Endometriosis & infertility

Endometriosis & infertility-

- 15-60 % of women presenting with subfertility have e/o endometriosis at laparoscopy.
- may be asymptomatic

Rx options -

1. Conservative    2. Medical     3. Surgical     4. Assisted reproduction

1. Conservative - 
- Minimal to mild endometriosis is of equivalent degree to unexplained infertility.
- The chances of spontaneous conception in the next 9 months are ~ 30-40 %


2. Medical -
- There is no role of medical Mx in subfertility associated with endometriosis
- Medical Mx will suppress the ovarian function & delay the pregnancy
- No benefits over no Rx.

3. Surgical -
a. Mild to moderate disease - Laparoscopic ablation of endometriotic deposits with adhesiolysis improves fertility.

b. Moderate to severe disease - Role of surgery is uncertain.

c. Advanced disease with dense pelvic adhesions - Laparotomy / laparoscopic Rx improves fertility

d. Endometrioma - Cystectomy (rather than drainage & coagulation) improves fertility.
- Risk of reduced or loss of ovarian function after surgery should be kept in mind.

e. Tubal flushing with oil soluble media - improves fertility.

4. Assisted reproduction techniques -

- effective at all stages of endometriosis
- Success rates ~ 25-40 %
- pregnancy rates not affected by disease
- IUI for 6 cycles - for mild disease with patent tubes
- Ovarian stimulation before IUI improves success, but risk of complications like OHSS & mutiple pregnancy
- IVF - in severe disease, blocked tubes or failure with IUI
- Treatment with GNRH agonists before IVF improves success.