Endometriosis: Often Fixable, Sometimes Not
There are two main complaints associated with endometriosis—pain and infertility, and these frequently emerge together. Medical treatment for endometriosis may be worth a try, but the definitive treatment is removing it, in hopes of ending it. Unfortunately, even surgery with the best intentions fails to actually end it, suggesting the need for subsequent surgery or surgeries; and frankly, sometimes even a series of surgeries fails to eliminate the pain or regain for a woman her fertility. There are some women who have become so fretful over repeated surgeries as to give up the fight rather than physically and psychologically deal with even one more that holds no better promise than the previous one(s).
Clouds in the crystal ball.
No one has a crystal ball, especially surgeons. All they can do is cite their own success statistics and what might be expected as a result for you, specifically. This means outcomes are always based on a case-by-case basis. What clouds the crystal ball is that no two cases of endometriosis are exactly alike, because what’s left in a woman’s pelvis is the outcome of a fight between two types of tissue: tissue meant to be there and tissue not meant to be there. The success or failure to eliminate endometriosis and restore fertility rests on the skill of the surgeon, the technology used to safeguard innocent tissue, and the invasiveness of the disease itself.
Endometriosis is an invasion.
The problem with endometriosis is that it is a functioning type of tissue with its own physiology.
Glandular tissue—similar to the lining of your womb (uterus) where it is designed to thrive and then gracefully exit—instead is trapped in places without exits, such as your pelvis and abdomen. Besides its inability to leave, its composition maintains a brisk pace of its own function. This pits its own survival against the survival of the tissues it invades. Your immune system jumps into the fight, provoking severe inflammatory changes that upset the biochemistry of the area as well as promotes migration of tissues to wall off this inflammation. This results is pain and organs stuck to each other—the two main problems with endometriosis, both of which interfere with the normal processes of your fertility.
It’s a tough fight.
To say that endometriosis is a tough opponent is an understatement. It is not life-threatening, except to the life you intend to bring forth through pregnancy. That’s what makes it as much an emergency as an illness that does threaten you. Your tissues and organs are designed in such a way as to function without being crowded, inflamed, or immobilized. Endometriosis does all of these things. The other thing that makes it somewhat of an emergency is that the longer you wait, the more that distortion to your organs and impairment of your fertility can occur.
How hard can it be?
One incorrect conception is one that raises a trick question: if there is tissue in the pelvis causing problems, just how hard can it be simply to remove it and make everything normal again? The answer: very hard. This isn’t just an appendix that’s misbehaving or a gallstone.
It is more than just a matter of picking up the endometriosis and whisking it away. Endometriosis really is an invasion, its glandular cells digging into the tissue upon which it has landed, proliferating and increasing the entire pathological suite of responses. This phenomenon can make removing it while sparing normal tissue—tissue you want to keep—difficult. Even when accomplished, however, there are residual areas of scarring. No tampering with your pristine tissue goes unpunished. The residual areas of inflammation may invoke their own inflammatory changes, distorting the anatomy, too. What may appear like a clean excision of all endometriosis may end up a scarred and gridlocked pelvis which can prevent fertility as much as the endometriosis did. Additionally, sometimes the endometriosis cannot be removed without leaving causing some damage to your tissue, breaching the integrity of its layers or the efficiency of its function.
When should you give up?
Statistically, the literature claims that the best chances for a return to fertility are after the first surgical attempt to treat endometriosis. After that first surgery, the pregnancy rates decline. This brings up two very important considerations:
1. Your very best opportunity to eradicate endometriosis and regain fertility is after the very first surgery. With a second and more surgical attempts, there begins a cruel rate of diminishing returns.
2. Assisted reproductive techniques, such as in vitro fertilization, may present as your best hope of not only getting pregnant, but also for not wasting crucial reproductive age time in fruitless attempts to pursue the “natural” conception.
Pain complicates the picture.
If fertility is not the goal but, instead, the relief of pain due to endometriosis, repeat surgeries are indeed justified, especially if residual disease interferes with the normal functioning of your bowels, rectum, urinary tract, or bladder. Anatomical dysfunction requires anatomic restoration. There is no such thing as “in vitro” organ repair: conception can occur outside of your body, but organ repair cannot. Therefore, you are likely to continue with problems if you hope to wait out your illness.
Ironically, there are few women with endometriosis who are concerned about only the pain. Few women have endometriosis and its painful complications after the successful completion of their families. Most women are afflicted before any babies are born at all, making a pursuit of fertility and pain relief the same. Even if a woman were adamant to remain childless by choice, it would not set right with her to forego her options for the future in case she changed her mind.
So now what?
Of the two points listed above, the first surgery being your best chance for successful treatment prompts a third important consideration:
3. If you are to put the lion’s share of your faith and optimism into the first surgery for your endometriosis, you are best served by choosing a doctor with the most experience with severe endometriosis, the most state-of-the-art technology (such as robotic excision and minimally invasive surgery), and the finest surgical skills to perform it.
This narrows the field of prospective specialists considerably, but narrowing it down to the perfect surgeon for you only requires you ask about these things. And if only the pain indicates a need for more surgery, the same criteria are just as important, because the outcomes are traditionally less each time, as well.
Yes, sometimes surgery for endometriosis fails. Sometimes the deck is stacked against the doctor and patient. But having a family is important, and you owe it to this pinnacle of societal evolution to take your best shot. It has too much implication for the generations to come.
