IVF Is the Best Option to Become Pregnant for Women with Severe Endometriosis, or Is It Not?

A clinical trial suggests that surgery increase the chance of women with rectal endometriosis to conceive naturally.

Key Points

Highlights:

• Women undergoing surgery to treat their rectal endometriosis have a high chance of becoming pregnant naturally following surgery.

Importance:

• ESHRE currently does not advise surgery for women with deep endometriosis before IVF treatment to improve pregnancy rates.
• However, current research has shown that surgery can reduce endometriosis-associated pain, increases the chance of a woman getting pregnant naturally.

What's done here:

• Researchers from Bordeaux, France, followed up the pregnancy outcome of 55 women with severe endometriosis who underwent surgery to treat their condition.

Key results:

• 81% of women who underwent surgery and who wanted to become pregnant after the operation did become pregnant. 
• 59% of these women became pregnant naturally.
• The probabilities of achieving pregnancy at one, two, three, and four years following surgery were 33.4%, 60.6%, 77%, and 86.8% respectively.
• In infertile patients, the pregnancy rate after surgery was 74% with 53% of pregnancies being achieved naturally.
• Women who were advised to try to become pregnant naturally after surgery became pregnant significantly earlier than those who were advised to have IVF.

Limitations:

• The aim of the clinical trial was originally to assess the digestive outcome of endometriosis surgery, not pregnancy. 
• Because the analysis only included 55 women, several factors impacting fertility could not be revealed. 
• Most women in the study were young (average age 28) and had a naturally high chance of becoming pregnant. The results obtained in the study might not be valid for older women. 
• Only large infiltrations of the rectum were included in the study and the outcome might not be the same for surgery where small nodules are cut out.
• All operations were performed by a single skilled gynecologic surgeon. The rates might be different if women are operated by other surgeons.

Lay Summary

Treating rectal endometriosis with surgery seems to increase the chance of a woman conceiving, with most pregnancies occurring naturally. This is according to a study published in the medical journal Human Reproduction. 

The optimal treatment for women with severe endometriosis wishing to become pregnant is strongly debated with some doctors supporting the use of surgery as the best treatment option and others favoring assisted reproductive techniques such as IVF. 

The European Society of Human Reproduction and Embryology (ESHRE) states that there is no evidence supporting the use of surgery in women with deep endometriosis before IVF treatment to improve pregnancy rates. However, research has shown that surgery can reduce endometriosis-associated pain, which could increase the chance of a woman getting pregnant naturally because it might increase the rate of regular sexual intercourse.

In the present study, a team of researchers led by Dr. Benjamin Merlot at Clinique Tivoli-Ducos in Bordeaux, France analyzed 55 out of 60 women who enrolled in a clinical trial, the aim of which was to assess the digestive and urinary outcomes of surgery to treat deep endometriosis infiltrating the rectum. All 55 women had endometriosis surgery and were followed for between four and six years. A total of 36 of these 55 women wanted to get pregnant after their surgery. 

The researchers found that at the end of the follow-up period 29 patients became pregnant (80.5 percent of those wanting to become pregnant), 17 of them doing so naturally.  The probability of becoming pregnant at one, two, three, and four years after endometriosis surgery was 33.4, 60.6, 77, and 86.8 percent respectively.

Importantly, women who were advised to attempt natural conception following surgery became pregnant significantly earlier than those who were advised to undergo IVF treatment.

The authors concluded that both surgery and pregnancy are possible for women with severe endometriosis despite most women diagnosed with the disease thinking that the only way they can become pregnant is by undergoing IVF and keeping their painful nodules.

They also stressed the importance of surgeons giving adequate advice to women who undergo surgery about their chance of conceiving naturally following the operation. “Physicians should ultimately offer patients a balanced perspective of the potential benefits and potential harms of alternative options, including considerations on the strength of the available evidence supporting them, in order to help them in choosing the best strategy adapted to their goals, symptoms, and beliefs,” the researchers wrote.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/30052994