Ovarian endometriosis and infertility: in vitro fertilization (IVF) or surgery as the first approach?

Fertile Battle
Ovarian endometriosis and infertility: in vitro fertilization (IVF) or surgery as the first approach?

Volume 110, Issue 7, Pages 1218–1226


Bruce A. Lessey, M.D., Ph.D., Stephan Gordts, M.D., Olivier Donnez, M.D., Ph.D., Edgardo Somigliana, M.D., Ph.D., Charles Chapron, M.D., Juan A. Garcia-Velasco, M.D., Jacques Donnez, M.D., Ph.D.


Prosurgery: surgery should be the first approach for ovarian endometriosis and infertility

IVF is commonly applied to all indications for infertility, but increasingly unexplained causes predominate (www.sart.org). Specifically, endometriosis is listed as the primary diagnosis in less than 4% of cases in the United States, primarily because laparoscopy is not performed for the basic infertility workup, as it once was (1). Unexplained cases of infertility show a high prevalence of endometriosis (2, 3). Visible endometriosis such as endometriomas present a special challenge, especially since ovarian reserve may be compromised when ovarian surgery is performed. 

Pro-IVF: IVF should be the first approach for ovarian endometriosis and infertility

Informative randomized controlled trials on the comparison between surgery and IVF for infertile women carrying ovarian endometriomas are lacking, and available guidelines are contradictory (43). Moreover, from the patient perspective, these two management strategies are extremely different and involve several clinical and personal aspects that are beyond the mere pregnancy rate. One may even wonder whether randomized controlled trials will ever provide a satisfactory answer to the question (44). Therefore, a shared and informed decision with the patient is mandatory, and, to be balanced, this requires in-depth and transparent information in a multidisciplinary context that can offer both surgery and IVF.

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Go to the profile of Micah J Hill
about 4 years ago

Great debate again by expert authors!  I voted for the IVF side.  I just think the burden of proof in this debate is on surgery to demonstrates it improves live birth outcomes, especially given the risks of surgery, published numbers needed to treat to get an additional live birth (as high as 40), and known decrease in ovarian reserve.  I would want to see level 1 evidence demonstrating better reproductive results from surgery before it became my first line treatment.

Go to the profile of Pietro Bortoletto
about 4 years ago

I love this debate because it is a very real one faced by patients and providers alike. I guess the answer, to me, lies in what the presenting complaint is.  An infertile but asymptomatic patient presenting with an incidentally found endometrioma should have IVF -> treat the presenting complaint. However, the minute the patient reports symptoms, this is becomes a little trickier.I think surgery serves several purposes: 1) diagnosis, 2) treatment, and 3)  improvement in IVF outcomes (maybe). The importance of diagnosis cannot be understated as it can validate a woman's symptoms and provides a  clear treatment algorithm for management outside of fertility treatment/pregnancy.

Go to the profile of Alexander Quaas
about 4 years ago

Great debate. It is a  close call but I voted for IVF because in the setting of endometriomas there may be significant harm caused by removing normal ovarian tissue (especially in the hands of surgeons who do not prioritize fertility), and because in most instances the "number needed to treat" (NNT) for IVF is difficult to beat.

Nevertheless both sides make good points, and it is important to view every case on an individual basis. 

For everyone interested in this debate: there will be a F&S Journal Club Global on this topic with some of the authors at this year's PCRS meeting. My understanding is that I will be one of the discussants arguing in favor of surgery alongside Dr Lessey. Should be an entertaining live debate.