ASRM pagesEndometriosis and infertility: a committee opinion
Section snippets
Endometriosis and infertility
The hypothesis that endometriosis causes infertility or a decrease in fecundity remains controversial. Whereas a reasonable body of evidence demonstrates an association between endometriosis and infertility, a causal relationship has not been clearly established. However, endometriosis can result in adhesions or distorted pelvic anatomy that precludes fertility. The fecundity rate in normal couples is in the range of 15% to 20% per month and decreases with age of the female partner 3, 4. The
Biologic mechanisms that may link endometriosis and infertility
No mechanism has been identified to explain the link between endometriosis and subfertility; however, several mechanisms have been proposed 6, 7, 8. It should be emphasized that none of these mechanisms has been proven to decrease fecundity in women with endometriosis. These mechanisms are briefly discussed below.
Diagnosis and staging
In current clinical practice, a surgical procedure such as laparoscopy is required for a definitive diagnosis of endometriosis. Histologic evaluation is warranted whenever the diagnosis is not apparent on visual inspection at surgery. When addressing whether or not to perform a laparoscopy on a woman presenting with a complaint of infertility, one should consider both the likelihood of the diagnosis of endometriosis as well as potential benefit of treatment. A history and physical examination
Medical therapy for endometriosis
Whereas medical therapy is effective for relieving pain associated with endometriosis, there is no evidence that medical treatment of endometriosis improves fertility. In actuality, fertility is essentially eliminated during treatment because all medical treatments for endometriosis inhibit ovulation. Several options have been suggested for medical treatment: progestins and combined estrogen-progestin therapy, gonadotropin-releasing hormone agonists and antagonists, danazol, and, most recently,
Surgery for endometriosis
In stage I/II endometriosis, laparoscopic ablation of endometrial implants has been associated with a small but significant improvement in live birth rates. Two RCTs have evaluated effectiveness of laparoscopic surgery for Stage I or II endometriosis associated with infertility, with only one study demonstrating benefit 26, 27. Both studies permitted surgical discretion in the intervention regarding excision or ablation. The primary outcomes were slightly different: the Italian study analyzed
Combination medical and surgical therapy
Combination medical and surgical therapy for endometriosis consists of either preoperative or postoperative medical therapy. Although theoretically advantageous, there is no evidence in the literature that combination medical-surgical treatment significantly enhances fertility, and it may unnecessarily delay further fertility therapy. Preoperative therapy is reported to reduce pelvic vascularity and the size of endometriotic implants, thus reducing intraoperative blood loss and decreasing the
Superovulation and intrauterine insemination
Several studies report success with superovulation (SO)/intrauterine insemination (IUI) in the treatment of endometriosis-associated infertility. Review of this subject is complicated as most studies have included women whose endometriosis was “treated” prior to SO/IUI or have included women with unexplained infertility (some of whom are presumed to have minimal endometriosis). In a cross-over RCT among patients with unexplained infertility or surgically corrected endometriosis, the pregnancy
Assisted reproductive technology
A recent report on in vitro fertilization-embryo transfer (IVF-ET) outcomes in the United States indicates that the overall delivery rate per retrieval in infertile women ranges from 44.6% in those under 35 years of age to 14.9% in those 41–42 years of age. The average delivery rate per retrieval for all diagnoses was 33.2%, compared with 39.1% for women with endometriosis (45). This is in contrast to a meta-analysis of observational studies which found that women with endometriosis-associated
Pregnancy outcomes in women with endometriosis
Women with endometriosis have been shown to have adverse obstetrical outcomes compared to those without endometriosis. A Swedish cohort study evaluated 8,922 women diagnosed with endometriosis who delivered 13,090 singleton infants from the national medical birth registry of over 1.4 million singleton births (55). Compared to women without endometriosis, the risk of preterm birth associated with endometriosis among women with ART was 1.24 (95% CI, 0.99–1.57), and among women without ART, 1.37
Decisions among infertile women with endometriosis
Clinical decisions in the management of infertility associated with endometriosis are difficult because many clinical decision points have not been evaluated in RCTs. Moreover, the observational data are conflicting and prevent confident conclusions.
For infertile women with suspected stage I/II endometriosis, a decision must be made whether to perform laparoscopy before offering treatment with clomiphene, gonadotropins, or IVF-ET. Clearly, factors such as the woman's age, duration of
Summary
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There is insufficient evidence to indicate that resection of endometriomas prior to IVF improves outcomes.
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IVF success rates in women with endometriosis appear to be diminished compared to women with tubal factor infertility; however, IVF likely maximizes cycle fecundity for those with endometriosis.
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Women with endometriosis have higher incidences of preterm delivery, pre-eclampsia, antepartum bleeding/placental complications, and cesarean section when compared to women without endometriosis.
Conclusions
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Female age, duration of infertility, pelvic pain, and stage of endometriosis should be considered when formulating a management plan.
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The benefit of laparoscopic treatment of minimal or mild endometriosis is insufficient to recommend laparoscopy solely to increase the likelihood of pregnancy.
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When laparoscopy is performed for other indications, the surgeon may consider safely ablating or excising visible lesions of endometriosis.
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In younger women (under age 35 years) with stage I/II
Acknowledgments
This report was developed under the direction of the Practice Committee of the American Society for Reproductive Medicine as a service to its members and other practicing clinicians. Although this document reflects appropriate management of a problem encountered in the practice of reproductive medicine, it is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment. Other plans of management may be appropriate, taking into account the needs of the
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Correspondence: Practice Committee, American Society for Reproductive Medicine, 1209 Montgomery Hwy., Birmingham, AL 35216 (E-mail: [email protected]).