Management of endometriosis-associated infertility.

Management of infertility associated with endometriosis remains challenging. The clinician must rule out all other causes of infertility before creating a treatment plan. It is important to remember that women with infertility and endometriosis with tubal patency can conceive spontaneously, albeit at lower rates than in the fertile population. Surgical ablation or resection seems to provide benefit even in the absence of correctable anatomic defects. One should note, however, that the goal of surgery is not only to eliminate disease effectively but also to restore pelvic anatomy to normal. After reconstruction or in patients with less extensive disease, controlled ovarian hyperstimulation techniques potentially in conjunction with intrauterine inseminations can be effective. It is important to monitor patients carefully given the risk of high order multiple gestation reported with these techniques. IVF represents an effective means of bypassing the hostile peritoneal environment and anatomic distortion associated with this disease state. Although medical suppression of endometriosis alone has virtually no benefit in the asymptomatic patient, there seems to be significant benefit of pretreatment with GnRH agonists immediately before IVF cycle initiation. Whether only a specific subset or all patients with endometriosis would benefit from this approach has not yet been determined. The use of endometrial implantation markers may be helpful in this regard. The selection of the most effective approach to overcome infertility must be individualized and based on extent of disease, additional infertility factors, patient comfort, and a frank discussion of success rates and risks with patients.