[Endometriosis and fertility: physiopathologic aspects and therapeutic options].

The relationship between endometriosis and infertility is not clear despite a large literature. 30-40% of women with endometriosis are infertile, compared to fewer than 10% in the general population. A direct relationship has never been proven, but numerous physiopathological hypotheses have been advanced to explain such a relationship. The role of severe forms of endometriosis in infertility is clear and there is consensus concerning treatment. In cases of destruction of the ovarian parenchyma by voluminous endometriomas, drug treatment is not sufficient and laparoscopic removal of the cyst is required. In cases of complete bilateral obstruction of the proximal tubes, drug treatment is usually disappointing and surgery or in vitro fertilization is required. Treatment choice for nonobstructing lesions is less clear. The role of small polyps and isolated localized diverticuli is doubtful. The most difficult treatment problems arise in cases of minimal to moderate endometriosis. Several cycle anomalies have been reported. In order to establish causality, such effects must be studied hormonally and sonographically for at least six consecutive cycles. Several potential mechanisms have been suggested to explain such effects, including hyperproduction of prostaglandins, hyperprolactinemia, anomalies in luteolysis, and biphasal LH peak, among others. Peritoneal endometrial implants may cause an aseptic inflammatory reaction and an antigenic stimulation leading to increased volume of peritoneal liquid, elevation of prostaglandins in the peritoneal liquid that then cause other problems, augmented number and activation of peritoneal and tubal macrophages with various effects, or auto-immune type responses. Associated male infertility factors may play a role. If endometriosis is a cause of infertility, pregnancy rates should be increased by specific treatment. Efficacy of different treatments was evaluated in a meta-analysis of 25 studies. Systematic destruction of lesions during laparoscopy appeared to offer the best results. In vitro fertilization may be proposed in severe forms or associated male infertility. The results have been similar to those for other indications, except possibly in severe and extensive forms characterized by diminished retrieval of oocytes. It is possible that endometriosis does not explain infertility except in forms severe enough to alter pelvic anatomy.