Should Women with Endometriosis have IVF Treatment to Conceive Following Laparoscopic Surgery?

Yes, but only if they belong to a predefined group, study suggests.

Key Points

Highlights:

• IVF treatment following endometriosis surgery can be considered as the gold-standard in the management of endometriosis-associated infertility in women younger than 35, have a good ovarian reserve, and partners with standard semen parameters, and only if they failed to become pregnant naturally within a year following surgery.

Importance:

• The results of this study could help the decision about the treatment of patients who are affected by endometriosis-associated infertility.

Key results:

• There were no significant differences in delivery rate between women with endometriosis who underwent laparoscopic surgery and conceived naturally and those who had IVF following surgery.
• There were differences between the two groups of women in several parameters measuring neonatal outcomes in agreement with what is already known for IVF pregnancies.
• 92 out of 237 women analyzed became pregnant for the second time. 54 out of 61 women who only had surgery and no IVF became pregnant naturally the second time too. Of the 31 women who needed IVF treatment following surgery to conceive, 17 became pregnant naturally the second time.

Limitations of the study:

• This is a retrospective study, so data about 14 percent of pregnancies and 17 percent of deliveries were lost to follow-up.
• It was a single center study which could introduce some bias to the study results.
• The study only examined a subgroup of carefully selected women. The results obtained may not be valid for all women with endometriosis who are infertile.

Lay Summary

Women affected by endometriosis-associated infertility who are younger than 35, and have a good ovarian reserve and a partner with normal semen parameters can benefit from a so-called integrated approach for the management of their infertility, according to a study published in the scientific journal Archives of Gynecology and Obstetrics.

An integrated approach is defined as "endometriosis surgery followed by in-vitro fertilization (IVF)" if pregnancy does not occur naturally within a year following surgery.

This is based on the analysis of 237 infertile women due to endometriosis. All women were referred to the University Medical Centre in Ljubljana, Slovenia between January 2004 and December 2007 with a complaint of endometriosis-associated infertility.

For the study, the researchers evaluated the women’s delivery rate, the maternal and neonatal outcomes of their first pregnancies, and whether subsequent conceptions where spontaneous or required IVF. All women underwent laparoscopic surgery. A total of 139 women had spontaneous pregnancies between six to twelve months after surgery. The remaining 98 were offered IVF, of whom 93 accepted the treatment.   The researchers analyzed whether there were differences in delivery rate between women who underwent surgery only and those who had IVF following surgery and found no significant differences between the two groups. 

However, when they analyzed the data further, the authors found that women who had IVF treatment following endometriosis surgery had babies with lower birth weight. Their babies were also born earlier, were smaller for their age, and were more likely to be treated in the neonatal intensive care unit compared to babies who were conceived naturally.

It is already known that IVF pregnancies are more likely associated with adverse neonatal outcomes, mainly due to higher rates of twin pregnancies following IVF treatment and the findings of this study were consistent with this knowledge. 

The researchers did not find any significant difference between women who had IVF treatment following endometriosis surgery and those who did not, regarding the rate of Cesarean sections, placenta praevia (a condition where the placenta is lying unusually low in the uterus), and heavy bleeding before or after delivery. 

Interestingly, 61 women who had endometriosis surgery and 31 women who had IVF treatment following surgery became pregnant a second time. A total of 54 of the 61 women (88.5 percent) who only had surgery conceived the second time without medical assistance, while 17 of the 31 women (54.8%) who also had IVF treatment conceived naturally.   

These findings led the authors to conclude that among women who are infertile due to endometriosis those who are younger than 35, have a healthy ovarian reserve and partners with a healthy semen parameters would particularly benefit from an integrated approach. However, according to the authors, it is essential that women are encouraged to pursue natural conception after the surgery, which would reduce the risks associated with IVF. IVF should only be offered if pregnancy does not occur between six to twelve months after surgery, they said. 

The management of endometriosis-associated infertility remains a challenge for women who are older than 35. 

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/29274003