Endometriosis and infertility
The Practice Committee of the American Society for Reproductive Medicine
Women with endometriosis typically present with pelvic pain, infertility or an adnexal mass. Surgery forpersistent adnexal masses may be indicated to remove an endometrioma or other pelvic pathology. Surgical ormedical therapy is efficacious for pelvic pain due to endometriosis, but treatment of endometriosis in the femalepartner of an infertile couple raises a number of complex clinical questions that do not have simple answers.
(Fertil Steril 2006;86(Suppl 4):S156 – 60. 2006 by American Society for Reproductive Medicine.)
Women with endometriosis typically present with pelvic
the 1980s in which fecundity of women with minimal endo-
pain, infertility or an adnexal mass. Surgery for persistent
metriosis was similar to that of other women undergoing
adnexal masses may be indicated to remove an endometri-
donor insemination On the premise that endometriosis
oma or other pelvic pathology. Surgical or medical therapy is
does cause infertility, then eradication of the disease should
efficacious for pelvic pain due to endometriosis, but treat-
improve fecundity. Two randomized controlled trials (RCTs)
ment of endometriosis in the female partner of an infertile
have compared outcomes following laparoscopic ablation or
couple raises a number of complex clinical questions that do
expectant management of endometriosis. In the Canadian
not have simple answers. There are few infertility problems
Collaborative Group on Endometriosis RCT involving 341
requiring greater clinical acumen than those needed to plan
women with stage I/II disease followed for 36 weeks after
therapy for an infertile woman with endometriosis.
laparoscopy, monthly fecundity was 0.047 and 0.024 in theablated and untreated groups, respectively In theGruppo Italiano per lo Studio dell’ Endometriosi RCT in-
FECUNDITY IN WOMEN WITH ENDOMETRIOSIS
volving 101 women with stage I/II disease followed for 52
Fecundity is defined as the probability of a woman achieving
weeks after laparoscopy, fecundity was 0.016 and 0.019 in
a live birth for any given month In normal couples,
the ablated and untreated groups, respectively Although
fecundity is in the range of 0.15 to 0.20 per month and
fecundity was significantly improved only in the Canadian
decreases with age In untreated women with endome-
surgical trial, fecundity remained significantly lower than that
triosis and infertility, monthly fecundity is 0.02 to 0.10
observed in normal fertile women. Thus the visible lesions of
Early studies suggested that 25% to 50% of infertile women
endometriosis contribute only a small fraction of the reduced
have endometriosis and that 30% to 50% of women with
fecundity seen in women with endometriosis.
endometriosis are infertile There is a higher prevalenceof endometriosis in infertile women (48%) compared withfertile women undergoing tubal sterilization (5%) Other
BIOLOGIC MECHANISMS THAT MAY LINK
reports have confirmed that infertile women are 6 to 8 times
ENDOMETRIOSIS AND INFERTILITY
more likely to have endometriosis than fertile women
Several mechanisms have been proposed to clarify the asso-ciation between endometriosis and infertility It shouldbe emphasized that none of these mechanisms has been
ENDOMETRIOSIS AND INFERTILITY: CAUSE AND EFFECT
proven to decrease fecundity in women. These mechanisms
The hypothesis that endometriosis causes infertility or a
decrease in fecundity remains controversial. Whereas thereis a reasonable body of evidence to demonstrate an associ-ation between endometriosis and infertility, a cause and
Distorted Pelvic Anatomy
effect relationship has not been established. In a prospective
Major pelvic adhesions, including those that result from
study of women undergoing therapeutic donor insemination,
endometriosis, can impair oocyte release from the ovary or
fecundity was 0.12 in women without endometriosis and
0.036 in those with minimal endometriosis The results ofthis study were at odds with two retrospective studies from
Altered Peritoneal Function
Many studies demonstrate that women with endometriosis
have an increased volume of peritoneal fluid, increased con-
Reviewed June 2006.
centration of activated macrophages and increased peritoneal
Received January 12, 2004; revised and accepted January 12, 2004.
fluid concentrations of prostaglandins, interleukin-1, tumor
necrosis factor and proteases. Peritoneal fluid from women
Correspondence to: Practice Committee, American Society for Reproduc-
tive Medicine, 1209 Montgomery Highway, Birmingham, Alabama 35216.
with endometriosis reportedly contains an ovum capture
Fertility and Sterilityா Vol. 86, Suppl 4, November 2006
Copyright 2006 American Society for Reproductive Medicine, Published by Elsevier Inc.
inhibitor that prevents normal cumulus-fimbria interaction
endometriosis (ASRM 1996) is the most widely accepted
These alterations may have adverse effects on the oocyte,
staging system Unfortunately, the staging system does
sperm, embryo or fallopian tube function
not correlate well with a woman’s chance of conceptionfollowing therapy. This poor predictive ability is related tothe arbitrary assignment of a point score for the observed
Altered Hormonal and Cell-Mediated Function
pathology and the arbitrary cut-off points chosen to establish
IgG and IgA antibodies and lymphocytes may be increased
the stage of disease. The ASRM 1996 classification system
in the endometrium of women with endometriosis. These
might be enhanced by including a description of the mor-
abnormalities may alter endometrial receptivity and embryo
phologic subtype of disease or other biological markers
implantation. Autoantibodies to endometrial antigens are re-
It is unlikely that any accurate staging system will be intro-
ported to be increased in some women with endometriosis
duced until we have a better understanding of the pathophys-iology of endometriosis-associated infertility.
