Infertility and Endometriosis



All women are born with all of the eggs they will ever ovulate. That means that if your daughter or son is 8 years old and you had her or him at age 22, the product of that egg and fertilization, technically, is 30 years old, not really 8.

Women are born with 1-2 million eggs within their ovaries. Prior to puberty, this number dwindles as many are lost from a process called “atresia.” At puberty, there will be a few hundred thousand left, but a thousand still die each month through atresia, while only one is lucky enough to ovulate. (Each one of us was 1-in-a-million at the time of our mother’s birth, and 1-in-a-thousand at conception—not to mention 1-in-60-million times that 1-in-a-thousand if you’re considering the sperm lottery. Yes, that’s a 1-in-60 billion throw of the dice!)

The numbers deplete each month, and out of the 1-2 million eggs each woman was born with, she will only end up ovulating about 500 of them over her lifetime. At menopause, all of the eggs are depleted.

Back in the olden days…

This, of course, is a completely new thing for our species—we were never meant to last past age 40 or so, and with life expectancy now well over 80, many women are spending half their lives without eggs. Then again, other age-related things are new to us—Type 2 diabetes, breast cancer, atherosclerosis, heart disease, erectile dysfunction, and countless other things not typically encountered before the age of 40. Eons ago, all we had to worry about—and the things that probably did us in by 40—were wild animals, infections, trauma and accidents, and hostile acts. But most of the women who died still had eggs. The point of all of this is that your fertility declines with age.

Primary infertility is infertility in women who have never conceived:

  • Age 15-34 have a 7-9% infertility rate.
  • Age 35-39 have a 25% infertility rate.
  • Age 40 + have a 30-50% infertility rate.

This age-related infertility is part of a complex set of interactions in women conspiring to bring down the menstrual cycle and, with it, ovulation. But it also probably has to do with the fact that those eggs have become 15-34 years old, 35-39 years old, or over 40.

Lack of rhythm. 

The menstrual cycle, well…cycles. That is, it is a complicated set of tumblers in a lock that all fall together to release an egg each month. If any of those conditions goes awry, the whole cycle can fail. Things that upset the rhythm of a normal menstrual cycle include

  • Quality of the egg follicle.
  • Quality of the egg.
  • Quality of the layer of tissue in your uterus that prepares for conception/implantation.
  • Thyroid disorders.
  • Ovarian cysts
  • Many others.

If an adequate egg is ovulated from an adequate follicle, which itself is adequate to produce enough progesterone to support a new pregnancy, and if implantation goes without a hitch, pregnancy can occur. Some hormones go up, some go down, some stay the same. It’s all an elaborate outcome of our evolution, but any one of a number of things can go wrong.

Even after fertilization (conception) and implantation, the wrong rhythm in your cycle can cause a miscarriage. As a species, we are all grateful for those 500 or so eggs that are ovulated over a woman’s fertile lifetime.

Barriers and the birds and the bees.

Sperm must meet egg and they must interact. Only one sperm makes it and its incorporation into the egg makes the egg resistant to all the other sperm. This puts each one of us “all in” with just one sperm. But it is usually the strongest, healthiest—and fastest swimming sperm—that wins her hand. Unless there’s a roadblock. 

Scarring inside the tube from old infections (sexually transmitted diseases or E. coli) can present as such a block. If outside the tube(s) there are scars from old pelvic infections or kinks in the tube from adhesions or endometriosis, the sailing may not be so smooth. Besides causing a failure in sperm meeting egg, these also can cause a hang-up in a fertilized egg traveling successfully toward implantation in the uterus. If this happens, the pregnancy can develop inside the tube, which is doomed to failure or can even pose a threat to your life.

Uterine fibroids can present as barriers, bulging into your uterine cavity and compromising implantation or blocking the exposure of the end of your tube to your ovary, preventing ovulation from being captured by your tube.


The biochemistry can be all wrong, especially with endometriosis, which releases inflammatory substances that interfere chemically in the pelvis during ovulation and conception. Therefore, endometriosis is a double-threat: creator of physical barriers and biochemical sabotage.

How is infertility diagnosed? 

Most define infertility as a failure to conceive after 12 months of consistent sexual activity. Some infertility experts move that deadline up to 6 months for women in their late 30s or 40s due to the unrelenting clock and egg atresia.

Diagnosis is based on identifying a lack of rhythm (menstrual dysrhythmia), mechanical barriers from endometriosis or adhesions, and biochemical interference from inflammatory conditions like endometriosis. (And lest we forget, a low sperm count, but that is another story.)

Your tube’s patency must be determined, as well as the vaginal and cervical environment for incoming sperm (pH, mucus, etc). Dye tests can demonstrate tubal patency. Laparoscopy can show adhesions, blocked or kinked tubes, or the presence of endometriosis.

 How is infertility treated?

This depends, of course, on the cause(s):

  • Age is addressed with enhancements to the hormonal cycle (hormonal support or ovulation promoters).
  • Barriers are addressed surgically, eliminating them or restoring the normal anatomy to “un-kink” any distortions.
  • Endometriosis should include surgery in cases of infertility, because time is too precious to spend on less successful methods like hormones and medical suppression of the endometriosis.
  • Fibroids are removed via robotic surgery.

How does Dr. Bozdogan deal with infertility?

At Advanced Endometriosis Center, which will deal with your infertility from barriers and/or bad biochemistry after your cycle has been addressed by an infertility associate, we feel any surgical remedies that become necessary must be indicated, efficient, and respectful of the goal in mind—your having children. The surgical treatment of choice is robotic surgery using the da Vinci robotic system.

Dr.Bozdogan explains:

“When I am beginning a surgery for infertility, I already have a pretty good idea what I’ll be doing, but I am also ready to deal with any surprises. In cases of dense pelvic adhesions and severe endometriosis, I go in prepared to remedy any difficult presentations. For this reason, I use the technology that gives me my best dexterity, control, and visualization, whether dealing with endometriosis, fibroids, or a “frozen pelvis.” Not only does robotic technology give me all that, after having done thousands of these I’ve learned that it also gives a hopeful woman her best chances. I’m all about hope, and I use every skill to keep that hope alive toward her achieving her life goals.”


Infertility is an ugly word, with many causes and many heartaches. Identifying all of the bad players that cause it and attacking them methodically and efficiently requires a skilled, experienced surgeon using state-of-the-art technology for gentle, efficient, and curative strategies.

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