Macer, M. L., & Taylor, H. S. (2012). Endometriosis and infertility: a review of the pathogenesis and treatment of endometriosis-associated infertility. Obstetrics and Gynecology Clinics of North America. https://doi.org/10.1016/j.ogc.2012.10.002
Macer ML, Taylor HS. Endometriosis and infertility: a review of the pathogenesis and treatment of endometriosis-associated infertility. Obstetrics and Gynecology Clinics of North America. 2012. doi:10.1016/j.ogc.2012.10.002
Macer, Matthew Latham, and Hugh S. Taylor. "Endometriosis and infertility: a review of the pathogenesis and treatment of endometriosis-associated infertility." Obstetrics and Gynecology Clinics of North America, 2012.
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RRM Academy Synopsis
Excising an endometrioma links to more pregnancies than draining
This paper reviews existing endometriosis research; it is not a new patient study. Excising an endometrioma was linked to more pregnancies than draining or burning it. A large review found that hormone-suppressing drugs did not help women get pregnant.
Pregnancy, mild endometriosis: Endometriosis surgery, 30.7 in 100; Diagnostic surgery alone, 17.7 in 100. Source: Macer ML et al., 2012, DOI 10.1016/j.ogc.2012.10.002.Study at a glance, narrative review: Excising an endometrioma links to more pregnancies than draining. Source: Macer ML et al., 2012, DOI 10.1016/j.ogc.2012.10.002.
Key Findings
A 2010 Cochrane review of 25 trials found ovulation-suppressing drugs did not raise pregnancy odds versus placebo or no treatment across the whole group (odds ratio 0.97, 95% CI 0.68 to 1.34).
The same review found no benefit for couples with trouble getting pregnant either (odds ratio 1.02, 95% CI 0.70 to 1.52).
A trial of 341 women with mild endometriosis found surgery raised pregnancy chances versus diagnostic surgery alone (30.7% versus 17.7%; P = 0.006).
A Cochrane review found excising an endometrioma was linked to a higher spontaneous pregnancy rate than draining or ablating it (odds ratio 5.21, 95% CI 2.04 to 13.29) in subfertile women.
A separate Cochrane review of 3 trials found giving a GnRH agonist before IVF raised the odds of pregnancy in women with endometriosis (odds ratio 4.28, 95% CI 2.00 to 9.15).
Interpretation
This is a narrative review. The authors combine trials, animal research, and Cochrane reviews on endometriosis and infertility. The review's strongest claims, like excision beating ablation for endometriomas, come from randomized trials and Cochrane reviews. The authors' explanations for why endometriosis lowers fertility, such as immune changes, rest mostly on lab and animal research. Trials in infertile couples have not tested them directly. The mechanisms remain proposed and still need direct confirmation. The review covers women of reproductive age with diagnosed endometriosis. The review adds no new follow-up data beyond the studies it cites.
RRM Context
Restorative reproductive medicine treats endometriosis by cutting the disease out. The goal is to remove the lesion itself. For endometriomas, the review reports fewer cyst recurrences and better pain relief after excision than after ablation.
Our editorial summary of this paper, not the article's abstract.
Abstract
Endometriois has been associated with infertility; however, the mechanisms by which it affects fertility are still not fully understood. This article reviews the proposed mechanisms of endometriosis pathogenesis, its effects on fertility, and treatments of endometriosis-associated infertility. Theories on the cause of the disease include retrograde menstruation, coelomic metaplasia, altered immunity, stem cells, and genetics. Endometriosis affects gametes and embryos, the fallopian tubes and embryo transport, and the eutopic endometrium; these abnormalities likely all impact fertility. Current treatment options of endometriosis-associated infertility include surgery, superovulation with intrauterine insemination, and in vitro fertilization. We also discuss potential future treatments for endometriosis-related infertility.