Endocrine and Ovulatory Abnormalities
It has been proposed that women with endometriosis may
MEDICAL THERAPY FOR ENDOMETRIOSIS
have endocrine and ovulatory disorders, including the lutein-
Whereas medical therapy is effective for relieving pain associ-
ized unruptured follicle syndrome, luteal phase dysfunction,
ated with endometriosis, there is no evidence that medical
abnormal follicular growth and premature as well as multiple
treatment of endometriosis improves fecundity. Several options
luteinizing hormone (LH) surges Whereas these hypoth-
have been suggested for treatment: danazol, gonadotropin-
eses have been proposed, there is no evidence to validate them.
releasing hormone agonists (GnRH-a) and antagonists, pro-gestins and combined estrogen-progestin therapy. Several
RCTs demonstrate that danazol, other progestins or GnRH-a
Mounting evidence suggests that disorders of endometrial
are not effective treatments for infertility associated with
function may contribute to the deceased fecundity observed
minimal to mild endometriosis In two RCTs in-
in women with endometriosis. Reduced endometrial expres-
volving 105 infertile women with minimal to mild endome-
sion of the ␣v␤ integrin (a cell adhesion molecule) during
triosis, pregnancy rates were no better with danazol than
the time of implantation has been described in some women
expectant management In an RCT involving 71
with endometriosis More recently, very low levels of an
infertile women with minimal to mild endometriosis, the one
enzyme involved in the synthesis of the endometrial ligand for
and two-year cumulative pregnancy rates were similar in the
L-section (a protein that coats the trophoblast on the surface of
groups receiving GnRH-a treatment (6 months) or expectant
the blastocyst) have been observed in infertile women with
management In a small RCT involving 37 infertile
endometriosis These data lend credence to the hypothesis
women with minimal to mild endometriosis treated with
that functional disorders of the endometrium may both predis-
progestins or expectant management, pregnancy rates were
pose to the development of endometriosis and impair implan-
similar at one year in both groups Also, in a small RCT
tation mechanisms in affected women.
involving 31 women, pregnancy rates with progestins andexpectant management were 41% and 43%, respectivelyIn a meta-analysis that included seven studies compar-
DIAGNOSIS AND STAGING
ing medical treatment to no treatment or placebo, the com-
The current clinical opinion is that a surgical procedure such
mon odds ratio for pregnancy was 0.85 (95% CI 0.95, 1.22)
as laparoscopy is required for definitive diagnosis of endo-
Thus hormonal treatment does not improve the fecundity
metriosis. Given this state of clinical practice, an important
of infertile women with Stage I/II endometriosis.
question is when to perform laparoscopy to determine ifendometriosis is present. A history and physical examinationcan yield a number of significant findings, including affected
SURGERY FOR ENDOMETRIOSIS
first degree relatives, chronic pelvic pain and dysmenorrhea,
In stage I/II endometriosis, laparoscopic ablation of endometrial
retroverted uterus, adnexal masses, cul de sac nodularity and
implants has been associated with a small but significant im-
uterosacral ligament thickening and tenderness, but none is
provement in live birth rates. Two RCTs have reported on the
diagnostic. Ultrasound can help the clinician establish a
effectiveness of laparoscopic surgery for Stage I or II endome-
presumptive diagnosis of ovarian involvement with endome-
triosis associated with infertility Both studies permit-
triosis, but laparoscopy is necessary to confirm the diagnosis.
