K Jayakrishnan
Fertility Research and Gynec Centre, KJK Hospital, Shawallace lane, Nalanchira, Trivandrum, Kerala, India.

Corresponding Author: Dr. K Jayakrishnan, Fertility Research and Gynec Centre, KJK Hospital, Shawallace lane, Nalanchira, Trivandrum, Kerala, India 695015. Phone: 9447038040. E-mail: drranupama@gmail.com.

ABSTRACT

Most endometriosis patients have fertility complaints and, in spite of the improvement of assisted reproduction procedures, outcomes remain unsatisfactory. This suggests that there are unknown etiopathogenic influences that adversely affect fertility. Medical treatment with gonadotropin- releasing hormone (GnRH) agonists prior to ART is associated with an increase in pregnancy rates, but clinical therapy alone is considered inefficient for treating endometriosis-associated infertility. Undoubtedly, the best approach must be individualized to each infertile couple, combining improvement of pregnancy rates, reduction of morbidity and following good practice principles. The evaluation must be undertaken in a global manner and the essential factors to be considered are patient’s age, grade and type of endometriosis (ovarian, peritoneal or deep infiltrating) and clinical symptoms of the disease.

Most endometriosis patients have fertility complaints and, in spite of the improvement of assisted reproduction procedures, outcomes remain unsatisfactory. This suggests that there are unknown etiopathogenic influences that adversely affect fertility. Laparoscopic treatment of endometriosis is of questionable efficiency with regard to achieving better fertility results, with controversies mainly surrounding ovarian residual reserve. However, the laparoscopic approach follows good practice principles and is considered a minimally invasive procedure, with the advantage of being diagnostic and therapeutic. Decision to excise endometriomas must be taken cautiously, considering factors such as patient’s age, previous ovarian reserve, previous pelvic surgery, presence of pain or malignancy suspicion, disease extension and the mean diameter of the lesions.Infertility complaints occur in almost 60% of women with endometriosis. Mechanical interference is the most accept phenomenon, But there is an increasing role attributed  to immunological, genetic and hormonal factors, which is still under investigation and certainly contributes to the etiopathogeny of this enigmatic disease.

Although the etiopathogeny of endometriosis and also its causal relationship with infertility remain unclear, the advent of assisted reproduction techniques (ART) allowed an important advance on infertility treatment. However, the outcomes of ART in endometriosis remain unsatisfactory, revealing impaired pregnancy and implantation rates in comparison with infertility due to tubal and male factors according to the meta-analysis of Barnhart et al. in 2002, even though other studies do not support this affirmative.

Medical treatment with gonadotropin- releasing hormone (GnRH) agonists prior to ART is associated with an increase in pregnancy rates, but clinical therapy alone is considered inefficient for treating endometriosis-associated infertility. Owing to its high rates of recurrence (approximately 50% after 5 years of therapy cessation), we are frequently presented with a dilemma between performing ART or adopting a surgical approach as the first choice to achieve better results when treating infertile couples.

Undoubtedly, the best approach must be individualized to each infertile couple, combining improvement of pregnancy rates, reduction of morbidity and following good practice principles. The evaluation must be undertaken in a global manner and the essential factors to be considered are patient’s age, grade and type of endometriosis (ovarian, peritoneal or deep infiltrating) and clinical symptoms of the disease.

End Note

Author Information

Dr. K Jayakrishnan, Fertility Research  and Gynec Centre, KJK Hospital, Shawallace lane, Nalanchira, Trivandrum, Kerala, India – 695015.
Phone: 9447038040. E-mail: drranupama@gmail.com    

Conflict of Interest: None declared