Combine Surgery and In Vitro Fertilization (IVF) in Endometriosis-Related Infertility: When and Why

Abstract

Endometriosis is a chronic, estrogen-dependent inflammatory disease characterized by the presence of endometrial tissue outside the uterus, causing pelvic pain and infertility. Infertility arises mainly due to inflammatory mediators in the peritoneal fluid, contributing to local hypoestrogenism, which appears to exacerbate chronic inflammation and sensitize pelvic nerves. Local hypoestrogenism within endometriotic lesions contrasts with the systemic estrogen-dependent nature of the disease. This localized reduction in estrogen levels, resulting from an altered hormonal response, can contribute to the altered immune response and inflammation characteristic of endometriosis, potentially exacerbating tissue damage, promoting fibrosis, adhesions, and endometrioma formation that distort pelvic anatomy, and affecting fertility. Chronic pelvic pain and dyspareunia further complicate conception in affected women. In vitro fertilization (IVF) and laparoscopic surgical excision of endometriotic lesions are the two primary management options for endometriosis-related infertility, although current data provide limited guidance on when to prefer one approach over the other. It is generally accepted that treatment strategies must be individualized according to the patient's wishes, symptomatology, age and the preferences of the woman and the couple. Timely intervention and structured follow-up for symptomatic women wishing to conceive may maximize conception rates within two years post-surgery, while minimizing the need for repeated interventions, which should be avoided. On the other hand, first-line IVF is particularly viable in cases of unoperated deep infiltrating endometriosis in asymptomatic women, or for those ineligible for or opposed to surgery. This review aims to evaluate the most recent data on endometriosis-related infertility to identify evidence-based key points that can enhance tailored management in clinical practice.

Keywords: endometriosis; in vitro fertilization; infertility.

Figure 1

PRISMA 2020 flow diagram which includes searches of PubMed. Literature search diagram. A total of 1035 papers filled the search string. Of these, 563 articles were excluded because the full text was not available. In addition, 453 were excluded because they were meta-analyses, reviews or systematic reviews, only clinical trials and controlled trials were included. A total of 18 papers were eligible for review. After evaluating the titles and abstracts, 15 articles were excluded because they were not relevant to the topic of the review [18].

Figure 2

Different ultrasonographic cases of pelvic endometriosis. Ovarian involvement may be unilateral (A) or bilateral (B), giving the characteristic ‘kissing ovaries’ sign when the two affected ovaries are attached posteriorly to the uterus. Parametrial endometriosis, nodule involving the right ureter (C). It is important to note that pelvic structures are closely located and therefore it is common for adjacent structures to be infiltrated or retracted by endometriosis, as in the case of the ureter (D,F). Figure (E) shows a case of endometriosis of the anterior wall of the rectum. Often the lesions are multiple, resulting in complex presentations with possible involvement of the ovary, uterosacral ligaments, and rectum, resulting hypomobility of the structures, Douglas’ obliteration and even frozen pelvis.

Figure 3

Laparoscopic view of endometriosis of the posterior compartment involving the left uterosacral ligament and the rectum.

Figure 4

Flowchart for the management of infertile patients in relation to the location of lesions and the presence of symptoms.