During this live session, Dr Elias Tsakos, MD, FRCOG, Medical Director of Embryoclinic, Greece, shared his expert insights on two complex and often misunderstood conditions affecting fertility: Endometriosis and Asherman’s Syndrome.
Dr Tsakos discussed the causes, diagnosis, treatment options, and the impact these conditions can have on reproductive health, as well as how to navigate them on your fertility journey.
Endometriosis and Asherman’s syndrome are two conditions that frequently intersect with fertility challenges, yet they are often underdiagnosed or misunderstood. In this event, Dr Elias Tsakos explained how these conditions affect fertility, IVF outcomes, pregnancy, and long-term reproductive health, and why accurate diagnosis and individualised care are essential.
Dr Tsakos described endometriosis as a common but complex disease that affects a significant proportion of fertility patients. He explained that up to half of women seeking fertility treatment may have endometriosis, whether diagnosed or not. Adenomyosis, he added, is a form of endometriosis affecting the uterine muscle and should be considered part of the same disease spectrum.
Endometriosis occurs when tissue similar to the endometrium grows outside the uterus. These implants can be found almost anywhere in the body, most commonly within the pelvic and abdominal cavity. Although benign, Dr Tsakos emphasised that endometriosis behaves locally like a malignant disease because it disrupts normal anatomy and organ function and causes chronic inflammation.
He stressed that endometriosis should be viewed as a generalised condition rather than a localised pelvic problem, affecting multiple systems and requiring long-term, multidisciplinary management.
According to Dr Tsakos, endometriosis is often underdiagnosed because its symptoms vary widely. Some women experience severe pain, while others have minimal or no symptoms. He likened the condition to a “chameleon” that can present in many different ways.
Symptoms may include:
pelvic or abdominal pain
painful periods
lower back pain
bloating
fatigue or low energy
pain during intercourse
infertility without an obvious cause
Dr Tsakos noted that women with advanced endometriosis can sometimes have normal ultrasound findings, while others with small ovarian cysts may have extensive disease. Although ultrasound technology and diagnostic expertise have improved, accurate diagnosis still depends heavily on specialist skill and experience.
In his clinical practice, Dr Tsakos explained that 30–50% of women with infertility have endometriosis. In cases of so-called unexplained infertility, this figure is even higher. He challenged the concept of unexplained infertility, stating that it often reflects insufficient investigation rather than the absence of an underlying cause.
Endometriosis can impair fertility through multiple mechanisms, including:
distortion or blockage of the fallopian tubes
reduced ovarian reserve or ovarian function
increased oxidative stress
impaired implantation
inflammatory effects on sperm and embryos
Dr Tsakos explained that endometriosis negatively affects IVF success rates. Women with endometriosis generally have lower implantation rates and may retrieve fewer oocytes during IVF stimulation. He also highlighted a higher risk of ectopic pregnancy and more complex ectopic presentations.
Even after successful IVF, endometriosis can influence pregnancy outcomes. Dr Tsakos emphasised that pregnancies in women with endometriosis are at a higher risk and require careful obstetric management. Undiagnosed endometriosis, in particular, is associated with pregnancy complications affecting both mother and baby.
Management of endometriosis must be individualised. Dr Tsakos stressed that treatment decisions should balance fertility preservation with relief of physical symptoms. Factors such as age, severity of disease, ovarian reserve, uterine involvement, and reproductive goals all influence the treatment plan.
Treatment options may include:
medical management
surgical intervention
assisted reproductive techniques such as IVF or ICSI
fertility preservation strategies
oocyte or embryo donation in severe ovarian damage
surrogacy or, in rare cases, uterine transplantation
He noted that surgery is not always the optimal solution for fertility and should not be applied universally. Surgical intervention is most beneficial when symptoms are severe or the anatomy is significantly distorted.
Dr Tsakos explained that robotic surgery has significantly advanced the surgical management of endometriosis. In experienced hands, robotic techniques allow for precise excision of lesions, improved visualisation, and better preservation of healthy tissue.
