INTRODUCTION

Ovulatory disorders, tubal obstruction, and semen abnormalities are relatively easy to diagnose and account for the cause of infertility in approximately 75 percent of couples [1]. When couples with these abnormalities are excluded, infertility in the other 25 percent of couples is usually due to endometriosis, which may be present in 40 percent of the female partners of these couples [2]. The remaining cases are classified as unexplained infertility (table 1). (See "Causes of female infertility" and "Evaluation of female infertility".)

Although endometriosis impairs fertility, it does not usually completely prevent conception. A combination of surgery, ovulation induction plus intrauterine insemination, and in vitro fertilization can be used to help these women conceive.

This topic will provide an approach to treatment of infertility in women with endometriosis. Other aspects of endometriosis are reviewed separately:

• (See "Pathogenesis, clinical features, and diagnosis of endometriosis".)
• (See "Overview of the treatment of endometriosis".)
• (See "Diagnosis and management of ovarian endometriomas".)
• (See "Thoracic endometriosis".)

PATHOGENESIS OF INFERTILITY

Mechanisms of infertility associated with endometriosis are controversial and likely depend, in part, on the stage of disease. Endometriosis is surgically staged using the American Society of Reproductive Medicine (ASRM) staging system (figure 1). The spectrum of disease ranges from minimal presence of ectopic tissue (eg, 1 to 5 mm implants on the pelvic peritoneum) to severe anatomic distortion (deep ovarian endometriomas, major pelvic adhesions with obliteration of normal pelvic organ relationships).