Improving fertility in peritoneal endometriosis

Is surgery superior to medication to treat infertility in minimal/mild endometriosis?

Key Points

Importance:

• Recent ESHRE guideline suggests operative laparoscopy for stage I/II of endometriosis to improve pregnancy rates.

Highlights:

• Routine surgery before assisted reproductive technique to improve live birth rates in women with minimal/mild endometriosis is still in debate.

What's done where:

• This article summarized the pregnancy outcomes in women with stage I/II (minimal/mild) endometriosis.

Basic Outlines:

• Peritoneal endometriosis or mild endometriosis (stage I/II) can be found in 40 % of women with endometriosis. It was observed in 19% of all women undergoing sterilization.
• The critical molecular mechanism explaining the pathophysiology of infertility in peritoneal endometriosis is abnormal cell adhesion and invasion.
• Some research in the recent literature shows removing those lesions could improve fecundity.
• Removal of lesions before the treatment of infertility in minimal/mild endometriosis is controversial.
• Studies aimed at improving infertility for minimal/mild endometriosis showed ovulation induction, and IUI is superior to ART cycles.
• Pregnancy of a woman with endometriosis always carries risks such as miscarriage, placenta previa, ectopic pregnancy, preterm delivery, gestational hypertension, and postpartum hemorrhage, regardless of its stage and classification.

Lay Summary

Endometriosis is the most common gynecologic disease that affects 10-15% of women in their reproductive age. The causal relationship between endometriosis and infertility is not clear yet, but adhesions and anatomical distortions due to the progression of the disease are blamed. Although there are many classification systems for endometriosis, the most used one is the revised ASRM (rASRM) classification, based on visualizing the lesions during the operation. According to this classification system, minimal/mild or stage I/II endometriosis is defined as lesions on the surface of the peritoneum and the ovaries without deep and severe adhesions.

Dr.Aydogan Mathyk et al. from the Division of Reproductive Endocrinology and Infertility of the Department of Obstetrics and Gynecology of the University of South Florida, USA, summarized the possibility of infertility and pregnancy outcomes in women with stage I/II endometriosis. Although ESHRE's recommendation for improving live births in minimal and mild endometriosis is operative laparoscopy, using the medication and ART cycles before the laparoscopic surgery is still under discussion.

In asymptomatic cases and unexplained infertility situations, diagnostic/operative laparoscopy may be helpful because of diagnosing endometriosis in 30-40% of percentages among those.

The authors concluded, " Studies comparing the surgical approach to those applying assisted reproductive techniques for improving fertility will eliminate heterogeneity while addressing mild endometriosis cases in the future."

This review was recently published in Best Practice & Research Clinical Obstetrics & Gynaecology.

Research Source: https://pubmed.ncbi.nlm.nih.gov/38760260/