How can fertility be improved in patients with endometriosis?

Improving Fertility in Patients with Endometriosis

Surgical treatment of endometriosis is the most effective approach to improve fertility in patients with endometriosis, with laparoscopic excision/ablation of endometriotic lesions significantly improving both spontaneous pregnancy rates and outcomes with assisted reproductive technologies. 1, 2

Diagnostic Assessment for Fertility Planning

• Gold standard diagnosis: Laparoscopy with histologic confirmation 1
• First-line imaging: Transvaginal ultrasound (TVUS) with expanded protocols 1
• Prognostic tool: Endometriosis Fertility Index (EFI) - most validated clinical tool for predicting fertility outcomes after surgical staging 1

Treatment Algorithm Based on Disease Stage

Minimal to Moderate Endometriosis

1. Surgical intervention: Laparoscopic excision/ablation of visible lesions

   • Reduces inflammation that impairs fertility 2
   • Improves spontaneous pregnancy rates 1, 2
   • Conventional or robotic laparoscopy is preferred 2

2. Post-surgical fertility enhancement:

   • Intrauterine insemination (IUI) with ovarian stimulation after surgical treatment 3
   • Consider IUI within 6 months post-surgery when fertility benefits are highest 1

Severe Endometriosis

1. Surgical management:

   • Laparoscopic excision of deep infiltrating lesions
   • Use multistep technique to minimize reduction of ovarian reserve 3
   • Remove adhesions and restore normal pelvic anatomy 2

2. Advanced fertility treatments:

   • In vitro fertilization (IVF) is recommended after surgery 1, 4
   • Note: Success rates with IVF decrease with more advanced disease stages 4

Important Considerations

• Avoid hormonal/medical therapy alone for fertility improvement as it has little to no effect on fertility outcomes 4
• Timing is critical: Surgical benefits on fertility may diminish over time with recurrence rates up to 44% within one year 1
• Ovarian reserve concerns:
  • Endometriosis itself causes sustained reduction of ovarian reserve through inflammation 3
  • Surgical treatment can further reduce ovarian reserve during endometriotic tissue resection 3
  • Balance between complete lesion removal and preservation of healthy ovarian tissue is essential

Pitfalls to Avoid

• Delaying surgical intervention when fertility is desired can reduce chances of conception as endometriosis progressively damages ovarian reserve 3
• Relying solely on medical therapy for fertility enhancement is ineffective and should only be used in conjunction with ART 4
• Overlooking the multifactorial nature of endometriosis-related infertility, which includes:
  • Anatomical distortions from adhesions and fibrosis
  • Endocrine abnormalities
  • Immunological disturbances
  • Altered ovarian, tubal, and uterine function 2, 4

By following this evidence-based approach, fertility outcomes can be optimized for women with endometriosis seeking to conceive.