**3.4. More advantages include**


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

32 Enhancing Success of Assisted Reproduction

exclude malignancy (13).

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

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).

In a meta-analysis (15)the chance of achieving pregnancy after IVF was significantly lower for patients with endometriosis (odds ratio, 0.56; 95% confidence interval, 0.44-0.70), as compared to those withtubal factor. They also reported decreased fertilization rates,

The same study (15) reported that the probability of pregnancy was reduced in women with

Contrarily, a recent retrospective poorly designed study (16) demonstrated that ovarian endometriosis does not reduce IVF outcome compared with tubal factor. Furthermore, laparoscopic removal of endometriomas does not improve IVF results, but may cause a decrease of ovarian responsiveness to gonadotropins. Nevertheless, they included a bizarre group of patients with one or more endometrioma, unilateral or bilateral with a size of6 cm and more importantly symptomatic as well as asymptomatic cases. In addition to being a retrospective analysis, these heterogenous criteria would weaken this study. We believe that stripping off cyst wall of a unilateral endometrioma wouldn't be expected to affect ovarian

**3.3. Advantages of laparoscopic surgery for endometriosis prior to IVF (ESHRE** 

Elimination of pelvic pain by destruction of the peritneal endometriotic lesions which

**3.1. Is there a need to treat endometriosis in patients undergoing IVF?** 

**3.2. Mild endometriosis Vs severe endometriosis prior to IVF/ICSI** 

implantation rates and in the number of oocytes retrieved.

severe endometriosis as compared to those with mild disease.

reserve or ovarian response to gonadotropins.

**Recommendations, 2005) (17)** 

 reduces the risk of infection improvesaccess to follicles Improves ovarian response.

**3.4. More advantages include** 

confirms the diagnosis histologically

Spontaneous pregnancy in mild and moderate disease.

may be mistaken by OHSS if the patient is subjected to IUI.

