Endometriosis and Assisted Reproductive Technologies: Maximizing Outcomes

Eric S. Surrey, MD

Disclosures

Semin Reprod Med. 2013;31(2):154-163. 

In This Article

Abstract and Introduction

Abstract

In vitro fertilization (IVF) represents the most efficient means of overcoming endometriosis-related infertility. Compromised pelvic anatomy and a hostile peritoneal environment are bypassed. Despite the results of early trials, more contemporary outcomes data would suggest that when controlled for age, IVF cycle outcome is not compromised by the presence of endometriosis. One exception to this concept is the finding that patients with ovarian endometriomas demonstrate poorer response to gonadotropin therapy, although it is not clear that this affects the likelihood of implantation. Surgical ablation of superficial endometriosis has no clear impact on IVF pregnancy rates, although a small number of recent trials suggest that pre-cycle resection of deeply infiltrative disease may be beneficial. With the exception of traditional gynecologic indications, there is no evidence to suggest that resection of ovarian endometriomas has any positive impact on cycle outcome. There are, in fact, data demonstrating that resection may exert a deleterious effect on ovarian reserve. A subset of patients will benefit from administration of a prolonged course of a gonadotropin-releasing hormone agonist prior to an IVF cycle. However, the characteristics of that subset have not been identified. It would be logical to consider this approach in women with more advanced disease, severe symptoms, and a history of implantation failure. Data on the impact of other pre-cycle medical interventions such as aromatase inhibitors, danazol, or oral contraceptives are more limited. There is also no evidence to suggest that the ovarian stimulation associated with IVF induces progression of endometriosis.

Introduction

The relationships between endometriosis and infertility and possible etiologies have been previously discussed. Although surgical management can overcome anatomical distortion caused by this disease, it would be unlikely that such intervention would have an appreciable effect on the alterations in cytokine concentrations, gene expression, or other inflammatory processes that might impede conception in patients with endometriosis. However, in vitro fertilization (IVF)-embryo transfer should not only bypass abnormal pelvic anatomy but also remove gametes from an otherwise hostile peritoneal environment. The 2010 Society for Assisted Reproductive Technology (SART) Clinic Summary reported that 3777 fresh IVF cycles with a primary indication of endometriosis using nondonor oocytes were initiated in the United States during that year.[1] This represented only 3.9% of the 95,625 total cycles. Given the relatively common occurrence of endometriosis in infertile women, this rather low percentage may reflect the lack of performance of routine diagnostic laparoscopy, the inclusion of minimal endometriosis under the category of "unexplained infertility," or the inclusion of endometriosis patients under other primary diagnoses, which were believed to be of greater significance, any one of which would result in an underrepresentation of this diagnosis.

In this review, I address the impact, if any, of endometriosis on IVF outcome and whether this impact can be altered by surgical or medical interventions. Lastly, the question of whether ovarian stimulation associated with IVF can have an impact on disease progression is discussed.

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