Is operation the best option for infertile patients with digestive endometriosis?

The benefits and risks of any chosen therapeutic strategy for infertile women with digestive endometriosis should be evaluated based on a comprehensive and personalized assessment integrating clinical history, pain symptoms, patient’s age, ovarian reserve, tubal status, and endometriosis lesions.

Key Points

Highlights:

• Although endometriosis causes disabling pain symptoms, it is still a benign disease. Surgical management such as complete resection surgery seems to improve the chances of pregnancy; however, the morbidity is still high to offer it systematically to infertile women.
• When painful symptoms are not disabling and are well controlled by medical treatment, In-vitro fertilization (IVF) / Intracytoplasmic sperm injection (ICSI) management alone could be an effective alternative.

Importance:

• Bowel endometriosis with associated infertility is a real therapeutic challenge for gynecologists. While resection of the lesions alleviates pain and restores spontaneous fertility to some extent, surgery remains technically challenging and may cause severe complications. An alternative strategy to improve spontaneous fertility is the use of medically assisted reproduction. The benefits and risks of each must be taken into consideration to determine whether the infertile patients with bowel endometriosis should be operated on.

What’s done here?

• The authors provide a literature review of many studies investigating surgery or assisted reproduction as a therapeutic strategy for infertile women with digestive endometriosis.

Key results:

• Surgical management improves the chances of pregnancy, although in most cases the pregnancies are not spontaneous but achieved by IVF/ICSI. However, the complications and even morbidity rates are high with surgery. In the presence of ovarian involvement (endometrioma), the surgery may result in alteration of the ovarian reserve.
• The choice of therapeutic strategy for infertile women must be personalized based on the clinical history, the location of endometriosis lesions, pain intensity, ovarian reserve, and the age of the patient.

Limitations of the study:

• Heterogeneity of the studies in literature prevented the complete assessment of treatment strategies. Most studies suffered from a lack of data on the existence of associated causes of infertility, ovarian reserve measures, the precise topography of endometriosis lesions, surgical management and completeness of the excision.

Lay Summary

A severe form of endometriosis affecting 8-12% of women with deep endometriosis is bowel endometriosis. Bowel involvement with associated infertility is a serious challenge for gynecologists who must choose between two main therapeutic options: surgery or medically assisted procreation (e.g. IVF/ICSI). Surgical management requires the intervention of a highly trained team as it can be technically difficult, cause complications, and in the case of ovarian involvement (endometrioma), it may result in the reduction of the ovarian reserve. Therefore, while surgical resection of the lesions alleviates pain and may restore spontaneous fertility, the surgical management of bowel endometriosis for the treatment of associated infertility remains controversial.

In literature, several studies tackled the question of whether operation helps restore fertility in infertile patients with digestive endometriosis. Several studies support radical surgery in order to improve fertility. One study by Vercelline et al., found that postoperative pregnancy rate of infertile patients was 24%. Other studies evaluated partial fertility surgery instead of a radical complete surgery with inconsistent results. Stepniewska et al. found that pregnancy rates were 40% in the radical surgery group versus 30% in the partial surgery group. Dauay-Hauser et al., however, did not find any improvement in pregnancy rates in the case of complete surgery versus partial. Both of these studies suffered from low numbers of subjects involved as well as lack of randomization and clear evaluation of preoperative fertility of the patients. In addition, most studies in the literature are biased and tend to overestimate spontaneous pregnancy rates after surgery due to the absence of a control group as well as missing data such as fertility before surgery, modalities of pregnancy, spontaneous or medically assisted pregnancy.

An alternative therapeutic strategy is the medically assisted reproduction techniques such as IVF/ICSI, which is widely practiced today. The pregnancy rates obtained in patients with digestive endometriosis are comparable to patients with other infertility issues. IVF/ICSI is an effective technique for the management of infertility in digestive endometriosis with few side effects or complications. If painful symptoms of endometriosis are not disabling and well controlled by medical treatment, IVF/ICSI management alone could be an effective alternative to complete surgery, which comes with complications and high morbidity rates.

"Before a radical surgery, an assessment of the benefits and risks is essential. Clinical history of the patient, pain intensity, endometriosis lesions, patient’s age as well as the presence of other associated infertility factors should all be considered" concluded French researchers in their recently published paper in Gynecologie Obstetrique Fertilite & Senologie.

Although there are many studies addressing the best possible therapeutic strategy for infertile women with bowel endometriosis, there is no sufficiently robust study to accurately distinguish which patients would benefit from surgery or assisted reproduction. Large, controlled, randomized prospective studies are needed to further assess the benefit/risk ratios of different therapeutic approaches.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/28864051