Effectiveness of postoperative adjuvant therapy in improving reproductive outcome of endometriosis-associated infertility

Background and purpose: Treatment of endometriosis-associated infertility has not yet become standardized. Various protocols including surgical treatment, medical therapy, and a combination of both have been suggested but their use remains controversial. The objective of the present study was to determine whether postoperative adjuvant therapy for endometriosis is effective in improving reproductive outcome. Methods: Medical records of infertile patients with newly diagnosed endometriosis treated in a university teaching hospital during a 50-month period were reviewed. After exclusion of patients with other major infertility factors, a total of 209 patients were included in the retrospective analysis. These patients were divided into those receiving (n = 78) or not receiving (n = 131) peri- or postoperative adjuvant medical therapy. The adjuvant therapies included danazol (n = 62), gonadotropin releasing hormone analogues (n = 11), progestins (n = 3), oral contraceptives (n = 1), and mixed treatment (n = 1). Results: The pregnancy rate was lower in those receiving adjuvant therapy, although this result was not significant (32.1% vs 45.8%; p = 0.05). When patients using postoperative danazol therapy were considered alone, the pregnancy rate in patients receiving adjuvant therapy was significantly lower than that in patients not receiving it (p = 0.047). When the stage of endometriosis was considered, the pregnancy rate in patients receiving adjuvant therapy was again lower than in those not receiving it in patients with minimal or mild endometriosis (42.9% vs 60%; p = 0.043). However, in patients with moderate or severe endometriosis, the pregnancy rate was not different in the two groups (31% vs 36%; p = 0.56). Postoperative assisted reproductive techniques (ART) including controlled ovarian hyperstimulation/intrauterine insemination insemination (COH/IUI) and in vitro fertilization (IVF) were effective in improving the pregnancy rates for all patients (53.9% with ART vs 33.1% without; p = 0.003) and for patients with advanced endometriosis (47.7% with ART vs 27.2% without; p = 0.016). Conclusions: Our results suggest that postoperative adjuvant therapy is ineffective in improving reproductive outcome in patients with either early (minimal or mild) or advanced (moderate and severe) endometriosis. This finding suggests that if fertility is the goal of treatment, adjuvant therapy may be unnecessary after surgery. In contrast, our data suggest that empirical ART, including COH/IUI or IVF, may be a better alternative to improve the pregnancy outcome after surgery.