Other studies reported a significant negative correlation between endometriosis stage and pregnancy rate and decreased pregnancy rates when the revised scores exceeded 15 or 70 (183,438,441). Data from different studies cannot be compared easily because of retrospective design, lack of a control group, significant variability and lack of standardization with respect to inclusion criteria, surgical procedures, extent of surgery, skill of the surgeon, variable duration of follow-up without life table analysis, postoperative hormonal suppression or medically assisted reproduction, and lack of control for other infertility-related factors such as male infertility or ovarian dysfunction. These limitations explain why management differed and was not standardized, and why the cumulative pregnancy rates 9 to 12 months after surgery for moderate to severe endometriosis vary between 24% and 30% (1,442–444).
Laparoscopic cystectomy for ovarian endometriomas greater than 4 cm diameter improves fertility compared with drainage and coagulation (300,303).
Medically assisted reproduction—including controlled ovarian hyperstimulation with intrauterine insemination, IVF, and gamete intrafallopian transfer—may be an option for infertility treatment in addition to surgical reconstruction and expectant management (284). Assisted reproductive technology (ART) is the method of choice when distortion of the tubo-ovarian anatomy contraindicates the use of superovulation with intrauterine insemination or gamete intrafallopian transfer (284).
The role of ART in the treatment of endometriosis-associated infertility may be limited in large tertiary care and referral centers for surgical treatment of endometriosis (445). After conservative surgery for endometriosis, 44% conceived in vivo (44%), and 51% of those who failed to conceive in vivo did not undergo ART treatment with the cumulative rate of IVF use at 36 months of infertility at 33%. The live birth/ongoing pregnancy rate per started cycle and per patient was 10% and 20%, respectively (445). For a full discussion on the application of ART infertility, see Chapter 32.
Management of Adolescents