Laparoscopic surgery may be of benefit in treating subfertility associated with mild to moderate endometriosis

Jacobson TZ, Duffy JMN, Barlow D, Farquhar C, Koninckx PR, Olive D

Published Online:

January 20, 2010

Endometriosis is the presence of tissue that normally lines the uterus in inappropriate sites (usually within the pelvic cavity). It can cause fertility problems and symptoms such as painful menstruation and painful sexual intercourse. Hormonal drugs including the oral contraceptive pill are used but have adverse effects and are not suitable for women wishing to become pregnant. Laparoscopic surgery (where small incisions are made in the abdomen) is performed to remove visible areas of endometriosis. The review of trials found that laparoscopic surgery may be of benefit in treating subfertility associated with mild to moderate endometriosis. However, the two studies on the subject show conflicting results. Additional studies in this field are needed before definitive conclusions can be drawn.

Abstract (click to read)

Background:

Endometriosis is the presence of endometrial glands or stroma in sites other than the uterine cavity. It is variable in both its surgical appearance and clinical manifestation, often with poor correlation between the two. Surgical treatment of endometriosis aims to remove visible areas of endometriosis and restore anatomy by the division of adhesions.

Objectives:

To assess the efficacy of laparoscopic surgery in the treatment of subfertility associated with endometriosis. The review aims to compare outcomes of laparoscopic surgical interventions compared to no treatment or medical treatment with regard to improved fertility.

Search strategy:

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of trials (June 2009), Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 2), MEDLINE (1966 to June 2009), EMBASE (1980 to June 2009), and reference lists of articles.

Selection criteria:

Trials were selected if they were randomised and compared the effectiveness of laparoscopic surgery in the treatment of subfertility associated with endometriosis versus other treatment modalities or placebo.

Data collection and analysis:

Two studies were eligible for inclusion within the review. Both studies compared laparoscopic surgical treatment of minimal and mild endometriosis compared with diagnostic laparoscopy only. The recorded outcomes included live birth, pregnancy, fetal losses, and complications of surgery.

Main results:

When combining live birth rate and ongoing pregnancy after 20 weeks, meta-analysis demonstrated an advantage of laparoscopic surgery when compared to diagnostic laparoscopy only. The odds ratio (OR) was 1.64 (95% confidence interval (Cl) 1.05 to 2.57) in favour of laparoscopic surgery. Meta-analysis also demonstrated an advantage of laparoscopic surgery when compared to diagnostic laparoscopy only in terms of clinical pregnancy rates, with an OR of 1.66 (95% Cl 1.09 to 2.51) favouring laparoscopic surgery. The results still need to be interpreted with caution as Marcoux 1997 reported a large positive effect of surgery whereas Gruppo Italiano reported a small negative effect. When considering fetal losses, meta-analysis did not demonstrate an effect of laparoscopic surgery when compared to diagnostic laparoscopy only. The OR was 1.33 (95% Cl 0.60 to 2.94) favouring diagnostic laparoscopy only.

Authors' conclusions:

The use of laparoscopic surgery in the treatment of subfertility related to minimal and mild endometriosis may improve future fertility.

This record should be cited as:

Jacobson TZ, Duffy JMN, Barlow D, Farquhar C, Koninckx PR, Olive D. Laparoscopic surgery for subfertility associated with endometriosis. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD001398. DOI: 10.1002/14651858.CD001398.pub2

Assessed as up to date:

June 1, 2008

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Primary Review Group:

Menstrual Disorders and Subfertility Group

Health topics:

Gynaecology > Subfertility > Female: associated with other medical conditions

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Laparoscopic surgery may be of benefit in treating subfertility associated with mild to moderate endometriosis

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