Surgical management of endometriosis associated infertility: Time for a paradigm change
Endometriosis is one of the most challenging clinical entities for gynecologists. The resultant pain and infertility are often difficult to manage, and strategies are limited. I propose a more cautious approach to endometriosis-associated infertility, based on emerging evidence that “less is more” in surgical management of this problem.
A recent case highlights the clinical issues.
J.E. is a 34-year-old P0 who initially presented in January 2014 after attempting pregnancy for 2 years. She reported a diagnosis of endometriosis as well as male-factor infertility. Her endometriosis was diagnosed via laparoscopy in December 2013 and her initial surgery was ablation of visible implants plus resection of a 4-cm endometrioma.
Prior fertility testing included a hysterosalpingogram obtained in November 2013, which demonstrated an occluded left Fallopian tube and an anti-Müllerian hormone (AMH) level that was reassuring at 1.6 ng per mL. Partner history was significant for a semen analysis that demonstrated 6 million sperm with 10% motility.
At J.E.’s initial infertility evaluation, a transvaginal ultrasound demonstrated suspected bilateral recurrent endometriomas measuring 5 and 10 cm. We discussed management options, including proceeding directly to in vitro fertilization (IVF) versus resection of the endometriomas. She was asymptomatic, but given the size of the endometriomas, I recommended repeat laparoscopy and resection of the endometriomas.
Four months postoperative, J.E.’s AMH was undetectable. Six months postoperative, she underwent an IVF. Despite an aggressive 16-day stimulation, no oocytes were recovered. Her AMH remains undetectable. She is now considering use of donor oocytes.