Endometriosis and infertility: how to improve clinical practice
Deep endometriosis is a disease that can cause pain and affect fertility. Its management is especially complex in two situations: the delay of motherhood and adenomyosis, which is characterized by the presence of endometrial tissue in the musculature of the uterus. One of the questions asked by specialists is whether the decision to intervene surgically can improve the results of in vitro fertilization (IVF). According to the scientific literature, surgery to remove endometriomas has a negative impact on the ovarian reserve and it has been proven that it does not improve the results in IVF. Therefore, when addressing this disease it is essential that the patient is studied by a multidisciplinary team of specialists in different fields, taking into account various aspects: patient's age, if she suffers from chronic pelvic pain, has digestive or urinary problems , suffers from dysmenorrhea or dyspareunia, has or not already undergone surgery, has a stable partner and the age and quality of the sperm of her partner, among other factors.
In general, when the patient has infertility problems a balance must be taken before deciding on the best treatment: the surgical intervention is more indicated if the patient is young (35 years old or younger), if she suffers pain that cannot be controlled with the usual treatments, if she has large endometriomas or other unforeseen problems, such as an ultrasound that does not allow to clearly appreciate the impact or extent of the disease, or a urethral or intestinal stenosis.
On the other hand, the fact that the patient has undergone some previous surgery, has adenomyosis, has a low ovarian reserve or bilateral endometriomas tip the balance in favour of an in vitro fertilization treatment. If the partner has infertility problems is also another factor in favour of IVF.
Moreover, the relationship between endometriosis and infertility cannot always be predicted. An early diagnosis and knowing the patient's medical history increase the possibility of controlling possible problems. Offering medical treatment and avoiding repeated surgeries are also two important factors that should be taken into account.
The possibility of complications arising from assisted reproduction treatment exists, so it is essential to make a good assessment of each case. In any case, and according to published studies, the risk that the pain increases after IVF is moderate and that the disease worsens because of the hormonal treatment of ovarian stimulation is low.
Therefore, it is essential that reproduction specialists and surgery experts jointly assess what may be the most appropriate treatment in each case and that patients are also offered information about it and about the options that exist so that they can make their own decisions under medical advice. If it is decided that it is not the optimal time for motherhood, it is convenient to offer the possibility of preserving the oocytes as soon as possible.
Conference: How accurate diagnosis, good surgical skills and simultaneous ART assessment become the best practice in DIE prior to any treatment
Pere N. Barri, Nuria Barbany, Carlota Vilarrubí, Iñaki Gonzalez.
ESGE 28th Annual Congress 2019, 6-9 October,Thessaloniki, Greece.