Role of Laparoscopic Surgery in Endometriosis Associated Infertility— Literature Review

Background: Endometriosis is a common disease of reproductive age group women. It was first described by Dr Sampson in 1925 as, “presence of ectopic tissue which possesses the histological structure and function of uterine mucosa”. There is controversy surrounding its pathogenesis and the mechanism by which it causes infertility. Laparoscopic surgery is often used to treat this condition. Controversy exists as to the benefits of such surgery in infertile women. Objective: To explore whether laparoscopic surgery improves the chances of conception both by natural and assisted conception methods in moderate to severe endometriosis. Methods: Retrospective review of English literature regarding role of laparoscopic surgery in managing endometriosis associated infertility using keywords Endometriosis, Laparoscopy, Infertility, Pregnancy rate. Results: A large prospective study by Adamson et al 1993 showed that laparoscopic surgery significantly increased the cumulative pregnancy rate which was confirmed by a further meta-analysis in 1994. A large retrospective analysis by Osuga et al 1997 reported that pregnancy rate is unrelated to the stage of endometriosis. Further studies in 2002 suggested that the laparoscopic surgery increases the pregnancy rates in the first 6-12 months post operation. Two randomized controlled trials demonstrated higher pregnancy rates after laparoscopic excision of endometriomata. Few studies showed the benefits of laparoscopic endometrioma excision before IVF like reduced oocyte retrieval risks, missing occult malignancy and worsening of endometriosis during ovulation stimulation overweighs the drawback of cost and surgical risk. In addition, studies have reported improvement of dyspareunia after laparoscopic debulking for rectovaginal endometriosis. Conclusion: There are no large prospective randomized double blind controlled trials available to date in this area. In spite of heterogenicity among the available studies, current evidence suggests that laparoscopic excision or ablation, either by electrocautery or laser is beneficial in improving pregnancy rates, both by natural and assisted. INTRODUCTION Endometriosis was first described in 1860 by Von Rokitansky and endometriosis is one of the most prevalent diseases in Gynecology. There is paucity of knowledge about its epidemiology. In addition there is also a lack of consensus on a precise definition and pathophysiology, but recent research suggests morphological differences between endometriosis and endometrium. Endometriosis can be a chronic, debilitating gynecological condition among women of reproductive age causing pain and infertility. The incidence of endometriosis remains unknown because of the poor correlation between its presence and symptoms. The pathogenesis and mechanism by which it causes infertility is poorly understood. Over the last two decades, there has been a large increase in the number of infertile patients found to have endometriosis. It is uncertain whether this represents an increase, or simply a reflection of the more frequent use of laparoscopy. Endometriosis accounts for 10 to 15% of infertility. There is an increasing trend towards treating infertile with endometriosis surgically. This review explores the evidence available particularly addressing the use of laparoscopic surgery and its effect on the probability of pregnancy. We reviewed the literature using all the available English databases, Cochrane register and articles which addressed the question “does laparoscopic surgery improve pregnancy rates in women with infertility associated with moderate-severe endometriosis?” The results are shown in Table 1.