While long-term evidence is still emerging, he expressed confidence that robotic surgery will become the gold standard for complex endometriosis cases, particularly when fertility outcomes are a priority.
Asherman’s syndrome involves adhesions within the uterine cavity that damage the endometrium. Dr Tsakos explained that these adhesions are relatively common among fertility patients and can significantly impair implantation, increase miscarriage risk, and reduce live birth rates.
The endometrium, he emphasised, is a highly sensitive and essential organ for implantation. Damage to this tissue can create a vicious cycle: implantation failure leads to further endometrial injury, worsening fertility outcomes over time.
Hysteroscopy remains the cornerstone of diagnosing intrauterine adhesions and endometrial pathology. Dr Tsakos explained that modern hysteroscopic techniques allow direct visualisation and treatment of adhesions, sometimes requiring multiple procedures to restore a functional uterine cavity.
Treatment approaches may include:
hysteroscopic adhesiolysis
hormonal therapy with oestrogen
temporary intrauterine devices to prevent re-adhesion
platelet-rich plasma (PRP) therapy
careful monitoring of endometrial response
He highlighted emerging research into endometrial microbiome testing, chronic endometritis, and inflammatory markers, noting that these advances are improving diagnostic precision.
Dr Tsakos discussed the growing evidence supporting PRP therapy for improving endometrial quality. PRP, derived from the patient’s own blood, may enhance endometrial thickness and receptivity when infused or injected into the uterine lining.
He noted that professional societies have begun to acknowledge PRP as a promising adjunct therapy, although further research is ongoing.
In rare cases where the uterus cannot support a pregnancy despite all interventions, absolute uterine factor infertility may be diagnosed. Dr Tsakos explained that these cases account for a small proportion of fertility patients. Options may include surrogacy or, in select cases, uterine transplantation, an emerging but highly specialised field.
Dr Tsakos concluded by emphasising several essential points:
Endometriosis is common and often underdiagnosed
It significantly affects fertility, IVF outcomes, and pregnancy
Early and accurate diagnosis is critical
The endometrium must be protected, evaluated, and treated carefully
Mild to moderate uterine adhesions can often be successfully managed
Severe cases require specialised, multidisciplinary care
He encouraged patients experiencing unexplained infertility, recurrent implantation failure, or persistent symptoms to advocate for thorough investigation and expert evaluation.
I don’t know for sure. It could be, but it depends on many factors. After so many failed transfers, I can give you a short list of suggestions. Don’t do another IVF unless you have tested embryos, at least to exclude abnormalities in the embryos. Make sure your anatomy is 100% tested with gold standard techniques, which include hysteroscopy with biopsies for tissue information.
In my opinion, essential tests include:
Histopathology (conventional biopsy)
Endometritis testing through immunohistochemistry, particularly CD138 measurement
Microbiology PCR testing (specialised microbiological diagnosis)
Microbiota testing
These four are absolutely vital. Now, natural killer (NK) cells are a matter of discussion and counselling. There is some evidence, but it’s not overwhelming. It depends on you and your doctor. When it comes to detecting endometriosis, I must thank my colleague Dr Alin Constantin, an excellent specialist practising in Germany, who is also an expert in scanning. In my facility, we regularly invite him to fly from Germany to scan patients together with us. We do this to ensure we don’t miss anything.
Scanning is like stargazing; you need a very strong telescope. Conventional scanning often doesn’t detect endometriosis. You need:
A very high-end scanner
A very experienced ultrasound specialist looking specifically for endometriosis
Your regular sonographer or gynaecologist likely won’t pick it up, especially if they use basic equipment.
We’ve published several papers and presentations on the value of advanced 3D/4D gynaecological scanning for detecting endometriosis. In my opinion, it has more than 90% diagnostic value, better than standard MRI.
Why? Because many MRI setups aren’t calibrated to detect endometriosis properly. Some radiologists may not look for the nodules that could be hidden.
