• Andrej Vogler Ginekološka klinika Klinični center Šlajmerjeva 3 1525 Ljubljana
  • Martina Ribič Pucelj Ginekološka klinika Klinični center Šlajmerjeva 3 1525 Ljubljana
  • Tomaž Tomaževič Ginekološka klinika Klinični center Šlajmerjeva 3 1525 Ljubljana
Keywords: endometriosis, infertility, surgical treatment, outcome


Background. Endometriosis is nowadays probably the most frequent cause of infertility or subfertility and is revealed in approximately 30–40% of infertile women. The association between fertility and minimal or mild endometriosis remains unclear and controversial. Moderate and severe forms of the disease distort anatomical relations in the minor pelvis, resulting in infertility. The goals of endometriosis treatment are relief of pain symptoms, prevention of the disease progression and fertility improvement. Treatment of stages I and II endometriosis (according to the R-AFS classification) may be expectative, medical or surgical. In severely forms of the disease (stage III and IV) the method of choice is surgical treatment. Combined medical and surgical treatment is justified only in cases, in which the complete endometriotic tissue removal is not possible or recurrence of pain symptoms occur. Nowadays, laparoscopic surgical treatment is the golden standard being the diagnostic and therapeutic tool during the same procedure. The aim of this study was to evaluate the fertility rate after surgical treatment of different stages of endometriosis.

Patients and methods. In prospectively designed study 100 infertile women were included. The only known cause of infertility was endometriosis. In group A there were 51 patients with stage I and II endometriosis, whereas in group B there were 49 patients with stage III and IV of the disease. Endometriosis was diagnosed and treated laparoscopically. Endometriotic implants were removed either with bipolar coagulation or CO2 laser vaporisation, whereas adhesions were sharp or blunt dissected, and endometriomas stripped out of ovaries. Pregnancy rates were calculated for both groups of patients, and statistically compared between the groups.

Results. Mean age of patients was 29.25 (SD ± 4.08) years and did not significantly differ between the groups of patients (29.5 years in group A and 29 years in group B). In group A 31 (60.8%) out of the 51 patients conceived spontaneously within 24 months after surgery. In group B 30 (61.2%) out of the 49 patients conceived spontaneously after surgery. The difference in pregnancy rates between the groups was not statistically significant.

Conclusions. Surgical treatment of endometriosis in infertile patients is by all means effective and most appropriate, although some have not confirmed its value in patients with minimal or mild endometriosis comparing it with the no-treatment protocol. The limitations of this study should be considered. The main drawback is its design: the trial was not a randomised controlled one. We advocate that endometriosis once diagnosed must be surgically treated, to prevent progression of the disease at least. Endometriosis appears to progress in two-thirds of patients within a year from the diagnosis, and it is impossible to predict, in which patients it will progress. It would be unethical, and even unprofessional not to remove even the smallest endometriotic implants when the disease is confirmed by laparoscopy.


Download data is not yet available.


Burns WN, Schenken RS. Patophysiology of endometriosis-associated infertility. Clin Obstet Gynecol 1999; 42: 586–610.

Barbieri RL, Missmer S. A cause – effect relationship? Ann N Y Acad Sci 2002; 955: 23–33.

Böhm M, Mohar J. Pogostnost endometrioze pri zdravih in neplodnih ženskah. Študentska raziskovalna naloga. Ljubljana: Medicinska fakulteta Univerze v Ljubljani, 2002.

Meyer R. Die Pathologie der Bindegewelsgeschwulste und Mischgechwulste. In: Stoeckel W ed. Handbuch der Gynäkologie Sechster Band Erste Halfte. München: J. F. Bergmann, 1930: 211–807.

Sampson JA. Perforating haemorrhagic (chocolate) cyst of the ovary. Arch Surg 1921; 3: 245–51.

Dmowski WP, Steel RW, Baker GF. Deficient cellular immunity in endometriosis. Am J Obstet Gynecol 1981; 141: 377–83.

Weed JC, Arquenbourg PC. Endometriosis: can it produce an autoimmune response resulting infertility. Clin Obstet Gynecol 1980; 23: 885–93.

Mathur S, Peress MR, Williamson HO et al. Autoimmunity to endometrium and ovary in endometriosis. Clin Exp Immunol 1982; 50: 259–66.

Lubbe WF, Butler WS, Palmer SJ, Liggins GC. Lupus anticoagulant in pregnancy. Br J Obstet Gynaecol 1984; 357–63.

Naaples JD, Batt RE, Sadigh H. Spontaneous abortion rate in patients with endometriosis. Obstet Gynecol 1981; 57: 509–12.

Yovich JL, Yovich JM, Tuvik AJ, Matsom PL, Willcox DL. In vitro fertilization for endometriosis. Lancet 1985; 2: 552.

O’Shea, Chen C, Weiss T, Jones WR. Endometriosis and in vitro fertilization. Lancet 1985; 2: 723–3.

