Infertility and deep endometriosis

Apart from the tubal or adhesive disorders in advanced stages, themechanisms by which endometriosis deteriorates fertility remainlargely hypothetical: defect in folliculogenesis, fertilization, implantationand/or inflammatory disease. Many papers mainly suggestinflammatory changes in peritoneal fluid.Deep endometriosis, defined by a subperitoneal involvement>/5mm, can be isolated or associated with a more or less severeovarian and/or peritoneal endometriosis. Pain is the main clinicalsign. Infertility is seldom in the foreground. However the patientsare generally very young nulliparous women, not having had timeto be unfertile yet, but eager to preserve their fertility.Medical treatment only has a partial and time-limited effectivenesson pain, and no proved result on infertility.Complete excision of all the infiltrating lesions constitutes the idealtreatment. It comprises wide dissection of the subperitoneal space,ureterolysis and often rectal resection / anastomosis, to be only performedby experienced surgeons, with risks of rectal-vaginal fistulasputting directly at stake the later fertility.Overall, 30 to 70% of pregnancies are obtained after excision of thedeep lesions, in favour of a causal relationship.In these severe forms of endometriosis, a multidisciplinary approachgenerally associates surgical resection, GnRH analogs andin vitro fertilization.