ted surgical discretion in the intervention regarding excision
Endometriosis is a heterogeneous disease with typical and
or ablation. The primary outcomes were slightly different:
atypical morphology and spanning a spectrum from a single
the Italian study analyzed pregnancies which occurred
1-mm peritoneal implant to 10-cm endometriomas with cul-
within one year after laparoscopy and proceeded to live
de-sac obliteration Consequently, a clinical staging system
births; the Canadian study analyzed pregnancies which oc-
is necessary to allow clinicians to communicate effectively
curred within 36 weeks after laparoscopy and proceeded to
regarding prognosis and treatment. The American Society
20 weeks gestation, an end- point which is nearly identical to
for Reproductive Medicine revised classification system for
the live birth rate. In the Italian study, 10/51 (20%) and 10/45
FERTILITY & STERILITY
(22%) of the ablation/ resection and no treatment patients,
monthly fecundity in the gonadotropin/IUI group (0.09)
respectively, were successful. In the Canadian study, 50/172
was significantly higher than the monthly fecundity in the
(29%) and 29/169 (17%) of the ablation/resection and no
IUI group (0.05), the gonadotropin/IC group (0.04) and
treatment patients, respectively, were successful. The base-
line untreated rates were 22% in 52 weeks and 17% in 36weeks, respectively, in the Italian and Canadian patients,
Several studies also report success with SO/IUI in the
indicating that the patient populations were similar. The
treatment of endometriosis-associated infertility. In an RCT
main difference was the lower power of the Italian study,
comparing clomiphene citrate and IUI with preovulatory
which was planned to detect a 2.7 fold higher live birth rate
intercourse in patients with unexplained infertility or surgi-
with ablation/resection When the results are combined,
cally corrected endometriosis, a statistically significant in-
there is no significant statistical heterogeneity and the overall
crease in cycle fecundity was seen with four cycles of
absolute difference is 8.6% in favor of therapy (95% CI 2.1,
clomiphene citrate/IUI compared with controls (0.095 versus
15) The number needed to treat is 12 (95% CI 7, 49).
0.033, respectively) Another study randomized patients
Thus, for every 12 patients having Stage I/II endometriosis
to receive either gonadotropins with intercourse or gonado-
diagnosed at laparoscopy, there will be one additional suc-
tropins with IUI All patients had endometriosis previ-
cessful pregnancy if ablation/ resection of visible endome-
ously treated with laser laparoscopy. The fecundity was
triosis is performed, compared to no treatment. There is no
greater in the gonadotropin/IUI group (0.129; n ϭ 109) than
evidence that the outcome is affected by the method of
in the intercourse group (0.066; n ϭ 76). A randomized trial
ablation, by electro-surgery or laser delivery systems
of 40 women with stage I/II endometriosis and infertilitystudied the effect of either three cycles of gonadotropin/IUI
A nonrandomized study demonstrated that the cumula-
or no treatment (expectant management) The fecundity
tive probability of pregnancy in 216 infertile patients with
was 0.15 in the gonadotropin/IUI group and 0.045 in the
severe endometriosis, followed for up to 2 years after lapa-
untreated group (P
Ͻ.05). Another study reported on the
roscopy or laparotomy, was significantly increased, 45% and
effects of expectant management, clomiphene citrate, gonad-
63%, respectively These and other observational stud-
otropins or in vitro fertilization-embryo transfer (IVF-ET) on
ies, that are not free from bias, suggest that in women with
fecundity in women with infertility and minimal or mild
Stage III/IV endometriosis, without other identifiable infer-
endometriosis The observed cycle fecundity with go-
tility factors, conservative surgical treatment with laparos-
nadotropin treatment alone (0.073) was significantly higher
copy and possible laparotomy may increase fertility
COMBINATION MEDICAL AND SURGICAL THERAPY
ASSISTED REPRODUCTIVE TECHNOLOGY
Combination medical and surgical therapy for endometriosis
The most recent report on in vitro fertilization-embryo transfer
consists of either preoperative or postoperative medical ther-
(IVF-ET) outcomes in the United States indicates that the overall
apy. Although theoretically advantageous, there is no evi-
delivery rate per retrieval in infertile women is 29.4%
dence in the literature that combination medical-surgicaltreatment significantly enhances fertility and it may unnec-
There are no large RCTs which definitely demonstrate that
essarily delay further fertility therapy. Preoperative therapy
IVF-ET is more effective than expectant management in the
is reported to reduce pelvic vascularity and the size of
treatment of stage-specific infertility associated with endome-
endometriotic implants, thus reducing intraoperative blood
triosis. In one small RCT, 21 women with endometriosis and
loss and decreasing the amount of surgical resection needed.
infertility were randomized to receive either IVF (n ϭ 15) or
Postoperative medical therapy has been advocated as a
expectant management (n ϭ 6) None of the women in the
means to eradicate residual endometriotic implants in pa-
expectant management group became pregnant compared to five
tients with extensive disease in whom resection of all im-
of the 15 women who received IVF-ET (33%, P
plants is impossible or inadvisable. Postoperative hormonaltherapy may also treat “microscopic disease”; however, none
Several studies suggest that in women with advanced
of these treatments has been proven to enhance fertility.