So while I can’t confirm it’s endometriosis in your case, I strongly suggest:
A high-end hysteroscopy and biopsies
A high-end gynaecological ultrasound scan
Possibly a diagnostic laparoscopy
Every year, I see about half a dozen women with multiple IVF failures who have never had a hysteroscopy or laparoscopy, and sometimes they have important, previously missed pathology.
One case we published involved widespread pelvic infection. We treated her for two years without doing a single IVF. The infection still wasn’t cured. If there’s an infectious environment, and you don’t detect it, IVF is unlikely to succeed.
After so many failures, you deserve to look for the rare causes, even if you have no obvious hints. Keep looking. As a wonderful colleague of mine always says:
There’s no such thing as unexplained infertility, only patients who haven’t been investigated enough.
Yes, to be honest, I’m very curious about this technology. I’m familiar with it. I haven’t tried it. I have applied to try it. The theory is there. I think it’s interesting. I don’t know where it’s available. I think it’s in England somewhere at the moment.
This is a test for those who are not familiar with it. You put some belts around your body, and they pick up signals that may be relevant to endometriosis.
I think there are a lot of good things about the EndoSure test. I don’t believe it should be standalone. I think the accuracy will probably improve in the future. I would use it together with other non-invasive techniques. Likewise, I have not tried it. Furthermore, I think my research team have applied to test it. I would be very curious to test and try it. I think these guys need to involve more endometriosis centres to improve the accuracy and diagnostic value.
My suggestion would be, if you have access to it and it’s reasonably priced (I’m not familiar with cost), I would probably use it together with conventional tests, which include a high-end ultrasound scan, very thorough history taking and also perhaps some markers. There are some biochemical markers that we can use, not very accurate, but I would try to get as much information as I can. I would also consider a laparoscopy.
I’m sorry about this. I’m frustrated as much as you are. I think things will change. I’m always hopeful. I believe that with AI, we’re going to have better diagnostic algorithms and better treatment algorithms. I’m very confident about this, maybe in the next couple of years. Now, what do we do until then?
I believe that if there is a suspicion of endometriosis, the chance of identifying endometriosis is more than 78%.
I believe that if someone has had a diagnostic laparoscopy somewhere, not in a highly specialised centre, and they found one spot of endometriosis, we have to consider that they probably have a couple more that have been undetected. In my opinion, even one spot of endometriosis doesn’t go on its own. It’s like the Red Arrows, they never fly solo.
So if you’ve had even minimal endometriosis diagnosed, I think it’s fair to say that you probably have a little bit more. How would I manage? I would manage with conservative, holistic approaches. I don’t like at all the very aggressive hormonal treatments like GnRH analogues for many reasons.
I would look into the scientific holistic aspect, diet, exercise, vitamin supplementation, and anything to reduce inflammation. Then, in the frozen embryo transfer, I would perhaps use a prolonged dedicated cycle with prolonged downregulation in order to suppress the inflammation as much as I can. That’s what I would do.
The thing is that endometriosis may not be visible. The effect of endometriosis may also not be visible. It’s not necessarily associated with adhesions. It’s not necessarily associated with lumps or cysts. But if it’s there, it’s there.
There are many mechanisms, as I mentioned in the slides, feel free to use them, that we don’t fully understand, but they may affect IVF success. We have to take this for granted. It’s been thoroughly studied. Even with donor eggs, for example, we take out of the equation the effect of endometriosis on egg quality. That’s all we do. But the equation includes other factors: the endometrium, the possibility of adenomyosis (which occurs in more than 50% of people with endometriosis), inflammation, and effects that could be exerted by various mechanisms.
Please maintain a holistic approach to managing endometriosis: diet, exercise, anti-inflammatory measures, and supplementation. There are some good non-hormonal options as well. We have to optimise a little bit of everything, just like in cancer treatment. It’s not just chemotherapy, or surgery, or therapy. It’s all combined with vitamin supplementation, lifestyle, stress reduction, perhaps yoga.
Endometriosis is a generalised disease, like diabetes. Diabetes doesn’t just affect glucose; it affects the whole body, from vision to kidneys. The same applies to endometriosis. Its main disruption is inflammation and the circulation of inflammatory factors throughout the body.
