How can individuals with endometriosis improve their fertility?

Improving Fertility in Individuals with Endometriosis

For individuals with endometriosis seeking to improve fertility, surgical treatment with the Endometriosis Fertility Index (EFI) scoring system should guide management decisions, followed by appropriate fertility treatments based on disease severity and ovarian reserve. 1, 2

Diagnostic Assessment

• Classification systems for fertility planning:
  • The Endometriosis Fertility Index (EFI) is the most validated clinical tool that predicts fertility outcomes after surgical staging 1
  • Traditional r-ASRM classification has poor correlation with fertility outcomes 1
  • Transvaginal ultrasound or MRI can help identify endometriomas and deep infiltrating endometriosis before treatment 1, 2

Surgical Management

• Surgical approach:

  • Laparoscopic excision/ablation of endometriotic lesions can significantly improve natural conception rates 2, 3
  • Surgery should be performed by experienced surgeons to preserve normal ovarian tissue, especially when dealing with endometriomas 4
  • After surgery, the EFI score should be calculated to counsel patients on the likelihood of natural conception and determine appropriate next steps 5

• Important considerations:

  • Criteria for avoiding endometrioma removal: bilateral cysts, history of previous ovarian surgery, or already compromised ovarian reserve 3
  • Surgical removal of deep infiltrating endometriosis may improve IVF outcomes, contrary to some previous recommendations 6
  • Risk of diminished ovarian reserve must be balanced against potential fertility benefits 4, 3

Medical Management

• Key points:
  • Hormonal suppression therapy alone does not improve fertility rates 2
  • Hormonal treatments for endometriosis (including combined hormonal contraceptives and progestins) are contraceptive and should be discontinued when attempting conception 2, 7
  • Medical therapy with GnRH agonists for 3-6 months before assisted reproductive technology (ART) can improve outcomes 3

Fertility Treatment Approaches

• For mild endometriosis (AFS/ASRM stage I/II or superficial peritoneal disease):

  • After surgical treatment, controlled ovarian stimulation with or without intrauterine insemination can enhance pregnancy rates 5
  • Gonadotropins should be first-line therapy for ovarian stimulation 5
  • Limit to no more than 6 cycles before moving to ART 5

• For moderate to severe endometriosis:

  • When age, ovarian reserve, and male/tubal factors permit, surgery followed by attempts at natural conception is recommended 3
  • In cases of compromised ovarian reserve or advanced age, GnRH analogs followed by ART without prior surgery may be preferred 3

Clinical Pitfalls and Caveats

• Approximately 25-44% of patients experience recurrent symptoms within 12 months of treatment, requiring ongoing management 2
• Ovarian surgery in endometriosis patients carries risk of removing normal ovarian tissue along with endometrioma walls, potentially compromising ovarian reserve 4
• The decision between surgery and direct ART should consider the woman's age, ovarian reserve, pain symptoms, and presence of hydrosalpinges or very large endometriomas 3, 6
• Fertility preservation options should be discussed with patients at risk of recurrent endometriosis or premature ovarian failure 4

Decision Algorithm

1. Initial evaluation: Assess endometriosis severity, patient age, ovarian reserve, and other fertility factors
2. For younger patients with good ovarian reserve:
   • Proceed with surgical treatment by experienced surgeon
   • Calculate EFI score post-surgery
   • If EFI score favorable: Try natural conception for 6-12 months
   • If no conception: Proceed with ovarian stimulation ± IUI for up to 6 cycles
   • If still unsuccessful: Move to ART
3. For patients with compromised ovarian reserve or advanced age:
   • Consider GnRH analog treatment for 3-6 months
   • Proceed directly to ART
   • Consider surgery only for pain, hydrosalpinges, or very large endometriomas