Endometriosis is the number 1 cause of infertility in the US. Endometriosis occurs when the endometrial tissue that makes up the inner lining of the uterus migrates to other places, like the ovary or pelvic wall. Endometriosis affects up to 10% of US reproductive-aged women, and, of women with endometriosis, about 35% experience infertility. So, what can we do to help women with endometriosis achieve pregnancy? Unfortunately, the number of medical treatments to increase fertility in the face of endometriosis are limited.
A common complication of endometriosis is an ovarian cyst called an endometrioma. Endometriomas form when migrating endometrial tissue grows on the ovary. The cysts can fill with blood and grow quite large. When a woman has an endometrioma and seeks treatment for infertility, removing the endometrioma can improve her chances of conceiving. Traditionally, removal is completed through a laparoscopic surgery. However, a new treatment called plasma energy ablation is showing great promise. The authors of the first study comparing plasma energy ablation to surgery presented their findings at the 2017 AAGL Global Congress.
During plasma energy ablation, the physician uses a tool that shoots high voltage radio frequency electrical current into a chamber filled with argon gas, which then turns into plasma. The heat from the plasma in the chamber is directed towards the endometrioma, causing ablation of this displaced endometrial tissue. The spread of heat energy is limited during plasma energy ablation, hopefully causing less collateral damage to ovaries and surrounding tissues.
The researchers enrolled 104 women with endometriosis on one or both ovaries who had 1 year or more of infertility. All the endometriomas were at least 3cm or larger. They did not randomize the patients to groups, but allowed physicians and patients to self-assign to plasma energy ablation or cystectomy (cyst removal) surgery. 64 patients received plasma energy ablation, and 40 received cystectomy.
The researchers followed the patients for 1 year after their treatment. 68% of women who received plasma energy ablation become pregnant in that year, and 80% of women who received a cystectomy did. 40% of the pregnancies in the plasma energy ablation group were spontaneous (no ART involved) and 18% of the pregnancies in the cystecomty group were spontaneous. After completing statistical analysis for a variety of outside factors that affect fertility, the two treatments had equal impact on future pregnancy rates. In fact, the women in the plasma energy group had more risk factors for infertility at baseline (like older age), and still achieved a comparable pregnancy rate.
After 2 and 3 years of follow up, the pregnancy rates were the still similar between the two groups. 61% of the women in the plasma energy ablation group were pregnant after two years and 84% after three years. 69% of the women in the cystectomy group were pregnant after two years and 78% after three years.
Should we all abandon cystectomy surgery? Not so fast! The women were not randomized to the two groups, so physicians likely chose the procedure for which they were more skilled or that they thought was a better fit for the individual patient. In the future, we can look forward to a randomized trial from these researchers to further evaluate these two methods. In the meantime, this is good news for our toolkit of treatments for endometriosis.
We want to hear from you! Do you use plasma energy ablation? Do you have a preference for plasma energy ablation or cystectomy?