BMJ  2007;334:328 (17 February), doi:10.1136/bmj.39121.866238.1F

Letters

Endometriosis

Infertility set in context

With an evidence based approach, Farquhar reviews the most outstanding aspects of endometriosis.¹ Nevertheless, we were left with the impression that some important issues are in need of further clarification.

A systematic review has shown an improvement in pregnancy rates after laparoscopic treatment of endometriosis for women with infertility,² but it is important to outline that, at the moment, this improvement seems to be true only for mild or minimal endometriosis and its effect on more advanced stages remains uncertain.³⁴

A recurrence of endometriosis does not inevitably mean further surgery. The evidence supporting systematic surgery for asymptomatic endometriosis is poor, and it has been suggested that re-operation is not always indicated for recurrent endometriosis. Transvaginal aspiration might prove to be a reasonable alternative for some patients to reduce impact on ovarian reserve as well as other potential surgical complications associated with re-operation.³

Whether endometriosis affects outcomes in the context of artificial reproductive techniques is still under debate,³ it has been proved in a recent systematic review that down-regulation with GnRH agonists for three to six months before starting in vitro fertilisation quadruples the odds of clinical pregnancy.⁵ Early referral to centres of excellence and early treatment of infertility should always be considered in these patients.³

Hewitt Centre for Reproductive Medicine, Liverpool Women's Hospital. Liverpool L8 7SS

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Competing interests: None declared.

References

1. Farquhar C. Endometriosis. BMJ 2007;334:249-53. (3 February.)[Free Full Text]
2. Jacobson TZ, Barlow DH, Koninckx PR, Olive D, Farquhar C. Laparoscopic surgery for subfertility associated with endometriosis. Cochrane Database Syst Rev 2002;(4):CD001398.
3. Chavez-Badiola A, Drakeley A. Optimising in vitro fertilisation (IVF) outcome in women with endometriosis. Rev Gynaecol Perinatal Pract 2006;6:153-60.[CrossRef]
4. Royal College of Obstetricians and Gynaecologists. RCOG green-top guideline for the investigation and management of endometriosis 2006 (24). www.rcog.org.uk/index.asp?PageID=517
5. Sallam HN, Garcia-Velasco JA, Dias S, Arici A. Long-term pituitary down-regulation before in vitro fertilization (IVF)for women with endometriosis. Cochrane Database Syst Rev 2006;(1):CD004635.

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Relevant Article

Endometriosis

Cynthia Farquhar
BMJ 2007 334: 249-253. [Extract] [Full Text] [PDF]