Ranney B. Endometriosis IV. Hereditary tendencies. Obstet Gynecol 1971; 37: 734–7.

Simpson JL. Genes and chromosomes that cause female infertility. Fertil Steril 1985; 44: 725–39.

Theofilopoulos AN, Prud’homme GJ, Fieser TM, Dixon TJ. B cell hyperactivity in murine lupus. I. Immunological abnormalities in lupusprone strains and activation of normal B cells. Immunol Today 1983; 4: 287–91.

Theofilopoulos AN, Prud’homme GJ, Fieser TM, Dixon TJ. B cell hyperactivity in murine lupus. II. Defectis in response to aproduction of accessory signals in lupus-prone mice. Immunol Today 1983; 4: 317–9.

Oral E, Arici A. Pathogenesis of endometriosis. Obstet Gynecol Clin N Am 1997; 24: 219–33.

Hull MG, Cahill DJ. Female infertility. Endocrinol Metab Clin North AM 1998; 27: 861–3.

Berube S, Marcoux S, Mylaine L, Maheux R. Fecundity of infertile women with minimal and mild endometriosis and women with unexplained infertiliy. The Canadian Collabrative Group on Endometriosis. Fertil Steril 1998; 69: 1034–41.

Matorras R, Rodriguez F, Pijoan Ji, Etxanojauregui A, Neyro JL, Elorriaga MA, et al. Women who are not exposed to spermatozoa and infertile women have similar rates of stage I endometriosis. Fertil Steril 2001; 76: 923–8.

Rodriguez-Escuedero FJ, Neyro JL, Corcostegui B, Benito JA. Does minimal endometriosis reduce fecundity? Fertil Steril 1988; 50: 522–4.

Adamson GD, Pasta DJ. Surgical treatment of endometriosis-associated infertility: Meta-analysis compared with survival analysis. Am J Obstet Gynecol 1994; 171: 1488–505.

Hoeger KM, Guzick DS. Classification of endometriosis. Obstet Gynecol Clin N Am 1997; 24: 347–59.

Ribič Pucelj M, Vogler A, Vrtačnik Bokal E, Jemec M. Surgical treatment of stage III-IV endometriosis in infertile patients: Laparotomy vs laparoscopy. In: Ribič Pucelj M, Tomaževič T, Keckstein J eds. Book of Proceedeings, 9th International Basic and Advanced Course on Gynecological Endoscopic Surgery. Ljubljana: Slovensko društvo za reproduktivno medicino, 2002: 77–8.

Crosignani PG, Vercellini P, Biffignandi F, Constantini W, Cortesi I, Imparato E. Laparoscopy versus laparotomy in conservative surgical treatment for severe endometriosis. Fertil Steril 1996; 66: 706–11.

Busacca M, Fedele L, Bianchi S et al. Surgical treatment of recurrent endometriosis: laparotomy versus laparoscopy. Hum Reprod 1998; 13: 2271–4.

Catalano GF, Marana R, Caruana P, Muzii L, Mancuso S. Laparoscopy versus microsurgery by laparotomy for excision of ovarian cysts in patients with moderate or severe endometriosis. J Am Assoc Gynecol Laparosc 1996; 3: 267–70.

Bateman BG, Kolp LA, Mills S. Endoscopic versus laparotomy management of endometriomas. Fertil Steril 1994; 62: 690–5.

Olive DL, Lee KL. Analysis of sequential treatment protocols for endometriosis-associated infertility. Am J Obstet Gynecol 1986; 154: 613–9.

Kim AH, Adamson D. Surgical treatment options for endometriosis. Clin Obstet Gynecol 1999; 42: 633–44.

Olive DL, Pritts E. Treatment of endometriosis. N Engl J Med 2001; 345: 266–75.

Hughes EG, Fedorkow DM, Collins JA. A quantitative overview of controlled trials in endometriosis-associated infertility. Fertil Steril 1993; 59: 963–70.

Marcoux S, Maheux R, Bérubé S, Canadian Collaborative Group on Endometriosis. Laparoscopic surgery in infertile women with minimal or mild endometriosis. N Engl J Med 1997; 337: 217–22.

Parazzini F. Ablation of lesions or no treatment in minimal-mild endometriosis in infertile women: a randomized trial. Hum Reprod 1999; 14: 1332–9.

Sututton CJG. Laser laparoscopy of the treatment of endometriosis. In: Thomas E, Rock J eds. Modern approaches to endometriosis. Boston: Kluwer Academic,1991: 199–219.

How to Cite
Vogler A, Ribič Pucelj M, Tomaževič T. SURGICAL TREATMENT OF ENDOMETRIOSIS IN INFERTILE PATIENTS. ZdravVestn [Internet]. 1 [cited 27May2019];72. Available from:
Professional Article

Most read articles by the same author(s)