Objective: To report our experience in patients with previous IVF failures who conceived after laparoscopic treatment of endometriosis. Design: Retrospective case series. Setting: Tertiary center IVF and endoscopy programs. Patient(s): Infertility patients with history of prior IVF failures. Intervention(s): Laparoscopic evaluation and treatment of endometriosis by the same surgeon. Main Outcome Measure(s): Occurrence of conception after laparoscopic treatment of endometriosis. Result(s): Of 29 patients with prior IVF failures, 22 conceived after laparoscopic treatment of endometriosis, including 15 non-IVF pregnancies and 7 IVF pregnancies. Conclusion(s): In the absence of tubal occlusion or severe male factor infertility, laparoscopy may still be considered for the treatment of endometriosis even after multiple IVF failures. (Fertil Steril 2005;84:1574–8.©2005 by American Society for Reproductive Medicine.) Key Words: Laparoscopy, endometriosis, infertility, IVF

Endometriosis is one of the most common gynecologic disorders and is significantly more prevalent in the setting of infertility^{(1, 2)}. The prevalence of endometriosis in infertile women ranges from 25% to 50% compared to 5% in fertile women^{(2, 3)}. Successful laparoscopic management of all stages of endometriosis was reported as early as 1986⁽⁴⁾. This has revolutionized the management of endometriosis. The benefits of surgical therapy for infertility associated with endometriosis have been well documented^(4–6). However,
with the advent of assisted reproductive technologies (ART), the number of patients undergoing laparoscopic evaluation as part of the initial workup has decreased. Recently, there has been a growing tendency to bypass diagnostic laparoscopy after a normal hysterosalpingogram⁽⁷⁾.

Patients are commonly in their mid-30s or older when they seek infertility therapy. This, combined with the risks of undergoing a surgical procedure, often leads patients with failed controlled ovarian hyperstimulation (COH) and IUI to the IVF path, without thorough evaluation or therapy of potential endometriosis. Furthermore, when initial IVF cycles fail, patients and physicians tend to choose additional IVF treatment and some may even elect oocyte donation after multiple failures. Many couples and physicians believe
that because the ultimate therapy, IVF, failed to result in a pregnancy, further infertility investigation and treatment are likely to be futile.

In this study, we report our experience with patients who have failed IVF treatment and underwent laparoscopic evaluation and management.

Materials and Methods
A retrospective analysis of infertility patients, with failed IVF treatment, was conducted. Typically, multiple cycles of COH/IUI had failed and these patients elected to proceed to IVF without undergoing laparoscopic evaluation. The patients were offered laparoscopy for further evaluation of infertility as an alternative to repeating IVF, oocyte donation, or adoption. Of this group, those patients who chose not to undergo a laparoscopic procedure were assigned as a control group. Patient characteristics including age, parity, FSH, number of failed IVF cycles, duration of infertility, stage of endometriosis, and modes of conception were recorded. The duration of infertility before seeking treatment varied largely, dependent on the presenting age of the patient.
Patients >37 years old tended to seek infertility treatment earlier than patients <37 years of age. These patients were followed for a minimum of 9 months and were closely matched for age, FSH, duration of infertility, and number of
failed IVF cycles. Patients with severe male factor infertility requiring intracytoplasmic sperm injection (ICSI) or tubal factor infertility with bilateral tubal obstruction were not included.

Surgical treatment consisted of thorough CO₂ laser ablation or excision of all peritoneal and nonperitoneal endometriotic lesions, lysis of adhesions, and appropriate management of ovarian endometriomas^(8–10). The surgical approach was based on intraoperative assessment of the pathophysiology or the type of endometrioma, which is found to be quite varied^{(8, 9)}. For example, reassurance was made that type I endometriomas are totally removed. In type
II endometriomas, only the endometriotic plaque, not the luteal cyst wall is removed^(8–10). No medical treatment of endometriosis was administered after surgery. All surgeries were performed by the senior surgeon (CN).

Statistical calculations were performed using Student’s t test and X² test as appropriate, and statistical significance was defined as P< .01. Institutional review board approval was obtained before chart review.

Results
Twenty-nine patients with multiple IVF failures underwent laparoscopic treatment. Eighteen of these patients were nulliparous. Three patients had a known history of endometriosis before IVF treatment, whereas the remaining 26 had no previous laparoscopy. At least one IVF cycle had failed in all
patients, with an average of 2.2 ( ±0.7) failed cycles. Twenty-two of 29 (76%) of the patients who had laparoscopic treatment of endometriosis conceived. The mean age of this group was 34.3 ± 3.6 years with a range of 28 – 40 years. The characteristics of these patients are shown in Table 1. Of the patients in the study who were diagnosed with stage I disease, 4/4 (100%) conceived. Five of 6 (83%) of patients with stage II disease conceived. Five of 6 (83%) of patients with stage III disease conceived and 8/13 (62%) of those with stage IV disease conceived.

Twelve patients conceived spontaneously and two patients conceived with clomid/IUI. Time to conception, in these 14 patients, ranged from 1 to 8 months after surgery. Seven patients conceived with additional IVF treatment after surgery. An additional patient conceived by IVF and also had a subsequent spontaneous conception. Twenty-four percent of the patients in the laparoscopy group did not conceive (7/29). The mean age of these patients was 36.4 ± 5.7 years, with a range of 31–40 years. The majority of these patients had stage IV endometriosis (5/7). For further analysis, the outcome
of patients who decided not to undergo laparoscopy was compared with those of patients who elected laparoscopic evaluation. The mean age of this group was 35.1 years and the average number of cycles was 2.4, which was not
significantly different from the laparoscopy group. In this nonlaparoscopy group 13 of 35 conceived. Of those who conceived, two of the pregnancies were spontaneous and the rest were from repeat IVF cycles.

The group who underwent laparoscopy after failed IVF cycles is compared to the control group in Table 2. There was no significant difference in the mean age or FSH level in either of the patient groups. A significantly higher pregnancy rate (PR) was demonstrated in the laparoscopy group vs. the
nonlaparoscopy group. Also, the number of patients who were able to conceive spontaneously was significantly higher in the group that had undergone laparoscopic treatment of endometriosis. Statistical significance was defined as P <.01.

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Received July 14, 2004; revised and accepted February 14, 2005. Reprint requests: Camran Nezhat, M.D., Stanford University Medical Center, Center for Special Minimally Invasive Surgery, 900 Welch Road Suite 403, Palo Alto, California 94304 (FAX: 650-327-2794; E-mail: cnezhat@stanford.edu). 1574 Fertility and Sterility® Vol. 84, No. 6, December 2005 0015-0282/05/$30.00 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc. doi:10.1016/j.fertnstert.2005.02.059

July 2006

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