Treatment for Infertility
The entire infertility evaluation should be completed before considering treatment for endometriosis. For infertile women with suspected minimal or mild endometriosis, a decision must be made whether to perform laparoscopy before starting treatments to enhance fertility. Clearly, factors such as a woman’s age, duration of infertility, and pelvic pain must be considered. Other infertility factors may co-exist and impact success rates and treatment outcome. If pain also is a concern, laparoscopy and surgical treatment seem prudent. In addition, laparoscopy and possible laparotomy (large incision) are recommended when moderate or severe endometriosis is suspected and no other cause of infertility has been found.
Surgery for Infertility
Laparoscopic treatment of minimal and mild endometriosis has been associated with a small but significant improvement in pregnancy rates. In the largest study to date, 29% of women who had their endometriosis treated conceived within nine months, in contrast to only 17% of women whose endometriosis was diagnosed but not treated during laparoscopy. Although this is a modest treatment benefit, it suggests that there is a period of enhanced fertility after laparoscopic treatment of endometriosis. Treatment of moderate and severe endometriosis by laparoscopy and/or laparotomy increases pregnancy rates for women in whom no other causes of infertility have been found. There is no evidence that the outcome is improved by any specific method used to treat endometriosis, such as electrosurgery, laser, excision, or ablation.
Medical Therapy for Infertility
Whereas medical therapy is effective for relieving pain associated with endometriosis, there is no evidence that medical treatment of endometriosis by birth control pills, progestins, GnRH analogs, or danazol improves fertility. Furthermore, surgery combined with medical therapy has not been shown to enhance fertility. Instead, medical treatment before or after surgery may delay unnecessarily further fertility therapy. Nevertheless, these treatments are effective in reducing pelvic pain and painful intercourse associated with endometriosis. Therefore, hormonal suppression may improve comfort and sexual activity in infertile women with endometriosis and pelvic pain, thereby improving fertility after the completion of the treatment.
Expectant Management
A “watchful waiting” approach, also called expectant management, may be an option for younger women after surgery for endometriosis. Up to 40% of women may conceive during the first 8 to 9 months after laparoscopic management of minimal or mild endometriosis. Fertility-enhancing treatments may be offered as an alternative to expectant management or if pregnancy fails to occur within a reasonable time frame. A woman’s age is an important factor in deciding upon specific treatment. Women aged 35 and older have lower fertility potential and higher chances of miscarriage. The decrease in fertility due to endometriosis and age may be additive. Therefore, more aggressive fertility treatments seem reasonable in older women with endometriosis. Watchful waiting is not a good option for women with infertility associated with severe endometriosis.
Fertility Enhancement Treatments
Controlled Ovarian Stimulation and Intrauterine Insemination
Several studies have shown that fertility is enhanced in women with minimal or mild endometriosis by controlled ovarian stimulation (COS) with intrauterine insemination (IUI). This treatment also is called superovulation with IUI. Without treatment, women with minimal/mild endometriosis-related infertility have spontaneous pregnancy rates of 2% to 4.5% per month. The monthly pregnancy rate with intrauterine insemination alone for endometriosis is approximately 5%, and it is approximately 4% to 7% per month for clomiphene citrate, human menopausal gonadotropin (hMG), or follicle-stimulating hormone (FSH) injections when used without intrauterine insemination. However, clomiphene plus IUI improves the monthly pregnancy rates to approximately 9% to 10%, at least for the first 4 treatment cycles. Human menopausal hormone (hMG) or FSH plus IUI improves the success to 9% to 15% per month. COS with clomiphene plus IUI carries a 5% to 15% risk of twins. Multiple pregnancy and ovarian hyperstimulation are risks associated with hMG IUI therapy.
Assisted Reproductive Technology
In general, couples diagnosed with endometriosis have success rates with assisted reproductive technology (ART) procedures such as in vitro fertilization and embryo transfer (IVF-ET) that are similar to those for couples with other causes of infertility. Success rates for ART procedures vary greatly depending on a woman’s age. Nationally, live-birth rates for IVF-ET are approximately 42% for women under age 35, 32% from ages 35 to 37, 22% from ages 38 to 40, and about 12% between 41 and 42 (2010 data). IVF-ET is the most effective treatment for moderate or severe endometriosis, particularly if surgery fails to restore fertility. Some physicians recommend long-term pretreatment with GnRH analogs before starting IVF in women with severe endometriosis, since some, but not all, studies have shown that this approach may improve IVF-ET outcomes.