Does Surgical Management of Nonovarian Endometriosis Improve IVF Outcome?
The effectiveness of surgical ablation or resection of endometriotic implants as the sole treatment of endometriosis-related subfertility has been addressed elsewhere. The question of whether such intervention in the absence of ovarian endometriomata would enhance IVF cycle outcome has been less extensively evaluated. One prospective randomized trial reported that, although laparoscopic carbon dioxide laser ablation of endometriosis at the time of gamete intrafallopian transfer (GIFT) had no effect on cycle outcome, pregnancy rates in subsequent cycles of patients who failed to conceive were significantly higher than in controls with endometriosis who underwent GIFT alone. Surrey and Schoolcraft reported that controlled ovarian hyperstimulation and IVF cycle outcomes were similar between two groups of patients with endometriosis but without endometriomas, one of which had undergone surgical resection within 6 months and the other had undergone surgical resection >6 months to 5 years prior to oocyte aspiration (ongoing pregnancy rates 63.6% versus 60.53%, respectively). (Fig. 1) Regression analysis revealed no impact of either the time interval between surgery and oocyte aspiration or endometriosis score on implantation rates. Bedaiwy et al confirmed this finding. It would appear that the previously described benefit derived from such surgery in enhancing spontaneous conception may be masked by the greater impact on implantation and pregnancy achieved with the assisted reproductive technologies.
Ongoing pregnancy and implantation rates in patients undergoing surgical resection of nonovarian endometriosis either ≤6 months or 6 to 60 months prior to oocyte aspiration and in vitro fertilization. Modified from Surrey and Schoolcraft (Fig. 1).25
Two more recent studies would appear to suggest that surgical management may improve cycle outcomes in certain circumstances. A Norwegian retrospective trial compared IVF outcomes in patients with stage I/II endometriosis who either underwent complete surgical resection of lesions or diagnostic laparoscopy only. Implantation (30.9% versus 23.9%; p = 0.02) and live-birth (27.7% versus 20.6%; p = 0.04) rates were significantly higher in the patients who underwent surgical intervention. A second trial evaluated two groups of patients with "symptoms and/or signs" of deeply invasive endometriosis who elected to undergo extensive surgical resection prior to IVF or to proceed directly to IVF. Patients who underwent surgery required significantly higher gonadotropin doses resulting in a lower number of oocytes retrieved, but implantation (32.1 ± 30.6% versus 19 ± 25.1%; p = 0.03) and overall pregnancy rates (41% versus 24%; p = 0.004) were significantly higher. The design of both of these studies is subject to selection bias. An additional weakness of the latter trial is the lack of definitive diagnosis of endometriosis in all patients. Thus one cannot draw definitive conclusions. In an analysis of patients with all stages of endometriosis who failed an initial IVF cycle and then underwent surgical resection prior to a second cycle, no differences in day 3 embryo quality were appreciated. The need for appropriately designed prospective randomized trials to address this issue are critical before one can state that surgical intervention prior to IVF is of benefit in any specific patient population.
Semin Reprod Med. 2013;31(2):154-163. © 2013 Thieme Medical Publishers