**Abstract**

Endometriosis is one of the most common gynecological diseases in the world with a great variety of symptoms and clinical features. The true prevalence rates in the general population are not known, but according to different authors, endometriosis is to be found in 10% in women of reproductive age. According to different publications, around half of the patients with infertility were diagnosed with endometriosis which change the significance of this disease from the only female to a socio-economical problem. In this chapter, we will focus on the current view on endometriosis-associated infertility, from superficial to adenomyosis, with a closer view of surgical treatment, as it is still the standard of care for diagnosis and in severe cases—treatment of the disease.

**Keywords:** adenomyosis, DIE, deep infiltrative endometriosis, endometrioma, peritoneal endometriosis, infertility, IVF

## **1. Introduction**

Today, the medical community considers endometriosis as a significant disease and problem. According to different resources, about 176 million women are suffering from the disease worldwide. In multination, multicenter study [1] about 50% of gynecologists polled in Russia in 2007 examined 7–28 patients with endometriosis per month (240 patients per year). The number was almost equal to that of patients with myoma.

Endometriosis is known to be found in 60% of women aged under 30. More important is the fact that there is a 7-year delay from the first disease manifestation to the diagnosis [2].

The physician should suspect the endometriosis if the following complaints are present [3]:


Even though the exact mechanism of endometriosis-associated infertility is still unknown, some aspects are well studied. Endometriosis has an influence on the

quality of peritoneal fluid with growing macrophage concentration as well as proteases and cytokines negatively influencing the quality of oocytes, sperm, embryo, and fallopian tube potential.

It is difficult to recommend the optimal treatment as the development of the disease is unpredictable—from asymptomatic to very aggressive though pelvic pain and infertility usually called "active endometriosis" [4].

The American Society of Reproductive Medicine (ASRM) classification of endometriosis describes four stages of the disease. But that does not always correlate with the actual symptoms (pain, infertility, etc.) [5–7]. The more you work with this classification, the more it becomes obvious that patients with the same stages of the disease by ASRM classification, in fact, are incomparable. The ideal approach to endometriosis treatment should take into consideration how active the disease is. The "active" disease requires a combined treatment. The combination of surgical, hormonal treatment, and in vitro fertilization (IVF) could be individually chosen in each specific case of infertile patients.

For an easier understanding of how to treat endometriosis-associated infertility, it is better to separate the disease in four different phenotypes: superficial, endometrioma, deep infiltrated endometriosis, and adenomyosis.
