Vasilios Tanos MD PhD, Head IVF unit, Aretaeio Hospital, Nicosia, Cyprus

Ovarian endometriomas derange the physiological mechanisms of ovulation. In presence of advanced endometriosis not only lower number and quality of oocytes achieved but also lower implantation rates have been reported. Mechanical and vascular effect of endometriotic adhesions may decrease the number of M2-oocytes retrieved in IVF. Gonadal damage is at least partly initiated by the presence of endometriotic cells per se preceding surgery causing local inflammation, creation of adhesions and destruction of microvascularization.

Infertility cases main concern is the choice of treatment, medical or surgical or combined. Considering endometriosis as a spontaneously regressive phenomenon, the risk of recurrence rate is high, hence the synchronization of remission and treatment is crucial for achieving a pregnancy. The results of in-vitro fertilization with advanced endometriosis are lower as compared to those that appropriate surgery was performed prior to IVF. The old opinion that whatever type of surgery is performed the IVF results are not impaired if ovarian cortex stays intact is wrong. The destruction of normal ovarian tissue increases with the persistence of endometriosis and larger the size of endometriomas or implants. Also the number of endometrioma cysts and extend of the disease reduces the pregnancy rate (PR). The rate of ovulation found to be 35% when one endometrioma cyst and 19% when 2 cysts were present, while the size of more than 30mm reduces significantly the PR.

The delay of first baby in the family planning of modern women over the age of 30 and 35 created more cases with advanced endometriosis and comorbidity. Surgery for minimal or mild endometriosis is debated due to modestly enhance fecundity in women with otherwise unexplained subfertility. Conflicting information may be due to the fact that endometriomas are mostly monolateral and most of these women, finally they do get pregnant. Probably a consensus will never be reached on the optimal treatment of minimal and mild endometriosis. Efficacy of medical and surgical treatment of endometriosis in infertility is an ongoing controversy. In addition we must take in consideration that there are no tools to predict who will progress to severe disease. Complete resolution of endometriosis is not yet possible and current therapy targets to reduce pain, to increase the possibility of pregnancy and to delay recurrence for as long as possible.

In cases of moderate and severe endometriosis-associated infertility, the combined laparoscopic surgery with GnRHa may be the ‘first-line’ treatment. The mean PR of 50% following surgery provides scientific proof that reproductive surgery should first be the first choice in order to give patients the best chance of conceiving naturally. In cases with large endometriomas >6cm, the ovarian reserve determined by AMH is less diminished after three-step procedure.

The ovary is explored to determine the extent of disease. Dark, punctuate lesions beneath the cortical ovarian surface give the orientation of the location of the disease. Adhesion formation could compromise distal tubal function. Inability to elevate the ovary is usually a sign of adhesions and endometriotic implants of the inferolateral surface of the ovary and the peritoneum of the ovarian fossa. Filmy adhesions are elevated with delicate tissue forceps and can resected with fine-needle cautery, a scalpel or laser. Maintain the integrity of the ovarian capsule. Peritoneal spillage of the contents of the endometrioma can and should be avoided. During the cortical incision preserve the normal anatomic relations of the ovary with the utero-ovarian ligament and fimbia ovarica. A shallow longitudinal incision over the endometrioma with the monopolar microneedle, scalpel, or laser is a good option. Facilitare creation of a cleavage plane between the cyst and normal ovarian tissue. Eliminate the dead space and maximize hemostasis. Minimize thermal injury to surrounding ovarian tissue and near the fimbria ovarica. The experience and the skills of the surgeon as well as the strict selection of the patients seem to be important to achieve pregnancy.