Endometriosis and Conception: Clinical Practice Facts and Myths

This point of view actually existed, but it has not been evidentially proven in controlled randomized studies of the recent years. Over many years, the so-called long and super-long IVF protocols were considered to be a perfect choice for patients with endometriosis because of the long-term administration of GnRH agonists. Today, when short and low-dose protocols as well as GnRH antagonists are used widely, it is possible to retrieve oocytes and obtain high-quality embryos in patients with endometriosis without inducing deep pituitary depression or achieving apparent ovarian hyperstimulation accompanied by high levels of estradiol and being critical for the progression of estrogen-dependent diseases (endometriosis, myoma, hyperplastic processes of the endometrium etc.).

Another controversial issue is the necessity of endometriosis treatment with GnRH agonists over 3-6 months. Separate risk groups in this case are made up by patients of middle and late reproductive age (after 30) who had ovarian surgery, especially, repeat ovarian surgery. The results of such treatment often include premature and pathological menopause, the impossibility of retrieving a patient's own egg cells, psychosomatic disorders, family breakdown and social adaptation disorders. The achievement of pregnancy by means of assisted reproduction is then possible only with the help of donor and surrogacy programmes.

The next myth is very dangerous: surgery as a means of endometriosis treatment should always precede assisted reproduction. Incidentally, in all fairness, we should note that there is a similar "radical" point of view as regards the treatment of another estrogen-dependent disease – uterine myoma. In endometriosis, the problem is that ovarian surgery leads to the reduction in their volume and in the reserve of follicles that can potentially release an egg cell. In cases when external endometriosis is misdiagnosed, the ovaries often suffer for nothing going through an irreplaceable loss of tissues with follicles.

A special place in this issue is reserved for endometriotic cysts whose conservative treatment holds little promise. After surgical interventions, relapses of endometriomas often necessitate a repeat surgery. As a result, we face ovarian depletion and "a closed door" for assisted reproduction. At present, dosed superovulation stimulation aimed at retrieving oocytes in patients with endometriomas of small size (up to 3-4 cm) is considered to be safe and quite effective. Any extent of assisted reproduction is also possible in patients with minor and asymptomatic forms of endometriosis without any prior preparatory surgery.

The efficacy of alternative methods for endometriosis treatment is also exaggerated quite often. Today, there are unequivocally no evidential data in favor of an increased probability of natural conception or increased success of assisted reproduction programmes after non-drug and non-surgical treatment of endometriosis. In fertility practice, we largely deal with cases when women spend the entire period of their effective reproductive age trying to treat endometriosis, both traditionally and non-traditionally, over many years.

A very common myth with late effects is a complete and irrevocable cure of endometriosis due to pregnancy. However, in talking about such a possibility, doctors and patients fail to mention the issue of progression of all estrogen-dependent diseases (myoma, endometriosis) in the first trimester of pregnancy, which is observed during the routine monitoring of such patients. Surely, further development of pregnancy and progesterone dominance have a favourable effect on these diseases but the complete cure is rarely achieved, and the pathological condition begins to progress as soon as the menstrual cycle is back. Consequently, such patients may have trouble conceiving again with underlying reasons similar to the reasons behind the difficulties they had before the pregnancy.

It is important that a patient with diagnosed endometriosis should be properly consulted and informed about the possibilities of modern treatment and fertility preservation before any active therapeutic intervention is started. She needs to know about the possible side effects and consequences of treatment including the permanent ones so that she could make an informed decision.