Endometriosis and Assisted Reproductive Technologies: Maximizing Outcomes

Eric S. Surrey, MD


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

In This Article


Although IVF clearly represents the most efficient way for infertile endometriosis patients to conceive, less invasive alternatives should not be ignored. Taken as a whole, patients with endometriosis should expect similar age-based outcomes from IVF as other patients. The possible exception to this contention may be the individual with advanced ovarian disease who may require more aggressive stimulation resulting in a more compromised number of oocytes and embryos.

There is inconclusive evidence to suggest that pre-cycle surgical ablation of superficial endometriosis is of benefit in enhancing IVF outcome, although the outcomes are more encouraging from a small number of studies with weaknesses in design specifically addressing the effects of resecting deeply infiltrative disease. The impact of endometriomas on IVF outcome is not overcome by resection. The indications for doing so should be limited to patients without prior diagnosis of endometriosis, those with symptoms directly related to the mass, rapidly growing lesions particularly with suspicious features, and masses that significantly limit safe access to normal ovarian tissue for oocyte aspiration. Care must be taken to preserve ovarian blood supply and normal ovarian tissue if endometrioma resection is considered to minimize any iatrogenic impact on ovarian reserve.

The administration of a prolonged course of GnRHa, and possibly other suppressive agents, appears to improve IVF cycle outcome. However, the ideal subset of endometriosis patients who are candidates for this approach has not been adequately defined. Nevertheless, primary attention might be given to those with more severe disease with severe pain and/or a history of implantation failure.

It goes without saying that patients with endometriosis who are IVF candidates should undergo the same thorough pre-cycle evaluation as any other patient. This should include at minimum an assessment of ovarian reserve, tubal patency, the uterine cavity, and sperm function. In this way, appropriate pre-cycle therapy, ovarian stimulation protocols, and laboratory techniques can be planned to maximize a successful outcome.