In conclusion, endometriosis is a common disease in women with pelvic pain and/or infertility. There is very limited role for surgery to either diagnose or treat asymptomatic patients with otherwise unexplained infertility after a thorough evaluation. Patients with large ovarian endometriomas (~4 cm or larger) without pathologic diagnosis may bene t from laparoscopic surgery to remove the cyst, potentially restoring anatomy and improving access to the ovaries if IVF treatment is necessary. Our patient presented here, due to her advanced disease and symptoms, should have undergone surgery before IVF for the reasons discussed above. She may have avoided the risks and expense of the rst unsuccessful IVF cycle altogether.

In patients who are already undergoing laparoscopic surgery for another indication, there is evidence to support ablating visible endometriosis discovered incidentally, as this may confer some bene t in fertility. In those patients with unexplained infertility, conventional treatments with ovulation induction and IUI, or IVF if IUI is not successful, should be the treatment of choice. Patients with documented endometriosis who undergo IVF have generally similar success rates as patients with other infertility etiologies undergoing IVF. Repeated surgeries to resect pelvic lesions or ovarian cysts should be avoided, as this will not result in improved pregnancy rates and will only serve to damage follicles and reduce ovarian reserve, thus lowering the overall probability of pregnancy.

References

1.\ Missmer SA, Hankinson SE, Spiegelman D, Barbieri RL, Marshall LM, Hunter DJ. Incidence of laparoscopically con rmed endometriosis by demographic, anthropometric, and lifestyle factors. Am J Epidemiol. 2004;160(8):784–96.

2.\ The Practice Committee of the American Society of Reproductive Medicine. Endometriosis and infertility: a committee opinion. Fertil Steril. 2012;98(3):591–8.

3.\ Marcoux S, Maheux R, Berube S. Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis. N Engl J Med. 1997;337(4):217–22.

4.\ Parazzini F. Ablation of lesions or no treatment in minimal-mild endometriosis in infertile women: a randomized trial. Gruppo Italiano per lo Studio dell’Endometriosi. Hum Reprod. 1999;14(5):1332–4.

5.\ Schenken RS. Modern concepts of endometriosis. Classi cation and its consequences for therapy. J Reprod Med. 1998;43(3 Suppl):269–75.

6.\ Garcia-Velasco JA, Somigliana E. Management of endometriomas in women requiring IVF: to touch or not to touch. Hum Reprod. 2009;24(3):496–501.

7.\ Sallam HN, Garcia-Velasco JA, Dias S, Arici A. Long-term pituitary down-regulation before in vitro fertilization (IVF) for women with endometriosis. Cochrane Database Syst Rev. 2006;(1):CD004635.

and surgical treatment options. In view of her desire to conceive, surgical options were discussed: abdominal, laparoscopic/robotic, and hysteroscopic myomectomy. The risks and bene ts of each method were explained. More importantly, the time to recovery before she can resume attempting to conceive was discussed.

She agreed to undergo a hysteroscopic myomectomy with the proper counseling that it might require more than one session, given the size of the myoma, to completely remove it; if during surgery, resection is deemed impossible hysteroscopically, converted to an abdominal approach would have to follow. During the rst hysteroscopy, more than 3 cm (around 60%) of the myoma was resected using TruClear morcellator with a 250 cc normal saline de cit. The remaining portion of the myoma could not be removed due to its depth in the myometrium. Six weeks later, she underwent another hysteroscopy. More of the myoma had protruded into the cavity; however, the procedure could not be completed due to the large fuid de cit (2400 cc normal saline) leaving approximately 10% of the myoma in situ. A month later, a third and nal hysteroscopy was performed, and the remaining portion of the myoma was removed. A follow-up vaginal sonogram a few weeks later con rmed the absence of any remaining myoma with a normal endometrial stripe. The amount of her menstrual fow became normal and bleeding lasted only 4–5 days. A few months later, the patient conceived naturally and had a normal vaginal delivery of a healthy baby boy at full term.

Discussion

Uterine myomas are common benign monoclonal tumors with an estimated cumulative incidence of almost 70% and more than 80% in white and black women, respectively. More importantly, approximately 50% of premenopausal women with no prior history of myoma may have a myoma identi ed on vaginal sonogram [1]. In addition to ethnicity, other factors which will increase the risks of developing myomas include pre-menopausal status (tenfold), family history of myomas (threefold), and more than 5 years since last birth (two to threefold) [2]. Classically, myomas are classi ed into three categories by location: sub-mucosal, intra-mural, and sub-­ serosal. More recently, the International Federation of Gynecology and Obstetrics (FIGO) updated the classi cations which are followed by most authorities [3].

Asymptomatic myomas in the past were typically diagnosed during routine bimanual pelvic exams. However, they needed to be of a certain size before they could be appreciated by pelvic examination. With abdominal and vaginal ultrasound readily available now, most myomas, even much smaller are diagnosed with imaging studies done at routine gynecologic visits. Due to their cost, MRIs are not usually recommended for routine use, but they are commonly ordered prior to surgery, especially in infertile patients. This is extremely helpful to delineate the uterine anatomy and more speci cally the relation of myomas to the endometrium.

Depending on their location, number, and size, symptomatic uterine myomas can present with heavy bleeding, pain, and urinary and gastrointestinal symptoms.