Laparoscopic surgery for subfertility associated with endometriosis.
BACKGROUND
Endometriosis is the presence of endometrial glands or stroma in sites other than the uterine cavity. It is variable in both its surgical appearance and clinical manifestation, often with poor correlation between the two. Surgical treatment of endometriosis aims to remove visible areas of endometriosis and restore anatomy by the division of adhesions.


OBJECTIVE
To assess the efficacy of laparoscopic surgery in the treatment of subfertility associated with endometriosis. The review aims to compare outcomes of laparoscopic surgical interventions compared to no treatment or medical treatment with regard to improved fertility.


METHODS
We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of trials (June 2009), Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 2), MEDLINE (1966 to June 2009), EMBASE (1980 to June 2009), and reference lists of articles.


METHODS
Trials were selected if they were randomised and compared the effectiveness of laparoscopic surgery in the treatment of subfertility associated with endometriosis versus other treatment modalities or placebo.


METHODS
Two studies were eligible for inclusion within the review. Both studies compared laparoscopic surgical treatment of minimal and mild endometriosis compared with diagnostic laparoscopy only. The recorded outcomes included live birth, pregnancy, fetal losses, and complications of surgery.


RESULTS
When combining live birth rate and ongoing pregnancy after 20 weeks, meta-analysis demonstrated an advantage of laparoscopic surgery when compared to diagnostic laparoscopy only. The odds ratio (OR) was 1.64 (95% confidence interval (Cl) 1.05 to 2.57) in favour of laparoscopic surgery. Meta-analysis also demonstrated an advantage of laparoscopic surgery when compared to diagnostic laparoscopy only in terms of clinical pregnancy rates, with an OR of 1.66 (95% Cl 1.09 to 2.51) favouring laparoscopic surgery. The results still need to be interpreted with caution as Marcoux 1997 reported a large positive effect of surgery whereas Gruppo Italiano reported a small negative effect. When considering fetal losses, meta-analysis did not demonstrate an effect of laparoscopic surgery when compared to diagnostic laparoscopy only. The OR was 1.33 (95% Cl 0.60 to 2.94) favouring diagnostic laparoscopy only.


CONCLUSIONS
The use of laparoscopic surgery in the treatment of subfertility related to minimal and mild endometriosis may improve future fertility.
Jacobson
Tal Z
TZ
Department of Obstetrics and Gynaecology, South Auckland Clinical School, Middlemore Hospital, Private Bag 93311, Auckland, New Zealand.
Duffy
James Mn
JM
Barlow
David
D
Farquhar
Cindy
C
Koninckx
Philippe R
PR
Olive
David
D
D004715:Endometriosis / Q000150:complications / Q000601:surgery*; D005260:Female; D006801:Humans; D007247:Infertility, Female / Q000209:etiology / Q000601:surgery*; D010535:Laparoscopy; D016032:Randomized Controlled Trials as Topic