Abstract:

Deeply infiltrating endometriosis (DIE) is a special form of endometriosis, in which about 26% of patients are complicated by infertility. Existing evidence shows that both surgery and in vitro fertilization (IVF) are effective treatment strategies for DIE patients with infertility, and that they have similar reproductive outcomes. However, there is no clear basis for clinical decision-making. In this review, we systematically compared the reproductive outcomes of surgery and IVF, integrated imaging evaluation, endometriosis fertility index (EFI) score and ovarian reserve, and proposed the decision-making reference. Imaging examination is helpful to clarify the scope of the lesion, predict the difficulty of surgery, and avoid unnecessary surgery. EFI score is the core tool for predicting the postoperative natural pregnancy: those patients with low EFI score should be suggested direct IVF, and those with high EFI score can be considered postoperative pregnancy test. Operation may damage the ovarian reserve function of DIE patients, and IVF should be given priority to those patients with diminished ovarian reserve. Meta-analysis showed that there was no significant difference in the overall fertility outcomes between surgery and IVF, but surgery may have additional benefits in patients with high EFI scores and severe pain. Direct IVF should be considered preferentially as the first-line treatment, while surgery is mainly suitable for patients with severe pain, organ obstruction risk and specific high EFI scores.

Key words: Endometriosis, Infertility, female, Gynecologic surgical procedures, Fertilization in vitro, Deeply infiltrating endometriosis