Dr Eric Daiter has served Monmouth and Middlesex Counties of New Jersey as an infertility expert for the past 20 years. Dr. Daiter is happy to offer second opinions (at the office or over the telephone) or new patient appointments. It is easy, just call us at 908 226 0250 to set up an appointment (leave a message with your name and number if we are unable to get to the phone and someone will call you back).
"I always try to be available for my patients since I do understand the pain and frustration associated with fertility problems or endometriosis."
"I understand that the economy is very tough and insurance companies do not cover a lot of the services that might help you. I always try to minimize your out of pocket cost while encouraging the most successful and effective treatments available."
Endometriosis and Infertility: treatment
The treatment of endometriosis for improvement of fertility is
controversial. Well controlled good quality studies have not
demonstrated an improvement in fertility following any of the
medical (drug) management protocols. Therefore, I usually restrict
my use of medical management for endometriosis to the treatment
of endometriosis associated pain. Surgical treatment for endometriosis
has been shown to improve fertility in advanced stages of endometriosis.
Modern surgical techniques such as those using ultrapulse lasers
are just now being shown to be of value in the treatment of less
extensive stages of endometriosis.
The surgical approach to a patient with endometriosis currently
leans strongly toward "minimally invasive procedures."
In the hands of an experienced laparoscopic surgeon, virtually
any endometriosis associated problem that can be treated by laparotomy
can now be dealt with via laparoscopy. The performance of more
conservative procedures primarily via the laparoscope has benefited
women in many ways. The difference in the approach includes:
opening the abdomen to perform the surgery directly through
a large open incision
cosmetically considered "disfiguring" to many younger
requires a stay (usually several days) in the hospital
postoperative recovery may be several weeks with significant
time out from work
minimally invasive same day surgical approach
a telescope is entered through an incision about 1 cm long
near the umbilicus and one to three smaller incisions are also
usually made in the lower abdomen for the entry of additional
postoperative recovery usually only a few days with little
time out from work.
There are several surgical tools designed to remove (ablate) tissue,
each with their own set of operating characteristics. The surgical
tools that remove, destroy or incise tissue include
(1) scalpels and scissors,
a variety of blade sizes and shapes as well as scissor sizes
and shapes are available.
the knife is ideal for cutting the skin, with research documenting
greater tensile strength and faster healing in skin cut with a
knife as compared to the carbon dioxide laser, harmonic scalpel
or electrosurgical devices.
scissors are ideal instruments for dissection of tissue and
can also be used effectively to cut tissues ranging from tough
to filmy. These instruments can be used to remove tissue on which
endometriosis has grown. Excised tissue will include some normal
tissue and any bleeding created needs to be controlled. This has
limited the use of these instruments in the routine treatment
(2) electrosurgical devices,
these can be adjusted to provide different amounts of power
(20 to 80 watts is usually used) with different blends of cutting
a wide range of effects is possible. Pure cutting current
has little char (which acts to coagulate). Fulgaration produces
a superficial layer of char by holding the electrode a small distance
from the tissue and allowing the current to spark. Lateral thermal
damage with these instruments due to heating of surrounding tissue
limits their use in the ablation of endometriosis, especially
when close to other vital structures.
(3) thermocoagulation devices,
these differ from electrocoagulation devices in that they
do not deliver high frequency electrical current to generate heat
in the tissues.
these devices deliver heat directly via a hot metal tip that
is applied to tissue.
these devices are adjusted to deliver heat at up to 160 degrees
centigrade, and tissue generally turns white when desiccation
of course it is necessary to avoid inadvertently touching
tissues other than those desired while using this tool and during
its cool down period.
this is an ideal coagulating device but extensive lateral
thermal damage has limited its use in the treatment of endometriotic
lesions that are close to other vital structures.
these devices can deliver fine beams of intense energy to
tissue with the power density (watts per square centimeter) at
the tissue site determining the effect (vaporization, excision,
there are different laser systems. These include fiber delivery
via KTP-532 or Nd:YAG lasers where the energy released from the
tip of the fiber diverges to dissipate the energy (highest closest
to the tip of the laser fiber). The carbon dioxide (CO2) laser
focuses the laser energy with a series of mirrors into differing
size spots that help to determine the power density at the tissue.
the CO2 lasers can deliver power in different wave forms that
determine the power density achieved and amount of lateral thermal
damage. The most common laser in use for most fertility work during
laparoscopy is the CO2 laser and the optimal wave form for fertility
work is the ultrapulse wave.
