ESHRE 2014 [5] | ASRM 2012 [73] | NICE 2017 [74] | |
---|---|---|---|
Imaging | TVS is useful to diagnose ovarian endometrioma and to rule out rectal endometriosis (level A) 3D USG to diagnose rectovaginal endometriosis: usefulness not well established (level D) MRI to diagnose peritoneal endometriosis: usefulness not proven (level D) | TVS is useful to diagnose suspected endometriosis and to identify endometriomas and deep endometriosis involving bowel, bladder, or ureter (low evidence) MRI—as primary investigation to diagnose endometriosis (very low evidence) | |
Diagnosis | Perform laparoscopy to diagnose endometriosis and confirm by histology. (GPP) CA-125 for diagnosis of endometriosis is not recommended (level A) | Laparoscopy with histological confirmation is required for definitive diagnosis of endometriosis, especially when it is not apparent visually on surgery | CA-125—not used to diagnose endometriosis (very low evidence) Diagnostic laparoscopy to diagnose endometriosis by systematic inspection of pelvis (moderate to very low evidence) |
Medical management | No role in endometriosis-related infertility (level A) | No evidence that it improves fertility | No role in endometriosis-related infertility |
Surgical management | Stage I/II Either excise or ablate lesions including adhesiolysis, to increase OPRa (level A) CO2 laser vaporization is preferred over monopolar electrocoagulation (level C) Excision of capsule, better than drainage and electrocoagulation (level A) Counsel about risks of reduced ovarian function after surgery (GPP) ASRM stage III/IV Operative laparoscopy better than expectant management, to increase spontaneous pregnancy rates (level B) | Stage I/II: laparoscopic ablation leads to improvement in LBR. Stage III/IV: repeat surgery rarely increases fecundability, and IVF will be better in these patients | Management of endometriosis-related subfertility should have multidisciplinary team approach. |
Combination of medical and surgical treatment | No hormonal treatment before surgery (GPP) No hormonal treatment after surgery (level A) | Preoperative and postoperative hormonal therapy does not enhances fertility | |
Superovulation and IUI | AFS/ASRM Stage I/II endometriosis, IUI + COSb, instead of expectant management (level C) | SO/IUIc may be given to stage I or II endometriosis as an alternative to IVF or further surgical therapy (level II) Insufficient evidence that SO/IUI is more successful after endometriosis is diagnosed and treated vs untreated minimal or mild endometriosis | |
ART | Preferred modality if other factors of infertility coexists. Recurrence rates of endometriosis are not increased after COS for IVF/ICSI (level C) GnRH agonists for a period of 3–6 months prior to treatment with ART to improve CPR (level B) | IVF likely maximizes cycle fecundity, especially in those with distortion of pelvic anatomy due to moderate or severe disease. | |
Surgery before ART | AFS/ASRM stage I/II—If undergoing laparoscopy prior to ART, may consider complete surgical removal of endometriosis, to improve LBR, benefit not well established (level C) Endometrioma larger than 3 cm: no evidence that cystectomy prior to treatment with ART improve pregnancy rate (level A) Endometrioma larger than 3 cm: consider cystectomy prior to ART only to improve endometriosis-associated pain or the accessibility of follicles.(GPP) | No benefit of surgery in asymptomatic women with endometrioma prior to IVF No studies evaluating impact of size of endometrioma on outcome. |