Pelvic Factor Endometriosis Endometriosis affects 6% to 10% of all women during their reproductive years but is present in 25% to 50% of infertile women (212,265). It is characterized by the presence of endometrial tissue growing outside the uterine cavity and is found primarily on the peritoneum, ovaries, and rectovaginal septum (265). Fecundability rates in affected patients are estimated at 2% to 10% per month (266). Possible mechanisms for infertility among women with endometriosis include anatomic distortion from adhesions or fibrosis and the known presence of inﬂammatory mediators that exert toxic effects on gametes, embryos, tubal fimbria, and eutopic endometrium (265,266). Laparoscopy for direct visualization remains the mainstay in the diagnosis of endometriosis. The disease is staged laparoscopically according to the Revised American Society for Reproductive Medicine’s classification, with stages III and IV (moderate to severe) including ovarian endometriomas, dense tubal or ovarian adhesions, and/or cul-de-sac obliteration (265). However, laparoscopy can miss deep disease that may better be detected by ultrasound (i.e., endometriomas) and rectovaginal examination (267). It is unclear whether the presence of endometriosis negatively affects IVF outcomes, although some reports indicate a worse prognosis for more severe disease (stages III and IV) (221,268).
Endometriosis Infertility Managment Hormonal suppression of endometriosis typically has a minimal benefit for endometriosis-related infertility (265). In minimal to mild disease, laparoscopic ablation appears to significantly improve pregnancy rates when compared to diagnostic laparoscopy alone, although there remains some dissent (267,269). One major randomized trial reported 31% versus 17% pregnancy rates over 3 years with a subsequent meta-analysis supporting these findings (265,266,270,271). Although authors have estimated that eight laparoscopies involving treatment of mild or minimal endometriosis would need to be performed for each pregnancy gained, that number is likely to be much higher given that not everyone who undergoes laparoscopy will have endometriosis (267,270). The benefit of surgical management of endometriosis is even less clear for moderate to severe disease, although removal of endometriomas may be indicated prior to IVF when they would interfere with oocyte retrieval (265–267). Endometrioma resection during IVF or ICSI treatment is associated with decreased ovarian function in up to 13% of cases (272,273). Furthermore, 40% of endometriomas recur postoperatively, and conﬂicting reports exist that show increases and decreases in pregnancy and live birth rates after surgery (267,272,273). Therefore, IVF is considered a reasonable first-line therapy for endometriosis-associated infertility because of the short time to pregnancy and avoidance of surgery (221).
Adhesions Adhesions may result from sharp, mechanical, or thermal injury, infection, radiation, ischemia, dessication, abrasion, or foreign body reaction. Adhesiolysis improves pregnancy rates by 12% at 1 year and by 29% at 2 years in infertile women with adnexal adhesions. Use of adhesion barriers reduces adhesion formation following laparoscopy and laparotomy, but there is no evidence to date for improvement in pregnancy rates (274,275).