Fadhlaoui, A., Bouquet de la Jolinière, J., & Feki, A. (2014). Endometriosis and infertility: how and when to treat? Frontiers in Surgery, 1, 24. https://doi.org/10.3389/fsurg.2014.00024
Fadhlaoui A, Bouquet de la Jolinière J, Feki A. Endometriosis and infertility: how and when to treat? Front Surg. 2014;1:24. doi:10.3389/fsurg.2014.00024
Fadhlaoui, Anis, et al. "Endometriosis and infertility: how and when to treat?" Frontiers in Surgery, vol. 1, 2014, pp. 24.
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Service de gynécologie obstétrique, HFR Fribourg - Hôpital Cantonal , Fribourg , Switzerland.
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RRM Academy Synopsis
Early endometriosis surgery improves pregnancy, suppression does not
Surgery helped women with early endometriosis get pregnant, and hormone suppression did not help women trying to conceive. This review pulls together guidelines and studies. For advanced disease, cohort studies report pregnancy in over half of women after surgery.
Study at a glance, review: Early endometriosis surgery improves pregnancy, suppression does not. Source: Fadhlaoui A et al., 2014, PMID 25593948.
Key Findings
Among women with endometriosis trying to conceive, ovarian suppression gave no gain in pregnancy or live births over placebo or no treatment, in a large meta-analysis.
For stage I and II disease, operative laparoscopy had a positive effect on live birth and ongoing pregnancy at 20 weeks over diagnostic laparoscopy only (OR 1.64; 95% CI 1.05–2.57).
After laparoscopic surgery, three prospective cohorts found crude spontaneous pregnancy in 57–69% (moderate) and 52–68% (severe). One study found 33% (moderate) and 0% (severe) under expectant management.
A systematic review found pregnancy in 22% after repeat surgery, against 40% after first surgery.
For endometriomas over 3 cm, the ESHRE guideline advises excising the cyst wall over drainage and electro-coagulation, because excision raises spontaneous pregnancy after surgery.
Interpretation
This paper reviews guidelines and studies on endometriosis and fertility. Surgery removed the disease and was linked with more pregnancies at every stage studied. Hormone suppression left the disease in place and did not help women trying to conceive. The authors note reports of lower egg reserve after surgery on endometriomas. The findings support larger, randomized studies of surgery for endometriosis-related infertility.
RRM Context
Surgery that removes lesions works on the disease itself. The review cites the ESHRE guideline's advice to excise endometriomas over 3 cm. It found no pregnancy gain from ovarian suppression in women trying to conceive. Suppression does not remove the disease. RRM Academy endorses excision as the surgical standard. A full fertility evaluation includes the male partner.
Our editorial summary of this paper, not the article's abstract.
Abstract
Endometriosis is defined as the presence of endometrial-like tissue (glands or stroma) outside the uterus, which induces a chronic inflammatory reaction. Although endometriosis impairs fertility, it does not usually completely prevent conception. The question of evidence based-medicine guidelines in endometriosis-associated infertility is weak in many situations. Therefore, we will highlight in this issue where the challenges are.
Endometriosis › Fertility and Outcomes › Conception After Excision · Clinical Guidelines and Standards › Guideline Appraisal › Evidence Base and Strength of Recommendation
Anis Fadhlaoui, Jean Bouquet de la Jolinière, Anis Feki
A Fadhlaoui, J Jolinière, A Feki
PMID 25593948 25593948 DOI 10.3389/fsurg.2014.00024 10.3389/fsurg.2014.00024 Fadhlaoui et al. 2014, Fadhlaoui 2014
01camvb92 
