Integrating IVF and Surgical Management in Endometriosis-Associated Infertility: A Review

Endometriosis is a chronic, debilitating condition characterized by heterogenous clinical manifestations. It has a prevalence of 5-10% in women of reproductive age, and 30-50% of individuals with endometriosis are affected by infertility. There are multiple mechanisms through which endometriosis can lead to infertility: reduced ovarian reserve, distorted pelvic anatomy, chronic inflammation, altered immunity, dyspareunia, and/or altered hormonal and cell-mediated endometrial function. The revised American Society for Reproductive Medicine (rASRM) classification was one of the initial methods to stage disease severity. The Endometriosis Fertility Index (EFI) score, based upon the rASRM score and other factors, can help guide management. Medical treatment for endometriosis is predominantly contraceptive; therefore, surgery and medical reproduction techniques are the mainstay of management for endometriosis-related infertility. The evidence regarding the benefit of surgery for endometriosis-related infertility is conflicting; however, ablative techniques for endometriomas may enhance conception spontaneously and via assisted reproduction techniques (ART). Medically-assisted reproduction techniques include intra-uterine insemination and ovarian stimulation, as well as ART such as in vitro fertilization or intracytoplasmic sperm injection. ART has similar outcomes in individuals with rASRM stage I to II endometriosis as it does in individuals without endometriosis; however, live birth rate, mean number of oocytes retrieved, and clinical pregnancy rate are reduced in individuals with rASRM stages III-IV. Ultimately, endometriosis-related infertility treatment plans should be patient-centered, individualized, and holistic, considering alternative factors which may influence which treatment option can be offered.