(5) the harmonic scalpel, and
this is a device that incorporates a tip that vibrates at
an ultrasonic frequency to rapidly denature proteins and separate
tissue with little generated heat.
conceptually, this is a great tool for ablation of endometriosis
and lysis of adhesions.
experience with the harmonic scalpel has not yet led to widespread
acceptance of this tool. Additionally, the results seen on second
look laparoscopy several weeks following its use have had mixed
(6) the cavitron ultrasonic surgical aspirator (CUSA),
this is widely used for tumor debulking by gynecologic oncologists.
It has a vibrating tip that reacts to an alternating electromagnetic
field (alternates 23,000 times per second) and produces significant
heat such that cooling is provided by saline liquid solution sprayed
over the tip at a rate of 3-10 ml per minute. This is not commonly
used for treatment of endometriosis.
The decision on whether to proceed with endometriosis surgery
includes the following considerations:
* reportedly there is a good cumulative long term pregnancy
rate with untreated stage I and stage II endometriosis, up to
90% in 5 years (compared to a normal fertility rate of 90% in
* in patients with endometriosis, COH (controlled ovarian
hyperstimulation) and IUIs (intrauterine inseminations) appear
to improve the fecundity (rate of pregnancy per cycle) but does
not clearly improve the overall cumulative pregnancy rates (which
are high if viewed over 5 years).
* endometriosis that causes mechanical interference
preventing or limiting the egg and sperm from meeting can be effectively
treated surgically. Medical management of endometriosis does not
effectively treat anatomic distortions and adhesions;
* when endometriosis must be removed from the ovary,
even when deeply invading or causing nonfunctional cysts (called
endometriomas), a goal should be to preserve as much ovary as
possible since as little as 10% of one ovary may allow fertility
* hormonal (medical) management of endometriosis has
no proven value in terms of fertility yet can effectively treat
some patients with pain due to endometriosis
* endometriosis tends to recur (return) since the cause
(such as retrograde menstruation, vascular or lymphatic dissemination
or metaplasia of the coelomic epithelium) of the endometriosis
can not be treated. The recurrence rate of endometriosis is unpredictable,
but is generally reported in the range of 5-20% per year with
a cumulative rate over 5 years of about 40%.
* progressive severe dysmenorrhea (pain during the
menses) is typically associated with deep lesions of endometriosis
that are often not adequately treated with medication alone
* many patients with infertility and endometriosis
have absolutely no dysmenorrhea (possibly due to a reduction in
nerve endings that register painful stimuli in the peritoneum
of the pelvis), incorrectly feel that the lack of pelvic discomfort
means that they do not have significant endometriosis, and continue
with their fertility efforts without treatment
* a couple that has not achieved a pregnancy after
2 years of appropriate management following surgical treatment
for endometriosis has a poor prognosis in term of fertility
* the most effective long term treatment of endometriosis
is removal of the uterus and the ovaries, an undesirable (or unacceptable)
option for women interested in reproduction.
* if a patient has decided to undergo radical endometriosis
surgery (removal of the uterus and some ovarian tissue) and is
younger than 40-45 years of age, leaving an "uninvolved ovary"
in place appears to increase the risk for recurrence of endometriosis
only slightly. The remaining ovary would then be able to supply
the patient with hormones that are beneficial to her until menopause.
* atypical endometriosis has a varied appearance that
takes experience to recognize, may be quite active in response
to the sex steroid hormones, and should be removed if the decision
to treat stage I or II endometriosis surgically has been made.
In fact, there is a high rate of endometriosis identified on pathology
report in biopsies of normal appearing peritoneum both in women
with endometriosis documented elsewhere (up to 40%) and in infertile
women without any visible endometriosis (up to 15%).
* when endometriosis is incidentally found in a young
woman who is not immediately interested in fertility, placement
on birth control pills may be considered if early stage disease
(to reduce the progression of the disease) or ovulation suppressing
medications if more advanced disease (to reduce the bulk of disease).