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National Collaborating Centre for Women's and Children's Health (UK). Fertility: Assessment and Treatment for People with Fertility Problems. London (UK): RCOG Press; 2004 Feb. (NICE Clinical Guidelines, No. 11.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Fertility: Assessment and Treatment for People with Fertility Problems.

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9Medical and surgical management of endometriosis

9.1. Medical management (ovarian suppression)

A systematic review and meta-analysis of 16 RCTs compared the effectiveness of ovulation suppression agents with no treatment (six RCTs) or danazol (ten RCTs). Treatment with ovulation suppression agents (medroxyprogesterone, gestrinone, combined oral contraceptives and GnRHa) did not improve clinical pregnancy rates in women with endometriosis-associated infertility compared with no treatment (pooled OR 0.74; 95% CI 0.48 to 1.15) or danazol (pooled OR 1.3; 95% CI 0.97 to 1.76).666 [Evidence level 1a] Similar results were reported in a subsequent RCT comparing medroxyprogesterone acetate to placebo.667 [Evidence level 1b] Two reviews in 1993 and 1994 which included RCTs and cohort studies also concluded that ovulation suppression was ineffective in the treatment of endometriosis-associated infertility.668,669 [Evidence level 1b–2b]

Commonly used ovulation suppression agents have been known to cause significant adverse effects such as weight gain, hot flushes and bone loss.666

A systematic review of two small RCTs assessing the effect of danazol in the treatment of unexplained infertility found no significant difference in pregnancy rates (OR 2.57, 95% CI 0.53 to 12.46) when compared with placebo.670 [Evidence level 1a]


Medical treatment of minimal and mild endometriosis does not enhance fertility in subfertile women and should not be offered. [A]

9.2. Surgical ablation

Minimal and mild endometriosis

A systematic review and meta-analysis of two RCTs (n = 444) showed that laparoscopic ablation or resection of minimal and mild endometriosis plus laparoscopic adhesiolysis increased ongoing pregnancy and live birth rates compared with diagnostic laparoscopy (pooled OR 1.64; 95% CI 1.05 to 2.57).671 [Evidence level 1a] There was no difference in miscarriage rates between the two treatment groups (pooled OR 1.33; 95% CI 0.60 to 2.94). Surgical complications were reported in one of the trials but these were minor and did not require laparotomy or transfusion.672 However, it was not clear from either trial whether the study subjects were blinded as to the treatments they received or whether intention-to-treat analysis was performed.

In women who had mild endometriosis as their only infertility factor, the pregnancy rate was higher after laser laparoscopy and laparotomy compared with medical treatment (81% with laser laparoscopy versus 84% with laparotomy versus 54% with medical treatment).673 [Evidence level 2b] The benefits of surgery should be balanced against the risks of general anaesthesia and surgical complications674 such as postoperative adhesions.

Endometrioma/ovarian cysts

One RCT found that laparoscopic cystectomy increased cumulative pregnancy rates at 24 months when compared with drainage and coagulation in the treatment of large ovarian endometrioma (66.7% versus 23.5%; OR 2.83, 95% CI 1.01 to 7.50).675 [Evidence level 1b]

Moderate and severe endometriosis

Cohort studies of women with moderate and severe endometriosis operative treatment with laparoscopy or laparotomy suggest that pregnancy rates may be the same or increased in those treated by laparoscopy (54–66% with operative laparoscopy versus 36–45% with laparotomy).676–679 [Evidence level 2b]

Postoperative medical treatment

Two RCTs compared postoperative GnRH with expectant management and found no significant difference in pregnancy rates between the two regimens (11.6% with goserelin versus 18.4% with expectant management and 33% with leuprolide depot versus 40% with expectant management, respectively).680,681 [Evidence level 1b] Similar outcomes were shown between postoperative danazol (55% with danazol versus 50% with expectant management)682 and between postoperative nafarelin and placebo (19% with nafarelin spray versus 18% with placebo),683 in women with moderate to severe endometriosis. [Evidence level 1b]


Women with minimal or mild endometriosis who undergo laparoscopy should be offered surgical ablation or resection of endometriosis plus laparoscopic adhesiolysis because this improves the chance of pregnancy. [A]

Women with ovarian endometriomas should be offered laparoscopic cystectomy because this improves the chance of pregnancy. [A]

Women with moderate or severe endometriosis should be offered surgical treatment because it improves the chance of pregnancy. [B]

Post-operative medical treatment does not improve pregnancy rates in women with moderate to severe endometriosis and is not recommended. [A]

Copyright © 2004, National Collaborating Centre for Women’s and Children’s Health.

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Bookshelf ID: NBK45922
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