Management of Endometriosis- Associated Infertility

Endometriosis is a disease characterized by ectopic endometrial glands and stromal tissue external to the uterine cavity. The prevalence of the disease has been reported to be 5?10% in women of reproductive age, 20?30% in women diagnosed with infertility, and 40?60% in women with chronic pelvic pain [1]. Fecundity, the probability of giving live birth in a menstrual cycle, has been shown to be 0.02?0.1 per month in women with endometriosis, but is 0.15?0.2 per month in normal women [2]. The live birth rate is also significantly decreased in women with endometriosis [2]. The pathophysiology of endometriosis has not been clarified. However, pain in endometriosis patients has been correlated with disease severity, degree of endometrial tissue infiltration, and the location of the lesion [3-5]. Although endometriosis seems to be highly related to infertility, how endometriosis contributes to infertility remains controversial [6]. The generally accepted process includes induction of local inflammation by estrogen-dependent ectopic endometriotic lesions that serially induce endometrial fragment adhesion, proliferation, and neovascularization, with subsequent development of fibrosis, adhesions, and distortion of the pelvic anatomy [3,6,7]. Infertility in women with endometriosis is thought to have multifactorial causes that can interfere with reproduction. The management of infertility in endometriosis patients should be considered in the context of understanding the pathophysiology between endometriosis and fertility. Medical treatment of endometriosis includes the use of gonadotropin-releasing hormone agonists, oral contraceptives, and progestins, which mainly suppress the secretion of estrogen from the ovary. These approaches cannot be used for women who are planning to conceive. When surgery and medical treatment fail or natural conception becomes impossible, assisted reproductive techniques (ARTs) are other options. The primary objective of this review is to examine the pathophysiology of endometriosis and infertility and to assess the current approaches and management modalities used for infertile women with endometriosis.