Review 10.1586/17474108.3.2.203 © 2008 Future Drugs Ltd ISSN 1747-4108 203 www.future-drugs.com Most endometriosis patients have fertility complaints and, in spite of the improvement of assisted reproduction procedures, outcomes remain unsatisfactory. This suggests that there are unknown ethiopathogenic influences that adversely affect fertility. Laparoscopic treatment of endometriosis is of questionable efficiency with regard to achieving better fertility results, with controversies mainly surrounding ovarian residual reserve. However, the laparoscopic approach follows good practice principles and is considered a minimally invasive procedure, with the advantage of being diagnostic and therapeutic. Decision to excise endometriomas must be taken cautiously, considering factors such as patient’s age, previous ovarian reserve, previous pelvic surgery, presence of pain or malignancy suspicion, disease extension and the mean diameter of the lesions. KEYWORDS: assisted reproduction • endometrioma • endometriosis • infertility • laparoscopy • treatment Laparoscopic treatment of endometriosis focusing on fertility outcomes Expert Rev. Obstet. Gynecol. 3(2), 203–209 (2008) Lauriane Giselle de Abreu, Bruno Ramalho de Carvalho, Ionara Diniz Evangelista Santos Barcelos, Ana Carolina Japur de Sá Rosa e Silva, Rui Alberto Ferriani and Júlio César Rosa e Silva † † Author for correspondence Laboratório de Ginecologia e Obstetrícia – 1º andar, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Av. Bandeirantes, 3900, Campus da Universidade de São Paulo, Bairro Monte Alegre, Ribeirão Preto, São Paulo, CEP 14.049-900, Brazil Tel.: +55 163 602 2583 Fax: +55 163 633 9633 juliocrs@convex.com.br Infertility complaints occur in almost 60% of women with endometriosis [1–3]. Mechanical interference is the most acceptable phenome- non [3], but there is an increasing role attributed to immunological, genetic and hormonal fac- tors, which is still under investigation and cer- tainly contributes to the etiopathogeny of this enigmatic disease [4,5]. Although the etiopathogeny of endometriosis and also its causal relationship with infertility remain unclear, the advent of assisted reproduc- tion techniques (ART) allowed an important advance on infertility treatment. However, the outcomes of ART in endometriosis remain unsatisfactory, revealing impaired pregnancy and implantation rates in comparison with infer- tility due to tubal and male factors according to the metanalysis of Barnhart et al. in 2002 [6], even though other studies do not support this affirmative [7,8]. Medical treatment with gonadotropin-releas- ing hormone (GnRH) agonists prior to ART is associated with an increase in pregnancy rates [9], but clinical therapy alone is considered inef- ficient for treating endometriosis-associated infertility. Owing to its high rates of recurrence (approximately 50% after 5 years of therapy ces- sation [10,11]), we are frequently presented with a dilemma between performing ART or adopting a surgical approach as the first choice to achieve better results when treating infertile couples. Undoubtedly, the best approach must be individualized to each infertile couple, com- bining improvement of pregnancy rates, reduction of morbidity and following good practice principles. The evaluation must be undertaken in a global manner and the essential factors to be considered are patient’s age, grade and type of endometriosis (ovarian, peritoneal or deep infiltrating) and clinical symptoms of the disease. Besides this, performing randomized, placebo- controlled studies regarding surgical treatment of endometriosis is difficult, resulting in a lack of evidence or reliable data. The aim of this review is to analyze the laparoscopic surgical procedure for infertility treatment in endometriosis in its different phenotypics presentations: peritoneal, ovarian and deep infiltrating disease. Peritoneal endometriosis (minimal/mild) Some randomized, controlled clinical trials have demonstrated that administration of danazol, progestins or GnRH agonists has not been effective in treating infertility associated with Future Drugs Ltd. For reprint orders, please contact: reprints@future-drugs.com