From the Guidelines
Surgical removal of endometriosis lesions, specifically laparoscopic excision, is the most effective treatment for improving fertility in women with endometriosis, with pregnancy rates increasing by 30-40% in mild to moderate cases. According to the most recent study 1, treatment of endometriosis is variable and largely determined by the patient’s individualized goals, with surgical excision by a specialist considered the definitive treatment. The study also highlights the importance of preoperative imaging in reducing morbidity and mortality, and in informing patient decision making and surgical planning.
Key considerations for improving fertility in women with endometriosis include:
- Timing of conception: women should try to conceive soon after surgery for best results
- Fertility medications: clomiphene citrate or letrozole may be used to stimulate ovulation
- Gonadotropins: injectable hormones can be effective when combined with intrauterine insemination
- In vitro fertilization (IVF): offers the highest success rates for more severe cases or when other treatments fail
- Hormonal treatments: generally not recommended when actively trying to conceive as they prevent ovulation
The World Endometriosis Society consensus on the classification of endometriosis 1 also emphasizes the importance of standardizing the classification of endometriosis to predict fertility outcomes and guide treatment plans. The study recommends using the r-ASRM classification system, Enzian classification for deep endometriosis, and the EFI score for women with fertility concerns.
Overall, the treatment choice for endometriosis-related infertility depends on the woman's age, endometriosis severity, duration of infertility, and whether other fertility factors are present. Laparoscopic excision remains the most effective treatment for improving fertility in women with endometriosis, with a significant increase in pregnancy rates.
From the FDA Drug Label
Endometriosis and Endometrial Carcinoma. The incidence of endometriosis and endometrial carcinoma increases with age as does the incidence of ovulatory disorders. Endometrial biopsy should always be performed prior to clomiphene citrate therapy in this population.
The FDA drug label does not answer the question.
From the Research
Treatments for Endometriosis that Improve Fertility
- Surgical management of endometriosis is an integral element of treatment for infertility caused by endometriosis, as it reduces inflammation and improves spontaneous pregnancy rates and assisted reproductive technology (ART) pregnancy rates 2.
- Laparoscopic surgery for endometriosis elevates both spontaneous and ART pregnancy rates above those achieved with expectant management alone, by reducing inflammation and improving ovarian, tubal, and uterine function 2.
- Fertility preservation techniques, such as embryo, oocyte, and ovarian tissue cryopreservation, are proposed for patients with endometriosis, with reported live-birth rates and endocrine function recovery after successive procedures 3.
- Gonadotropin-Releasing Hormone Agonist (GnRH-a) administration before assisted reproduction techniques may improve pregnancy rates in women with endometriosis, particularly in cases of severe endometriosis, by reducing inflammation and improving oocyte quality and endometrial receptivity 4.
- Gonadotropin-Releasing Hormone Antagonists may also be a new hope in endometriosis treatment, as they down-regulate the hypothalamic-pituitary-gonadal axis, induce a hypoestrogenic state, and prevent disease progression and recurrence after surgical removal of endometriosis 5.
Fertility Preservation Techniques
- Embryo cryopreservation has been reported to result in live-births after successive embryo-transfer in patients with endometriosis 3.
- Oocyte cryopreservation has been reported to result in cumulative live-birth rates in patients with endometriosis 3.
- Ovarian tissue cryopreservation has been reported to result in endocrine function recovery and pregnancy after successive procedures in patients with endometriosis 3.
Medical Management
- GnRH-a administration may be beneficial in improving pregnancy rates in women with endometriosis, particularly in cases of severe endometriosis 4.
- GnRH antagonists may be a new treatment option for pain reduction in endometriosis patients, by down-regulating the hypothalamic-pituitary-gonadal axis and inducing a hypoestrogenic state 5.