endometriosis, long-term treatment with GnRH-a before ini-tiation of a cycle may improve fecundity. Among patientswith severe endometriosis, 6 months of hormonal suppres-
SUPEROVULATION AND INTRAUTERINE
sion with GnRH-a resulted in higher numbers of oocytes
retrieved, embryos transferred, and pregnancies The
Superovulation (SO) with gonadotropins and intrauterine
investigators concluded that long-term GnRH-a therapy
insemination (IUI) are frequently used to treat women
might reduce preclinical abortions in patients with severe
with infertility An NIH Reproductive Medicine Net-
endometriosis who are undergoing IVF-ET A recent study
work study of 932 infertile couples with Stage I/II endo-
demonstrated the benefits of prolonged down-regulation with
metriosis or otherwise unexplained infertility randomized
GnRH-a before initiation of IVF-ET in patients with endome-
patients to intracervical insemination (IC), IUI, gonado-
triosis In this RCT, the overall experience with 51 patients
tropin/IC or gonadotropin/IUI. In this large RTC the
undergoing IVF-ET demonstrated significantly higher ongoing
Endometriosis and infertility
Cycle fecundity in women with stage I or II endometriosis, according to treatment.
No treatment or intracervical insemination
Ͻ.05 for treatment vs. no treatment.
ASRM Practice Committee. Endometriosis and infertility. Fertil Steril 2006.
pregnancy rates with prolonged dura- tion of GnRH-a use
tive surgery with laparoscopy and possible laparotomy are
before IVF-ET Although these studies suggest that longer
recommended. Several studies suggest that surgical therapy
periods of pretreatment with GnRH-a will improve implanta-
increases fertility in women with advanced endometriosis
tion rates in patients, with endometriosis who undertake IVF-
These studies indicate that expectant management is not a good
ET, support for this treatment strategy is not unanimous
option for women with infertility and severe endometriosis.
However, it should be pointed out that there are no RCTs to
CLINICAL APPROACH TO INFERTILE WOMEN
define results of surgical treatment for stage III/IV disease.
For infertile women who have stage III/IV endometriosis
Clinical decisions in the management of infertility associated
and have previously had one or more infertility operations,
with endometriosis are difficult because few RCTs have
IVF-ET is often a better therapeutic option than another
been conducted to evaluate and compare the effectiveness of
infertility operation. There is no sufficiently powered pro-
the various forms of treatment. Moreover, the available data
spective randomized trial evaluating the effect on pregnancy
are conflicting and prevent confident conclusions.
outcome of surgical treatment followed by IVF-ET versus
For infertile women with suspected stage I/II endometri-
IVF-ET alone. In one retrospective study, 23 women with
osis, a decision must be made whether to perform laparos-
stage III/IV endometriosis underwent IVF-ET and 18
copy before offering treatment with clomiphene, gonadotro-
women underwent repeat surgery The pregnancy rate
pins or IVF-ET. Clearly, the factors such as the patient’s age,
after two cycles of IVF-ET was 70%, whereas the cumula-
duration of infertility, family history and pelvic pain must be
tive pregnancy rate was 24% within 9 months of a repeat
taken into consideration. When laparoscopy is performed,
operation. If initial surgery fails to restore fertility in patients
the safe ablation or excision of visible endometriosis should
with moderate to severe endometriosis, IVF-ET is an effec-
be considered based on observations from RTC. This should
tive alternative. In summary, there are limited data available
be discussed openly with the patient when planning her
to estimate the effect of surgical treatment in addition to
treatment. Of course, if pain were also a concern, laparos-
IVF-ET on the outcome of pregnancy in endometriosis-
copy and surgical treatment would be appropriate. Expectant
management after laparoscopy is an option for youngerwomen. Alternatively, superovulation with IUI may be of-
SUMMARY AND RECOMMENDATIONS
fered. Female age is an important factor in designing ther-
● There are few RCTs on the treatment of endometriosis-
apy. After age 35, there is a significant decrease in fecundity
and an increase in the spontaneous abortion rate. The de-
● Female age, duration of infertility, family history, pelvic
crease in fecundity due to the two variables of endometriosis
pain and stage of endometriosis should be taken into
and age may be additive. Consequently, in the older infertile
account when formulating a management plan.
woman with endometriosis, a more aggressive therapeutic
● When laparoscopy is performed, the surgeon should consider
plan with SO/IUI or IVF-ET may be reasonable rather than
safely ablating or excising visible lesions of endometriosis.
● In women with stage I/II endometriosis-associated infer-
For infertile women with ASRM 1996 stage III/IV endome-
tility, expectant management or superovulation/IUI after
triosis and no other identifiable infertility factor the conserva-
laparoscopy can be considered for younger patients.
FERTILITY & STERILITY
Women 35 years of age or older should be treated with
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MS, et al. Trophoblast L-selectin-mediated adhesion at the maternal-
and possible laparotomy are indicated.
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● For women with stage III/IV endometriosis who fail to
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Expression profiling of endometrium from women with endometriosis
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infertility. Endocrinology 2003;144:2870 – 81.
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This report was developed under the direction of the
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Endometriosis and infertility
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