I'm doing or care to do anymore. And it's really tough surgery. And as I've heard from others too, sometimes, even harder than regular oncology surgery because of the scar tissue. Um, and yet I think R E I kind of led the way in that surgery for many, many years. But then I think it kind of ran into to use this analogy of the false of the earthquake because of the tragedy in Turkey that all heavy heavily on our mind. But with the impact of I V F and its growing acceptance where we did more I V F instead of surgery. And so our hands got a little, you know, in terms of going to the O R. And so our attention was a bit diverted having said that there are still many R E I s that do a lot of surgery, but it's dwindling. I think you're very right on that front. And there's great debates in our literature, pros and cons on how much we should be doing these days. And should we be really giving it up as another kind of corollary to endometriosis of with the topic of surgery in mind? I remember doing the first surgery of tubal reversal at U CS F. Um, because they hadn't done it in several years, it was done at an outside place. But tubal reversal surgery was kind of painstaking as a resident to watch and, you know, squirting the water, getting it in the right area and all. And these days, we don't even do it, we don't even offer it here. And subsequently, like when I was in Michigan, I went to Montreal to learn how to do laparoscopic tubal reversals. And so instead of putting multiple sutures to put the tubes together, they put one suture all the way through the tube. It seemed crazy. It broke the dogma, but their outcomes were wonderful. So it made surgery easier even though technically, it was hard to do straight stick laparoscopy tubal reversals, but then came along the robot. And so people are doing that these days to some degree. But even that is really for the most part, supplanted by saying, go ahead and do I V F. We're getting back to your question. We are grateful here that we have a superb mix division. Love these people. They are fantastic. Uh And I've been around with um visiting some other clinics given that I'm new here. And along with some of these uh meg attending and they are wonderful. So personally, I don't hesitate to send along patients surgeries for endometriosis. I do give that up. But medical management uh management for their fertility. Well, within my Bailey Bailey wi these days. And so I do address that. Yeah, Dr Middleton mentions his incidence of spontaneous pregnancy the same with and without excision. Um So I think if they're concentrating on surgery or no excision or, or no surgery, I don't think the I'm not certain if the question is ablation versus excision, which is also in great debate. Let me just summarize and tackle a spontaneous pregnancy the same with or without excision surgery. I'm gonna say surgery instead of excision. And that's those slides that I went over the Canadian study, the Italian. I believe there's a slightly higher rate with surgery but not enough to offer that if simply fertility is in order spontaneous or not. Ok. If you're asking if the patient's going to surgery, should you exercise versus a bla regarding fertility? Um So far, I think the literature would suggest that pain wise there may be a benefit to excision and I would go along with that for fertility as well. If you're trying to say you want that small benefit from surgery on fertility, if I'm understanding your questions correctly. OK. I would mention that like the Canadian study doctor uh ma who passed away. But that first study that came out those patients postoperatively did they undergo fertility treatment on or not? I don't remember the exact percentage but many of them did, but they were simply saying whether they do fertility treatment or not or they benefited from the surgery. So that didn't directly dissect Agger. Um Doctor S my colleague mentioned, how do we recoil patients on how pregnancy affects the long term outcome of endometriosis? If at all, so many folks come to our clinic patients thinking and they've heard or something they read on the web that if they get pregnant, their endometriosis will be improved and that somehow a pregnancy is a treatment for the endometriosis. Not really true. Postpartum. their endometriosis will have an impact on your day to day, will have pain and impact on their fertility. Once again, what is true? And what I think has led to this misperception is that during pregnancy, they do feel better. It's a high progesterone state which has a hormonally dependent disorder. Progesterone is beneficial to treating the pain. And so they do find during pregnancy, but afterwards, it is not the cure for pregnancy long term. Um There are many case reports or I should say just several the rupture of an enemy trauma during pregnancy. Um Also a lot of emerging literature, that's a pretty good consensus now that there is greater risk of pregnancy complications for women with endometriosis. It's not something that's gotten a lot of attention, but some high quality studies have come out and the exact complications for pregnancy are like preterm labor, greater risk of bleeding uh during pregnancy because of having endometriosis. Um preterm delivery being the most common though. So keep an eye out for that Doctor Bar Towell from says, are there studies looking at long term at A MH values after an endometrium or how long after the procedure are the values being tested? Yeah, great question. Each study has a different long term follow up on the A MH without looking directly at specific articles and pulling those out for you. My overall viewpoint on that having, you know, read these articles is that A H, takes a severe drop, a significant drop statistically after an endometrium surgery and then it can crawl back up, but I don't think it ever approaches what it was. So at the end of the day, it's still compromised, but not as bad as if you check it a month afterwards where it's at its worst. Ok. I hope that answers that one. Uh, Dickinson says, how you counsel patients about the recurrence after surgical management, um, to piggyback on Doctor Capelli, I would have doctor part of and her group. I answer that better. But in my viewpoint, having followed the literature and all it's all too common even after surgery. And that's my hesitation for patients going to surgery, although I'm certainly gonna send them if they have pain so that they can get the benefit of in a way removing as much disease as possible. And then importantly, follow up with hormonal therapy because I think there in lies the difference in terms of recurrence of their pain, their pelvic pain, um, after surgery that is, do they have any follow up hormonal suppression? I think it's essential as doctor um Jacques Dune mentioned in that short video that they be placed on something these days, the easiest is not trying to conceive would be a marina I U D or some such for Justin concluding I U D to try to keep their benefits from surgery rolling on forward. Um That was the question. Yeah. If they're not on hormonal therapy, the recurrence of the pain is quite common and I think is on the order of 20% or so after 23 years. And that's why we have often seen patients that come back for repeated surgeries if they're not on hormonal suppressive therapy. Thank you for the good questions.