If you’ve been struggling to start a family, are pursuing IVF, and have been diagnosed with endometriosis somewhere along the way, you may be left wondering what your best treatment option will be. Oftentimes, simply getting diagnosed with endo itself can be a long and treacherous road — one that leaves too many people feeling unheard, disbelieved, or wrestling with the medical trauma of having nobody to advocate for you but yourself.

Once a patient has received an endometriosis diagnosis, it can feel like a breath of fresh air to just finally have an answer to your symptoms and previously unexplained infertility. On the flip side, an endo diagnosis comes with a roadmap that can be rocky at best in terms of the best way to proceed with fertility treatments.

Treating endometriosis before an embryo transfer

When it comes to IVF and endo, you may be presented with two courses of action: Laparoscopy, a surgical procedure and the most commonly used method to diagnose and remove mild to moderate endometriosis, or Depot Lupron, an GnRH agonist suppression. Depot Lupron works by suppressing ovulation and reducing estrogen levels, a key hormone known to stimulate endometriosis. 

For more insight into the difference between these treatment options, we talked to Dr. Bruce Lessey about how utilizing a ReceptivaDx test, the only test that can identify endometriosis, progesterone resistance, and endometritis in a single sample, can help patients get the answers they need to move forward with treating endometriosis prior to an embryo transfer.

What’s the significance of a positive ReceptivaDx test in the context of endometriosis treatment?

“A positive test is detecting inflammation of the endometrium, usually due to endometriosis. High levels of  BCL6, a marker that identifies uterine inflammation, should not be present in the endometrium lining during the luteal phase when a biopsy is performed. In the setting of IVF failure or implantation defects, this test can help direct further therapy such as surgery to remove the endometriosis (laparoscopy) or GnRH agonist suppression (Depot Lupron).” 

What is the standard treatment approach for endometriosis, and how does it change when a patient receives a positive ReceptivaDx test result?

“If we suspect endometriosis based on the clinical history of the patient including a previous diagnosis or symptoms of endometriosis, we will likely offer laparoscopy or GnRH agonist suppression. However, if the patient comes to us with prior IVF failures, recurrent pregnancy loss, or general unexplained infertility, we commonly recommend doing a biopsy to rule out endometritis, a chronic bacterial infection commonly treated with a course of antibiotics. Now, with the availability of the ReceptivaDx test, we can also screen for both endometritis and endometriosis using CD138 and BCL6 staining respectively, before further treatment recommendations. If positive for BCL6, these patients and I can both feel better about undergoing further treatment rather than empirically risking another loss by not addressing underlying endometriosis.”

Are there specific medications or therapies that are recommended for managing endometriosis in patients with a positive ReceptivaDx result, as opposed to those with a negative result?

“In 2019, we investigated and published on the use of surgical laparoscopy vs. Depot Lupron suppression approaches after a failed IVF with a positive ReceptivaDx test, compared to no treatment at all. The results showed a 5 fold improvement in live birth rates for either approach. Recently, we analyzed all our euploid (normal) embryo transfers and the data shows that GnRHa restored normal expected success rates in prior euploid embryo failures, while expectant management (i.e. just doing another transfer) was inferior and resulted in repeat losses in a majority of cases.

Other studies have found that adding letrozole to the GnRHa (Depot Lupron) may be helpful.  While more studies on this are definitely needed, doing nothing does not appear to serve patients well. Having a test to help define patients at risk is, in my opinion, a real game changer.”

What surgical options are available for treating endometriosis, and how does the ReceptivaDx test influence the decision to proceed with surgery or other interventions?

“Laparoscopy is the only surgical treatment available, and it is considered the gold standard for diagnosing endometriosis.  Unfortunately, the time to diagnosis is almost 11 years in the USA and getting longer. The ReceptivaDx test is critical for those patients not presenting with typical symptoms beyond unexplained infertility or IVF failure and recurrent pregnancy loss. It is also useful for patients with low ovarian reserve or a limited number of stored embryos. Keep in mind that at least 30%-50% of patients with endometriosis are asymptomatic. Ultimately, deciding on surgery vs. medical suppression is a conversation a patient should have with their doctor.”

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Apart from surgery & Depot Lupron, are there alternative or complementary treatments that may be considered for patients with endometriosis, especially if they have a positive ReceptivaDx result?

“Other options include the use of letrozole with suppression or alone, based on a number of published reports. The quality of the evidence remains limited, however, and any intervention should be considered experimental at this point. Fortunately, letrozole has a proven safety record and has been shown to be helpful in other infertility treatment scenarios, and it will likely be found to be a useful approach, pending future studies. Our clinic has found letrozole is helpful & we continue to study it further.”

Laparoscopy vs. Depot Lupron: The bottom line 

When it comes down to it, the decision between utilizing surgery or medical suppression via Depot Lupron to treat endometriosis before an embryo transfer should be made between yourself and your doctors. However, one thing is for sure — using a ReceptivaDx test to identify endometriosis is a worthwhile way to gain answers and map out effective treatment options, significantly improving chances for successful embryo transfer and live birth.

Lindsey Williams is a library worker and writer who lives in Arizona with her daughter, husband, and their dog, Peaches.