**3. Pelvic endometriosis: A good example of how to individualize treatment**

The optimal management of endometriotic ovarian cysts in infertile patients is less well defined. Recent evidence of reduced responsiveness to gonadotrophins following

laparoscopic ovarian cystectomy has challenged the traditional surgical approach to treatment (12)*.* Indeed, it has been suggested that surgery should be undertaken only for the treatment of large endometriomas or pain that is refractory to medical treatment, or to exclude malignancy (13).

Endoscopy versus IVF: The Way to Go 33

**3.5. Precautions of laparoscopic surgery prior to IVF/ICSI** 

**4. Role of hysteroscopy prior to assisted reproduction** 

surgery and the loss of the ovary.

suture.

studies (21).



Failure of IVF treatment can be broadly attributed to embryonic, uterine or transfer factors, but remains unexplained in most cases (18). A number of interventions have been proposed to improve IVF outcome, many of which are not strictly evidence-based and their efficacy in improving pregnancy rates remains controversial (19,20). One of the main causes of failure of implantation after proper embryo transfer is intrauterine pathology. Whether to perform hysteroscopic evaluation of the endometrial cavity prior to IVF/ICSI especially in patients with repeated failures is a controversial issue that is open for criticism and deserves further

In a systematic review (Level Ia evidence), 5 reliable studies were included (22). Two RCT showed a statistically significant improvement in the clinical pregnancy rate in the group who had office hysteroscopy (pooled RR = 1.57, 95% CI 1.29–1.92, *P* < 0.00001). The miscarriage rate was not statistically different between the office hysteoscopy and control groups in either study (24% versus 29%, respectively, RR = 0.83, 95% CI 0.56–1.21, *P* = 0.33). Three non-randomized controlled studies suggests that office hysteroscopy improves the pregnancy rate in the subsequent IVF cycle (pooled RR = 2.01, 95% CI 1.60–2.52, *P* < 0.00001). In addition to the well known diagnostic as well as therapeutic advantages of performing hysteroscopy, even if the endometrial cavity was completely free, high pregnancy rate was achieved after diagnostic hysteroscopy since uterine instrumentation during hysteroscopy would inevitably cause a degree of endometrial injury and provokes a posttraumatic reaction that involves release of cytokines and growth factors (23,24), which in turn may influence the likelihood of implantation (25). Commencing IVF treatment soon after hysteroscopy may take advantage of this immunological response (26). Performing diagnostic hysteroscopy before assisted reproductive technologies (ART) may be advisable not only from the clinical but also from the economic point of view (27). Enhanced clinical pregnancy rates would be achieved on adding office hysteroscopy as a complementary step prior to IVFspecially patients with recurrent IVF embryo transfer failures even after normal hysterosalpingography findings. Some abnormal intrauterine findings that would affect the prognosis of IVF/ICSI can be easily diagnosed by hysteroscopy like chronic endometritis, Müllerian anomalies, retained fetal bones, or endocervical ossification. Moreover, contact hysteroscopy may reveal addition valuable findings such as polyposis, strawberry pattern,


Laparoscopic surgery may be of benefit in treating subfertility associated with mild to moderate endometriosis. However, additional studies in this field are needed before definitive conclusions can be drawn (14). Laparoscopic excision of ovarian endometriomas more than 3 cm in diameter may improve fertility. (level II evidence). The effect on fertility of surgical treatment of deeply infiltrating endometriosis is controversial (level II evidence).
