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Treatment of endometriosis-associated infertility in confirmed disease

Treatment of endometriotic lesions

Hormonal treatment

A
Supression 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 endometriomas without excision of the pseudo-capsule is associated with a significantly increased risk of cyst recurrence (Vercellini et al., 2003b; Hart et al., 2005).
Evidence
Level 1b

Post-operative treatment

A
Compared to surgery alone or surgery plus placebo, post-operative hormonal treatment has no effect on pregnancy rates (Yap et al., 2004).
Evidence
Level 1a

 

Supporting Documentation

 

 

 

 

This guideline, which is reviewed annually, was last updated on 30 June 2007

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