Endometriosis and infertility

Endometriosis is an estrogen-dependent chronic gynecological disease characterized by the development of endometrial tissue outside the uterus, especially in the ovaries, pelvic peritoneum, and rectovaginal septum. It affects approximately 150 million women worldwide and 7%–12% of women of reproductive age. The incidence of the disease in infertile patients can increase up to 50%, and 80% of unexplained infertility may be associated with endometriosis. Endometriosis is seen in 25% of patients who undergo assisted reproductive treatments (ART), and ovarian endometriosis is found in 20%–40% of these patients. Despite the scientifically supported relationship between endometriosis and infertility, it is difficult to prove a correlation between endometriosis and infertility since endometriosis has an impact on fertility status via different mechanisms given the heterogeneity of the disease. The mechanisms that lead to infertility in patients with endometriosis are the distortions of the pelvic anatomy because of the chronic inflammation and fibrosis, impaired endometrial receptivity, decreased ovarian reserve and oocyte quality and dysregulation of the immune system. In the management of the endometriosis-associated infertility, intrauterine insemination, ART, and surgery are the treatment options of which surgery has controversies. Treatment should be opted individually according to the woman’s age, ovarian reserve, presence of the cyst unilaterally or bilaterally, symptoms, presence of radiological features suggestive of malignancy, and previous history of surgery. And also, women with endometriosis should definitely seek fertility preservation counseling.