A comparison of ovulation suppression and ovulation stimulation in the treatment of endometriosis-associated infertility

Ovulation induction with clomiphene citrate or letrozole following laparoscopy in infertile women with minimal to mild endometriosis: a prospective randomised controlled trial

We conducted a prospective randomised controlled trial to explore the efficacy of clomiphene citrate (CC) and Letrozole (LTZ) for improving fecundity in infertile women with minimal to mild endometriosis after operative laparoscopy. We found that the ovulation rate of LTZ (88.7%) and CC (84.5%) were significantly higher than that of Control (70.5%) (p < .001). However, there was no significant difference in cumulative clinical pregnancy rates at 3, 6, 12 months after laparoscopy among the three groups (LTZ: 30%, 34.3%, 38.6% vs CC: 28.6%, 42.9%, 50.0% vs Control: 18.6%, 24.3%, 31.4%, respectively). No significant difference was observed in live-birth rate among the three groups (p = 1.125). For infertile women with minimal to mild endometriosis, ovulation induction with letrozole or clomiphene citrate after laparoscopy significantly increases ovulation rate, which are comparable between them; but does not demonstrate a significant advantage on improving pregnancy rate and live-birth rate when compared to laparoscopy alone.Impact statementWhat is already known on this subject? Endometriosis significantly decreases fecundity of women. Operative laparoscopy was recommended as an effective option to increase spontaneous pregnancy rate in infertile women with minimal to mild endometriosis. However, there is still no optimum treatment strategy for improving fertility of women with endometriosis.What do the results of this study add? For infertile women with minimal to mild endometriosis, ovulation induction with letrozole or clomiphene citrate after laparoscopy significantly increases ovulation rate, which are comparable between them; but does not demonstrate a significant advantage on improving pregnancy rate and live-birth rate when compared to laparoscopy alone.What are the implications of these findings for clinical practice and/or further research? Our results suggest that operative laparoscopy in conjunction with ovulation induction may improve fertility of women with minimal to mild endometriosis. Further research could focus on prolonging cycles of ovulation induction or choosing alternative ovarian stimulation protocols. More RCTs are still needed to compare the efficacy of letrozole with CC in ovulation induction.

Endometriosis: current management

OBJECTIVE

To review the clinical features, theories of pathogenesis, and current treatment of endometriosis-associated pain and infertility.

DESIGN

We review the manifestation of endometriosis and the possible mechanisms that lead to its symptoms, examine the efficacy of current therapeutic options for pelvic pain and infertility, and provide specific recommendations for treatment based on the current literature.

MATERIAL AND METHODS

Endometriosis is the presence of hormonally responsive endometrial tissue occurring outside the uterine cavity. This condition may be asymptomatic but is often found in association with pelvic pain or infertility (or both). The precise pathogenesis has not been clearly established but likely involves retrograde menstruation with subsequent seeding of endometrial glands at extrauterine sites. The definitive diagnosis and staging of endometriosis are performed by laparoscopy. Various strategies have been used to treat endometriosis including expectant, medical, surgical, and combination management.

RESULTS

The efficacy of treatment varies for pelvic pain and infertility. Endometriosis-associated pain may respond to both medical and surgical management. The use of medical therapy for endometriosis-associated infertility is not supported by current studies. Surgical management of infertility may be efficacious when pelvic anatomy is distorted because of endometriosis. The use of superovulation strategies and in vitro fertilization has been shown to be effective in overcoming endometriosis-associated infertility.

CONCLUSION

Pelvic pain and infertility in the presence of endometriosis necessitate individualization of therapy to achieve treatment goals. Neither medical nor surgical management is efficacious in all circumstances. As a better understanding of the pathogenesis of endometriosis evolves, treatment of this perplexing condition will probably continue to improve.