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Japanese Translation

Treatment of infertility
(supporting documentation)

Treatment of endometriosis-associated infertility in confirmed disease

Treatment of endometriotic lesions

Hormonal treatment

A

Suppression of ovarian function to improve fertility in minimal-mild endometriosis is not effective and should not be offered for this indication alone (Hughes et al., 2007). The published evidence does not comment on more severe disease.

Evidence Level 1a

Surgical treatment

A

Ablation of endometriotic lesions plus adhesiolysis to improve fertility in minimal-mild endometriosis is effective compared to diagnostic laparoscopy alone (Jacobson et al., 2002).

Evidence Level 1a

The recommendation above is based upon a systematic review and meta-analysis of two, similar but contradictory RCTs comparing laparoscopic surgery (± adhesiolysis) with diagnostic laparoscopy alone. Nevertheless, some members of the working group questioned the strength of the evidence as small numbers were treated in one of the studies (Parazzini, 1999), and although in the other, larger study (Marcoux et al., 1997) there was a significantly higher monthly fecundity rate in the treated compared to the control group, patients were seemingly not blinded to whether they were treated or not. Furthermore the fecundity rates in the latter study was below that observed in control groups from other studies (Hughes et al., 2007).

B

No RCTs or meta-analyses are available to answer the question whether surgical excision of moderate to severe endometriosis enhances pregnancy rate. Based upon three studies (Adamson et al., 1993; Guzick et al., 1997; Osuga et al., 2002) there seems to be a negative correlation between the stage of endometriosis and the spontaneous cumulative pregnancy rate after surgical removal of endometriosis, but statistical significance was only reached in one study (Osuga et al., 2002).

Evidence Level 3

A

Laparoscopic cystectomy for ovarian endometriomas >4 cm diameter improves fertility compared to drainage and coagulation (Beretta et al., 1998; Chapron et al., 2002). Coagulation or laser vaporization of endometriosis without excision of the pseudo-capsule is associated with a significantly increased risk of cyst recurrence (Hart et al., 2005; Vercellini et al., 2003b).

Evidence Level 1b

When endometriosis causes mechanical distortion of the pelvis, surgery should be performed if reconstruction of normal pelvic anatomy can be achieved. According to some published studies there seems to be a negative correlation between the stage of endometriosis and the spontaneous cumulative pregnancy rate after surgical removal of endometriosis. However, data from different studies can not easily be compared as the surgical procedures; extent of surgery, skill of the surgeon etc differed and has certainly not been standardised. No randomised controlled trials or meta-analyses are available to answer the question whether surgical excision of moderate to severe endometriosis enhances the pregnancy rate. Most studies present only crude pregnancy rates without detailed information regarding time of follow-up and are therefore not relevant.

Based on the available literature there is no consensus on the treatment of ovarian endometriosis cysts in women with subfertility. The presence of an endometriotic cyst in women undergoing IUI or IVF supposedly has a negative influence on the results of these treatments, although the literature is far from consistent on this point (Olivennes et al., 1995; Arici et al., 1996). The advantage of surgically treating a cyst before IVF or IUI is the acquisition of a histological diagnosis. A disadvantage is the loss of ovarian tissue containing follicles close to the cyst.

Based on the available literature it is difficult to decide which type of surgical treatment would be the most appropriate for ovarian endometriosis: fenestration and drainage, fenestration, drainage and coagulation of the cystic wall, or cystectomy (Fayez et al., 1988; Fayez et al., 1991; Hemmings et al., 1998; Saleh et al., 1999). Fenestration and drainage does not seem to be sufficient, although no randomised study has been performed (Saleh et al., 1999). A prospective randomised trial compared cystectomy with bipolar coagulation of the cyst wall using recurrence and pregnancy figures as endpoints of the study: cystectomy was shown to be the better treatment for both endpoints (Beretta et al., 1998).

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