PRP, it took me 10 years to be convinced about it. The tipping point was this courageous, amazing patient from London. I had referred her to other units, but she came back, still wanting us to do it. We did, and I’m grateful to her.
She hasn’t been successful yet, I must say. PRP is like the Coca-Cola recipe; unfortunately, it’s not standardised. That’s why the evidence is not solid. Everyone is using different protocols and techniques. Virtually no one checks what they are injecting. I would challenge any PRP practitioner to give you a report of what they are injecting. Nine out of ten wouldn’t know. For example, we prepare it, but what is the actual density of the product? Most people don’t know.
So I’m cautious about PRP. I believe it will become standardised. We’ve been using it for two years and are improving, though not perfectly. We collaborate with top experts in the field who pioneered PRP treatments. PRP is at the base of the pyramid—it’s the very basic stuff. If we speak in terms of antibiotics, it’s probably penicillin. A lot of progress is coming. I believe it has to be standardised with a certain platelet density—definitely over 800,000 per ml. Techniques may vary depending on what we’re treating. Not all thin endometria are the same. It could be focal endometritis, for example.
Here’s my quick protocol: If I suspect an endometrial issue, either because I’m using top-quality donor eggs or embryos, or PGT-A tested blastocysts, I standardise the technique. Each doctor and unit has their own success rates for embryo transfer. This depends on experience, technique, and more. Protocols vary. Many just give a little estrogen, a little progesterone, do one scan, maybe no blood test—and that’s it.
But there’s more. Scanning time is one factor. Thickness is another. There are at least 8 to 10 other endometrial factors. How far do we go to check them? How far have we gone to exclude adenomyosis? What if the patient has hydrosalpinx that hasn’t been diagnosed? Hydrosalpinx isn’t visible on a scan. I have many success stories where the only change was removing the tubes due to an undiagnosed hydrosalpinx. Then the patient got pregnant on the first try. It’s multifactorial. The important thing for all of you listening is to know at least the basics—and I must say, you do. I’m very happy about that. That is the purpose of this webinar. You are here to challenge us every single day.
Adenomyosis is a difficult condition. The answer is: it depends. Surgery, in my opinion, should be the last resort. We should try to classify it, to see if it’s isolated or associated with something else. I repeat—adenomyosis and endometriosis are sources of inflammation. So, we try to reduce the inflammation as much as we can.
If adenomyosis is mild, moderate, severe, diffuse, or localised, it depends. If the endometrium is normal or near-normal, and if adenomyosis is not massive, I hardly ever suggest surgery. Surgery can be challenging. It can be complex, complicated, and it doesn’t guarantee success. It leaves a scar on the uterus and may lead to complications in pregnancy. Yes, we do it if we have to.
If we do surgery, in my opinion, the robot is the best approach. I have amazing colleagues, endometriosis surgeons, who have stopped doing laparoscopy altogether because they feel they are not doing justice to their patients. I’m not one of them yet, but perhaps I will be in the next few years. The robot has revolutionised the ability of the surgeon to treat endometriosis and adenomyosis.
In my opinion, robotic surgery will, within two to three years, completely replace laparoscopic surgery—just like hysteroscopy replaced D&C—because of the level of accuracy, safety, complete resection, visualisation of lesions, and ability to suture. However, I resort to surgery only when there is no other option—when I’ve tried everything else and there have been multiple failures, or when there is severe adenomyosis. If it’s localised and looks like fibroids, sometimes we end up operating on adenomyosis by accident, thinking it’s a fibroid—only to find out it’s adenomyosis, or a combination of both. They can coincide. It can be very complex.
I prefer to operate on endometriosis, but sometimes we have to choose which battle to fight. If we open all fronts, it may be too challenging. Generally, if there is mild or even moderate adenomyosis, and the endometrium is normal, I prefer not to operate.
Medical management and dividing the cycle into collection and embryo transfer can be very effective. If it’s diffuse adenomyosis, what do you operate on? If the whole uterine wall is abnormal, what do you remove, what do you leave behind? It’s not easy. There has to be a balance. The better surgeon you are, the more aggressive you tend to be. But if you become an excellent surgeon, you become more conservative. That’s my approach.
