What we should know in managing infertility related to endometriosis?

Infertility management in endometriosis: basic facts revisited

Key Points

Importance:

• Infertility is a major cause of clinical concern in women with endometriosis. Both the pathogenesis of endometriosis and its surgical treatment may contribute to decreased ovarian reserve.
• Endometriosis surgeries are of utmost importance in managing infertility.

Highlights:

• Multiple mechanisms contribute to infertility in endometriosis patients.
• Besides those being related to its etiopathogenesis, iatrogenic causes related to surgery may also be important especially in decreasing ovarian reserve. 
• Surgical interventions should take the risk of damaging the ovarian reserve into consideration. 

What's done here:

• Physicians involved in the treatment of endometriosis and infertility have made a compilation of factors inherent in endometriosis leading to infertility along with preventing adverse effects of surgical procedures.

Key results: 

• Pelvic anatomy in endometriosis may inhibit ovum capture and fertilization, besides the inflammatory environment of the peritoneal fluid is an adverse factor for conception and embryogenesis.
• Dysregulation of progesterone receptors results in progesterone resistance and endometrial receptivity with luteal phase dysfunction. 
• Additionally, the ovarian reserve is negatively affected by endometriosis. 
• Surgery must be carried out carefully with attention to preserving of the ovarian tissue.
• Repetitive surgeries for endometriosis do not seem to improve fertility.
• Endometriosis patients who do not become pregnant following the first procedure are candidates for in vitro fertilization.

Lay Summary

Dr. Llarena and associates made a comprehensive review of the causes of infertility in endometriosis and adverse effects of surgical procedures in Clinical Medicine Insights: Reproductive Health.

Infertility is an important issue in endometriosis patients and about 30-50 % face infertility. Both the pathogenesis of endometriosis and its surgical treatment contribute to decreased ovarian reserve in this regard. There are multiple mechanisms contributing to infertility in endometriosis patients both being related to its etiopathogenesis and extrinsic causes related to surgery.

Distorted anatomy of the pelvic structures in endometriosis may inhibit ovum capture and fertilization. In addition, the inflammatory environment of the peritoneal fluid adversely affects conception and embryogenesis. Dysregulated progesterone receptors result in progesterone resistance in which endometrial receptivity with luteal phase dysfunction occurs. In addition, the ovarian reserve is reduced de novo in endometriosis patients. 

Surgical procedures are important risk factors in decreasing ovarian reserve. Hence, surgeries should be performed by experts with attention to preserving the ovarian reserve. An important issue not to be forgotten is that consecutive endometriosis surgeries do not improve fertility so that, in vitro fertilization should be taken into consideration early. Endometriosis surgeries are very important in adversely affecting the management of infertility. Endometriosis patients who do not become pregnant following the first procedure are candidates for in vitro fertilization (IVF).

Ovarian suppression may provide a logical method of preventing the development of endometriomas, which are a major threat to fertility.

The authors conclude that fertility preservation with an oocyte or ovarian tissue cryopreservation should be considered on an individual basis for women with endometriosis. 

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/31516316