Laparoscopic treatment of endometriosis in patients with failed in vitro fertilization cycles

(Fertil Steril 2005;84:1574–8.©2005 by American Society for Reproductive Medicine.)
Key Words: Laparoscopy, endometriosis, infertility, IVF

Endometriosis is one of the most common gynecologic disorders and is significantly more prevalent in the setting of infertility^{(1, 2)}. The prevalence of endometriosis in infertile women ranges from 25% to 50% compared to 5% in fertile women^{(2, 3)}. Successful laparoscopic management of all stages of endometriosis was reported as early as 1986⁽⁴⁾. This has revolutionized the management of endometriosis. The benefits of surgical therapy for infertility associated with endometriosis have been well documented^(4–6). However,
with the advent of assisted reproductive technologies (ART), the number of patients undergoing laparoscopic evaluation as part of the initial workup has decreased. Recently, there has been a growing tendency to bypass diagnostic laparoscopy after a normal hysterosalpingogram⁽⁷⁾.

Patients are commonly in their mid-30s or older when they seek infertility therapy. This, combined with the risks of undergoing a surgical procedure, often leads patients with failed controlled ovarian hyperstimulation (COH) and IUI to the IVF path, without thorough evaluation or therapy of potential endometriosis. Furthermore, when initial IVF cycles fail, patients and physicians tend to choose additional IVF treatment and some may even elect oocyte donation after multiple failures. Many couples and physicians believe
that because the ultimate therapy, IVF, failed to result in a pregnancy, further infertility investigation and treatment are likely to be futile.

In this study, we report our experience with patients who have failed IVF treatment and underwent laparoscopic evaluation and management.

Materials and Methods
A retrospective analysis of infertility patients, with failed IVF treatment, was conducted. Typically, multiple cycles of COH/IUI had failed and these patients elected to proceed to IVF without undergoing laparoscopic evaluation. The patients were offered laparoscopy for further evaluation of infertility as an alternative to repeating IVF, oocyte donation, or adoption. Of this group, those patients who chose not to undergo a laparoscopic procedure were assigned as a control group. Patient characteristics including age, parity, FSH, number of failed IVF cycles, duration of infertility, stage of endometriosis, and modes of conception were recorded. The duration of infertility before seeking treatment varied largely, dependent on the presenting age of the patient.
Patients >37 years old tended to seek infertility treatment earlier than patients <37 years of age. These patients were followed for a minimum of 9 months and were closely matched for age, FSH, duration of infertility, and number of
failed IVF cycles. Patients with severe male factor infertility requiring intracytoplasmic sperm injection (ICSI) or tubal factor infertility with bilateral tubal obstruction were not included.

Surgical treatment consisted of thorough CO₂ laser ablation or excision of all peritoneal and nonperitoneal endometriotic lesions, lysis of adhesions, and appropriate management of ovarian endometriomas^(8–10). The surgical approach was based on intraoperative assessment of the pathophysiology or the type of endometrioma, which is found to be quite varied^{(8, 9)}. For example, reassurance was made that type I endometriomas are totally removed. In type
II endometriomas, only the endometriotic plaque, not the luteal cyst wall is removed^(8–10). No medical treatment of endometriosis was administered after surgery. All surgeries were performed by the senior surgeon (CN).

Statistical calculations were performed using Student’s t test and X² test as appropriate, and statistical significance was defined as P< .01. Institutional review board approval was obtained before chart review.

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