No idea. She’s not my patient, and if she were, I wouldn’t share. I don’t know the answer. What I can say is this: I regret that some celebrities haven’t been more forward in helping others. That’s our failure as doctors; we should be approaching them, asking them to share their stories and remove misconceptions.
Some celebrities never admit to having had advanced fertility treatments, egg donation, embryo donation, or even surrogacy. Some pretend to be pregnant when it was a surrogate. They should be more open. Fertility is not a shame, not a blame. It’s a disease. It’s an illness. In today’s world, where infertility and demographic issues are worsening, it’s inspiring to see women, couples, and single women fighting over and over again, falling and getting up. Sometimes, after the third or fourth failure, it’s the patients who give me courage.
Regarding surrogacy, one single couple in England, 2 doctors helped me not give up. After so many disappointments and bad press, I was ready to stop offering surrogacy. They had their first child through surrogacy with us and came back for a second. I told them I couldn’t do it anymore. But thanks to them, I continued. Now they have 2 children. We now run a surrogacy program with more than 90% success, which is outstanding.
I believe celebrities should take a stand. They would receive the biggest applause of their lives if they did so properly.
Thank you so much for sharing. I’m sorry about the outcome. Anything can happen through various mechanisms—not necessarily through a direct link, but possibly an indirect one. On the other hand, the fact that you’ve gone so far is very optimistic. So, don’t give up. What I would suggest is: keep going. Your age is very good, reasonable. Keep going. Make sure you have good-quality embryos. Have more IVF.
I would seriously consider cervical cerclage. With cervical cerclage, the chance of going very near term is much higher. Make sure you examine your cervix properly—perhaps through hysteroscopy, biopsies for endometritis, inflammation, infection, microbiome, cervical smear, and HPV DNA testing. There are some amazing doctors in Sweden doing great work. There is some evidence that even HPV DNA positivity, without cellular damage, may affect the integrity of the cells.
Now that you have the experience of a successful IVF and a pregnancy reaching a certain stage, my suggestion is to keep going. Focus on the cervix. Protect your cervix. If there is evident insufficiency, perhaps consider an abdominal cerclage, done before IVF with robotic surgery. That’s pretty straightforward. If there’s no evidence, and if your cervix looks healthy, still consider placing a cerclage at 13–14 weeks in the next pregnancy.
Also, regular monitoring of your vaginal flora, high vaginal swabs, and microbiome testing. Even consider prophylactic antibiotics around the time you previously went into early labour. I’m sure it’s going to be fine. The prognosis for you is brilliant.
No, it wouldn’t make a difference. I wouldn’t encourage you to have IVF. I would encourage you to have another hysteroscopy, diagnostic hysteroscopy, together with a tissue biopsy.
Write this down:
By doing this, you would ensure you have a normal endometrium. Endometrial adhesions may be associated with tubal pathology—pathology of the tubes. You are trying naturally, and I would encourage that at age 31. Have an HSG—some form of tubal assessment. The gold standard is laparoscopy, if you can have it, either through the public system or through your private doctor.
For me, the gold standard would be:
That would give us 100% of the diagnosis. If you don’t have access to laparoscopy, the second-best option is a hysterosonogram—either with high-resolution ultrasound called HyFoSy (Hysterosalpingo-Foam-Sonography) with foam (foam is better than saline). We have published and presented a big study on this a couple of years ago.
If you don’t have access to high-level HyFoSy testing with 3D ultrasound, then even a conventional X-ray would be okay. That gives about 80–85% accuracy, if you want to avoid laparoscopy. I would foresee that in the next webinar, you’ll be pregnant. Also, remember that HyFoSy, we published a case where a woman like you got pregnant in the same cycle, naturally. We did a HyFoSy on day 7, she conceived on day 15, and delivered 9 months later. So, HyFoSy may also facilitate natural conception. I would be very happy and very optimistic for you. I don’t think you need IVF at this stage.
