I had a laparoscopy six weeks ago. The surgeon detected level 3 endometriosis and was able to laser it off, at least topically. If I don't conceive in the next three or four months, my OB-GYN is suggesting therapy with Lupron for six months. At age 35, and with no children, I am concerned about the side effects of Lupron therapy, as well as the time involved. I understand why Lupron therapy would be recommended, but I don't understand why IUI or IVF wouldn't be possible until after Lupron therapy. Would you please explain? With a mild endometriotic condition, why is Lupron so important?

Lynn

"Lasering off endometriosis" is inappropriate treatment. Endometriosis should be excised (cut out). Physicians who lack the skill to excise deep endometriosis that involves such organs as the ureters or is located in the space between the vagina and the rectum should refer these patients to more experienced surgeons.

Staging endometriosis is of little or no value. For those women whose endometriosis is associated with pain, the symptoms can be just as debilitating for those with "minimal" or "mild" stages as for those with more advanced stages. When it comes to infertility, minimal or mild endometriosis is just not a factor. Repeatedly, well-designed epidemiologic studies have shown that while minimal or mild endometriosis may be seen with an increased frequency in women with infertility, there is no credible data suggesting that the presence of minimal or mild endometriosis itself causes infertility. Endometriosis causes infertility when it is severe enough to cause scarring or adhesions; these complications can damage organs or otherwise interfere with their function.

Only one well-designed comparative study, done in Canada, demonstrates that treating minimal endometriosis offers any fertility benefit. And there are problems with this Canadian study, as the members of the non-treated group were far less likely to conceive than any untreated group in any other study. In fact, although the surgically treated group did better than the untreated group in this study, the treated group still did no better than the untreated groups from other studies.

In general, I've adopted the following policy: I will surgically excise all evident endometriosis due to its likelihood of getting worse, but I do not believe that such treatment improves fertility. However, treating scarring and adhesions caused by endometriosis can definitely improve chances for fertility.

What about drug treatment? The data here are even stronger. The use of a GnRH-agonist such as Lupron can help endometriosis pain, but these drugs offer absolutely no fertility-promoting benefit (unless combined with an ovulation regimen for intrauterine insemination or in vitro fertilization IVF). In any case, when the treatment ends, the benefit ends too, so a six-month course of these drugs merely postpones pain recurrence for six months. GnRH-agonists can be combined with a daily low dose of estrogen and progesterone to safely treat pain symptoms for periods longer than six months, so most physicians usually prescribe this treatment for endometriosis pain.

If a woman's ovaries are freely mobile (not stuck down) and her fallopian tubes are normal, endometriosis should not be considered a factor in her infertility. These women should be treated as any other women with unexplained infertility. This usually means using either clomiphene or injectable ovulation medications and intrauterine insemination (IUI). In vitro fertilization (IVF) should be considered for those women whose internal organs have suffered significant damage due to endometriosis.

I do not believe the plan as you have outlined above is supported by the best available medical evidence. You may wish to seek consultation for a second opinion by a fellowship-trained reproductive endocrinologist. Please educate yourself and make sure you are afforded the opportunity to participate in the decision-making process.