DEBATE Is it of value to treat endometriosis prior to IVF ?

Although endometriosis is a common finding in infertile women (1), the mechanism by which it is associated with infertility remains unclear. Not unexpectedly, the optimal treatment for women with endometriosis, who wish to become pregnant, is debatable. Women, who suffer from infertility and are diagnosed with endometriosis, may undergo surgical or medical treatment with the aim to enhance their reproductive potential or proceed immediately to IVF. In the first case, expectant management is advocated for a variable period of time. If conception does not occur, IVF is usually the proposed method of treatment, although ovarian stimulation with intrauterine insemination might be an option in certain cases with mild or minimal endometriosis. On the other hand, IVF may be immediately selected as the preferred mode of treatment, either due to other coexisting factors (e.g. severe male infertility, tubal infertility, female age etc) or because treatment of endometriosis is considered as not beneficial, and in cases where it involves destruction of ovarian tissue, as potentially harmful. It is not the purpose of the current review to discuss which the best treatment strategy is for infertile patients diagnosed with endometriosis (medical or surgical treatment and follow-up or immediately IVF treatment). A solid answer to the above dilemma requires data form prospective randomized trials in which infertile patients with endometriosis are allocated to proceed immediately to IVF treatment for a certain number of cycles or undergo surgical or medical treatment and expectant management for a certain period of time. Although such trials currently do not exist, indirect evidence, suggest that the fecundity is not improved with medical vs. placebo treatment (2) in patients with endometriosis. Moreover, it appears that the use of laparoscopic surgery in the treatment of minimal and mild endometriosis improves success rates (3), while pregnancy rates after laparoscopic treatment of endometriomas vary from 23-67% in follow-up studies (4-6). The question the current review focuses on is whether medical or surgical treatment of endometriosis is of value in patients for whom a decision has been taken to proceed to IVF in order to achieve pregnancy.