3.1. Treatment modalities and management of autoimmune infertility

Endometriosis management guidelines are valid for women with mild to moderate disease and do not recommend hormonal therapy for managing ovulation to improve fertility rate [135]. Despite reduction in ovarian function, one time laparoscopic operation to remove endometriosis and improve pregnancy rates is often recommended [136, 137]. Adjunctive hormonal therapy is prohibited pre- or post-surgery to improve pregnancy rates [138]. Intra uterine insemination along with controlled ovarian stimulation is recommended 6 months postsurgery since it shows similar pregnancy rates as that of women with unexplained infertility [139]. ART can also be recommended especially in cases of tubal factor or male factor infertility as controlled ovarian stimulation does not increase chances of recurrence of endometriosis after IVF/ICSI [140–143] however, it may not always be effective [144, 145].

POI seems to be an end-stage disease in women with an autoimmune disorder since it is detected at a late stage when the ovary has been substantially ravaged with little scope for fertility management. Thus treatment options for fertility management of women with POI are limited. Counseling for early marriage and pregnancy to complete the family is applicable only in case of early diagnosis or known familial origin. Other options include egg donation and IVF-ICSI or surrogacy. The women are administered corticosteroids in case of known autoimmune disease diagnosis and advised IVF-ICSI when AAb titers fall. However, this is not an option since it entails risk of osteoporosis and iatrogenic Cushing's syndrome [119]. In most cases, adoption is the only option along with psychological counseling and cardiovascular and bone health management of hypoestrogenism effects [146].

Additionally, there should be efforts to increase awareness among reproductive endocrinologists to recommend testing for undiagnosed autoimmune disease to couples on a case basis before embarking on ART-IVF [147].
