For women who are diagnosed with endometriosis, and who hope to become a mother, the addition of an infertility diagnosis can be doubly devastating. Adding to that stress, choosing next steps to motherhood can be overwhelming. So, where does one begin? "Traditional OB-GYNs can examine if [patients are] ovulatory or not," explains Dr. Karli Goldstein, an endometriosis excision specialist at Seckin Endometriosis Center. "They can do hormone testing on day two or three of their cycle, and the baseline fertility work up." An OB-GYN may also perform a hysterosalpingogram (HSG), or a test to visualize any possible abnormalities in the uterine cavity or blockages in the fallopian tubes. Goldstein knows the process all too well. She has suffered through an infertility diagnosis stemming from Stage IV Endometriosis, and says she has explored every avenue to motherhood possible. She suggests endo women can choose to, instead, go straight to a Reproductive Endocrinologist (REI) who is knowledgeable about endo. "You want to see someone that takes it seriously and is not doing IVF multiple times," says Goldstein. In some cases, she recommends an endometriosis excision surgery to increase odds of conception before a patient plunges into the world of ART (Assisted Reproductive Technologies) like IUI, IVF and egg donation.
Intrauterine Insemination (IUI)
Think of IUI as the “entry door into the fertility world,” says Goldstein. The process involves insemination where sperm is cleaned, washed, and injected into the uterus. “This requires functional fallopian tubes," that "pick up the egg and transport them to the uterus," as well as good ovulation and functioning ovaries. But Goldstein warns that IUI may be difficult for endo women because inflammation can compromise fallopian tube function.
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In Vitro Fertilization (IVF)
Goldstein says endo women have better odds of conceiving with IVF. “IVF is where the egg is actually aspirated from the ovary. You're given [hormonal] stimulation. Some places do a natural IVF where only one egg is removed [during] ovulation time, and then this is fertilized in a dish either with your partner’s sperm or a donor sperm," before it is implanted back in the uterus. There's “fresh” IVF, where egg retrieval and embryo implantation take place in the same cycle. And Intracytoplasmic Sperm Injection (ICSI): "Instead of putting a whole bunch of sperm in a dish," Goldstein explains, "they select one very good-looking sperm and then they'll implant it directly.” Goldstein recommends endo women ask for a lower estrogen dose protocol during hormonal stimulation. “Some fertility specialists will use a drug called Femara (Letrozole) to keep the estrogen level low. This can help with the endometriosis pain or redevelopment." Still, the process can be an emotional rollercoaster. "With IVF you could pay thousands and thousands, and there's still no baby there." Which leads many women to the next step.
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Goldstein recommends this route for women who have experienced IVF failure, destroyed ovarian tissue after ovarian surgery, or low ovarian quality. “Endo patients are often very strong and deal with a lot, but sometimes you have to know when you've put your body through enough, and you can say, I'm not going to do it anymore." Whether donor eggs are fresh or frozen, endo women still have options. “If your uterus is okay," she adds, “you could still put that donor egg in your uterus with whatever sperm you choose, and you can still carry the pregnancy. The baby has your blood—and it's your baby.”
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Endometriosis can mean a rocky road of pregnancy complications. “I think that the risk factors for preterm delivery and high-risk pregnancy are such that patients with endometriosis may need a surrogate and there's nothing wrong with that." Surrogates, "hold a baby like a kangaroo for you, for nine months, and deliver. It's your baby, and it's a phenomenal experience, and you're probably bonded with that person for life. It could be a beautiful story, too.”
It's a common, and often aggravating, question asked of endo women. Why don't you just adopt? While adoption is a wonderful and viable option, Dr. Goldstein says it’s not as easy as it seems. “To get your name on the books, to an adoption list, is about $10,000 to $15,000.” That's just the first step. Prospective adoptive parents must also meet with a social worker and attorneys. Whether you go through the foster care system or adoption agency, you could wait years for a baby. “[People] have no idea that it's actually even more difficult and expensive than going through an IVF round.”