In the era of assisted reproductive technology (ART), there are two reasons for the treatment of endometriosis. The first is to alleviate symptoms of pain. The second is in preparation for In Vitro Fertilization (IVF). Conventional surgical treatment of ovarian endometriosis involves either an abdominal incision or laparoscopic drainage of the cyst contents with subsequent removal of the cyst wall. Unfortunately, in many cases, normal ovarian tissue is inadvertently removed along with the cyst wall, which may decrease the number of available oocytes for subsequent fertility treatment. A large percentage of such women have advanced stage disease and have had multiple previous surgeries.
In the presence of pelvic adhesions, visualization of anatomic structures may be inadequate, leading to inadequate surgical removal with frequent cyst recurrence, which could further diminish the potential response to ovarian stimulation with gonadotropins. In addition, most women with advanced endometriosis (i.e. those who are also more likely to have endometriomas) are likely to have developed pelvic adhesions and accordingly are at increased risk of surgical complications. Many patients with recurrent ovarian endometriomas are uncomfortable with the prospect of repeat surgery and its avoidance is often a factor in the decision to proceed with IVF. There have been several reports on the use of sclerotherapy in the treatment of recurrent ovarian endometriomas. We had the experience in using sclerotherapy in many women with endometriomas, who are preparing for treatment with IVF.
Sclerotherapy for ovarian endometriomas involves needle aspiration of the liquid content of the endometriotic cyst, followed by the injection of 4-5% tetracycline into the cyst cavity. Treatment results in disappearance of the lesion within 6-8 weeks, in more than 75% of cases. Ovarian sclerotherapy can be performed under local, regional or general anesthesia. It has the advantage of being an ambulatory and office- based procedure, at low cost, with a low incidence of significant post-procedural pain or complications and the avoidance of the need for laparoscopy or laparotomy.
Sclerotherapy is an effective alternative to surgery for the treatment of recurrent ovarian endometriomas in a select group of patients planning to undergo IVF. Since the procedure is associated with a small, but yet realistic possibility of adhesion formation; it should only be used in cases where IVF is the only treatment available to the patient. Women who intend to try and conceive through fertilization in their fallopian tubes (e.g. following natural conception or intrauterine insemination) will be better off undergoing laparotomy or laparoscopy for the treatment of endometriomas. Dr. Bayrak recommends a detailed discussion and risk assessment before determining which option would be better for each individual case with advanced endometriosis.