34 - Reproductive Surgery for Endometriosis-Associated Infertility

Summary

In the reproductive-age female, estimates of the general prevalence of endometriosis range from 6 to 11 percent (1–4). Among infertile women, the prevalence of endometriosis has been estimated to be about 20 percent (5). This is in contrast to asymptomatic women undergoing tubal ligation who have a prevalence of 4 percent. Although endometriosis may not be the primary cause of infertility in many of these patients, evidence from several studies support that fecundity is reduced, even in patients with minimal to mild endometriosis (6–8). Having to sort through the diverse therapeutic approaches to endometriosis-associated infertility, to come to a decision regarding the treatment plan often can be a challenging process for even an experienced clinician.

The diversity of choices from expectant management to combined medical/surgical treatment reflects, to some extent, the complex nature of this disease and the explanations for the mechanisms of morbidity. Management decisions are further complicated by coexisting fertility factors, variability of endometriosis presentation, surgical outcome, and, until recently, relatively few good studies to guide us to the best treatment course. Endometriosis may interfere with reproductive outcome by disrupting the hormonal, anatomical, and immunologic milieu of the pelvis. Generally, as the severity of disease increases, alterations within the pelvis become more pronounced, making the timely diagnosis and treatment important to minimize the clinical sequelae.

In patients whose reproductive goals are to maintain or restore fertility, the treatment objectives involve removing or destroying endometrial implants, restoring normal anatomy, and preventing or delaying disease recurrence.