Clinical Takeaways

• The Dilemma: Surgery (laparoscopy) is often necessary for pain relief, but removing cysts from the ovaries can permanently lower your ovarian reserve or inventory of eggs.
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• The Gold Standard: Medical consensus increasingly recommends freezing eggs before undergoing excision surgery to protect your fertility potential (Cobo et al. 2020, Santulli et al. 2021).
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• The Risk: Research shows Ovarian Reserve  can drop by up to 50% following the removal of endometriomas (chocolate cysts) (Younis et al. 2022).
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• The Protocol: We use specialized and personalized "low-estrogen" stimulation protocols to safely retrieve eggs without "flaring" your endometriosis symptoms.

Endometriosis and Egg Freezing

Endometriosis is perhaps the most paradoxical condition in reproductive health. It is a disease defined by pain, yet often dismissed for years. It is a condition where the treatment for the symptoms (surgery) can sometimes threaten the fertility.

If you are one of the 1 in 10 individuals navigating this diagnosis, you are likely facing a difficult decision: Do I treat the pain now (surgery), or protect my future family (egg freezing)?

As a reproductive endocrinologist, my goal is to always make sure that the treatment of endometriosis results navigates you toward your reproductive goals.

The Biology: How Endometriosis Affects Fertility

Endometriosis is an inflammatory condition where tissue from the endometrium (the tissue uterine lining) grows outside the uterus. Most commonly it grows near the uterus, but can also do so on the ovaries, bladder, bowel and even as far away as the lungs and brain.  Endometriosis impacts fertility in three distinct ways:

1. Anatomy (The Structure): Scar tissue (adhesions) can distort the pelvic anatomy, blocking fallopian tubes and preventing the egg and sperm from meeting.
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2. Inflammation (The Environment): Endometriosis creates a "toxic" inflammatory environment in the pelvis. High levels of chemicals made during inflammation, called cytokines, as well as growth factors found in the follicular fluid of people with endometriosis, can hurt egg quality and sperm transport (Bonavina and Taylor, 2022).
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3. Ovarian Reserve (The Quantity): This is critical. When endometriosis grows inside the ovary, it forms cysts called endometriomas (or "chocolate cysts"). These cysts take up space, compressing healthy ovarian tissue.

The Surgical Double-Edged Sword

When you have a painful cyst, the instinct is to cut it out. However, ovarian surgery is traumatic to the ovary.

Even in the hands of the most skilled surgeon, peeling away an endometrioma cyst wall inevitably removes some healthy follicles attached to it. Additionally, the heat (cautery) used to stop bleeding can damage the remaining eggs.

The Data: Clinical studies consistently show that ovarian reserve or quantity of oocytes significantly declines after cystectomy (cyst removal).

The Risk: If you enter surgery with a low reserve, you risk waking up with a severely diminished reserve.

The Ovom Strategy: Freeze First, Operate Second

Due to the of the risk to ovarian reserve and reduced response to treatment and the conflicting data, it is safest for most patients to prioritize egg freezing and/or IVF before excision surgery.

This approach acts as an insurance policy:

1. Higher Yield: We retrieve eggs while your ovarian reserve is at its current baseline, before any surgical reduction.
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2. Biological Autonomy: Once your eggs are frozen, you can proceed with surgery to treat your pain or remove deep infiltrating lesions without the fear that you are sacrificing your fertility.
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3. Better Recovery: You can focus on surgical recovery without the immediate pressure to conceive.

Addressing the Fear: "Will Hormones Feed the Endometriosis?"

A common fear is that the hormones used for egg freezing will cause the endometriosis to grow or flare up the pain.

This is a valid concern, but manageable with Precision Protocols.

At Ovom, we do not treat endometriosis patients with standard IVF protocols. We use tailored approaches, often incorporating a medication that cause the endometriosis lesions to become quiet or inactive called gonadatropin-releasing agonists (GnRH a) and letrozole.

• How it works:  Suppression of the implants with 3-6 months og GnRHa and then employing letrozole keeps your circulating estrogen levels low while still allowing follicles to grow.
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• The Result: We can retrieve eggs effectively while minimizing the inflammatory flare-up.

When Surgery Must Come First

Medicine is rarely black and white. There are scenarios where we must often operate before freezing/IVF:

• Inaccessibility: If the ovaries are so encased in scar tissue that we physically cannot reach them with the retrieval needle.
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• Malignancy Risk: If the cyst looks suspicious or atypical on ultrasound, we must remove it to rule out cancer.
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• Acute Emergency: If a cyst has ruptured.

In these cases, we perform the surgery with "Fertility Preservation Intent," using delicate techniques to spare as much tissue as possible.

FAQ: Endometriosis & Egg Freezing

Does Endometriosis affect egg quality or just quantity?

Unfortunately, it can affect both. This is why freezing younger (when quality is naturally higher) is even more important for endometriosis patients than the general population.

Can you retrieve eggs if I have a cyst?

Yes. We carefully navigate the needle around the endometrioma to access the healthy follicles. We generally avoid puncturing the cyst itself to prevent infection or leakage of the cyst fluid. If it does occur you may have a longer course of antibiotics to prevent infection.

Is this covered by insurance?

This is a battleground. As discussed in our article on Social Freezing vs. Medical Freezing, many insurers consider egg freezing "elective" even for endometriosis patients. However, if you are facing surgery that compromised your fertility, we can often provide documentation to advocate for coverage under medical preservation clauses.

The Next Step

If you have an endometriosis diagnosis or are scheduled for a laparoscopy, please hit pause. Come see us for an assessment. We can check your ovarian reserve levels, map your anatomy with AI-enhanced ultrasound, and build a strategy that treats you, not just the disease.

Protect your future before your surgery. Book a Specialist Consultation.

Footnotes:

1. Cobo A, Giles J, Paolelli S, Pellicer A, Remohí J, García-Velasco JA. Oocyte vitrification for fertility preservation in women with endometriosis: an observational study. Fertil Steril (2020) 113:836–44. doi: 10.1016/j.fertnstert.2019.11.017

2. Santulli P, Bourdon M, Koutchinsky S, Maignien C, Marcellin L, Maitrot-Mantelet L, et al. Fertility preservation for patients affected by endometriosis should ideally be carried out before surgery. Reprod BioMed Online (2021) 43:853–63. doi: 10.1016/j.rbmo.2021.08.023

3. Younis JS, Shapso N, Izhaki I. Is ovarian reserve reduction following endometriotic cystectomy predicted? The implication for fertility preservation counseling. Front Endocrinol (Lausanne). 2022 Sep 21;13:996531. doi: 10.3389/fendo.2022.996531. PMID: 36213292; PMCID: PMC9532518.

4. Bonavina G, Taylor HS. Endometriosis-associated infertility: From pathophysiology to tailored treatment. Front Endocrinol (Lausanne). 2022 Oct 26;13:1020827. doi: 10.3389/fendo.2022.1020827. PMID: 36387918; PMCID: PMC9643365.

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