Endometriosis and Assisted Reproductive Technologies: Maximizing Outcomes

Eric S. Surrey, MD


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

In This Article

Does Endometriosis Severity Affect IVF Outcome?

If the overall population of endometriosis patients fare as well as controls in more recent analyses of IVF outcomes, then does this hold true with regard to varying degrees of disease severity? It has been suggested that advanced stage endometriosis may induce dysfunctional granulosa cell estrogen and progesterone receptor expression.[11]

Earlier trials had reported significantly lower pregnancy rates after IVF in patients with more advanced disease.[12,13] However, it is important to note that in these studies, oocytes were obtained by laparoscopic as opposed to by transvaginal ultrasound-guided techniques. Dense pelvic adhesions and ovarian disease may have significantly limited the ability to aspirate oocytes effectively in patients with more severe disease, thus compromising outcome. Using ultrasound-guided oocyte aspiration, Azem et al noted reduced fertilization, pregnancy, and birth rates per cycle in 58 patients with stages III and IV endometriosis in comparison with 60 controls with tubal factor infertility.[14] Unfortunately, no comparisons were made with patients with less extensive disease, and, in addition, delivery rates were low in both of the groups (6.7% versus 16.6%, respectively). Pal and coworkers reported that although fertilization rates were significantly lower in patients with stage III and IV in comparison with stage I and II endometriosis, implantation, clinical pregnancy, and miscarriage rates were similar between the groups.[15] Several large investigations have demonstrated no relationship between disease severity and ongoing pregnancy or miscarriage rates.[6,7]

As part of the previously described meta-analysis, Barnhart et al also compared outcomes in patients previously diagnosed with stage I/II endometriosis to those with stage III/IV disease.[9] Women with severe disease were noted to have significantly lower peak estradiol levels and number of oocytes retrieved as well as implantation and pregnancy rates than those with mild endometriosis.

More recently, Kuivasaari et al reported that despite a significantly younger mean age, implantation rates were lower for patients with stage III/IV endometriosis as opposed to either those with stage I/II disease or a control group with tubal infertility[16] (Table 2).

Ballester and coworkers reported that patients with deeply infiltrative endometriosis, which would not typically be captured with standard scoring systems, have significantly lower pregnancy rates than endometriosis patients with more superficial lesions (58% versus 83%; p = 0.003).[17] These investigators created a nomogram predicting pregnancy rates including such parameters as age, serum antimüllerian hormone (AMH) level, and number of cycles and reported that the presence of deeply infiltrative disease was the strongest predictor of clinical pregnancy.