Université Paris Descartes, Centre Hospitalier Universitaire Cochin, Service de Gynécologie Obstétrique II et Médecine de la Reproduction, Paris, France.
Lancet. 2010 Aug 28;376(9742):730-8. doi: 10.1016/S0140-6736(10)60490-4.
Endometriosis and infertility are associated clinically. Medical and surgical treatments for endometriosis have different effects on a woman's chances of conception, either spontaneously or via assisted reproductive technologies (ART). Medical treatments for endometriosis are contraceptive. Data, mostly uncontrolled, indicate that surgery at any stage of endometriosis enhances the chances of natural conception. Criteria for non-removal of endometriomas are: bilateral cysts, history of past surgery, and altered ovarian reserve. Fears that surgery can alter ovarian function that is already compromised sparked a rule of no surgery before ART. Exceptions to this guidance are pain, hydrosalpinges, and very large endometriomas. Medical treatment-eg, 3-6 months of gonadotropin-releasing hormone analogues-improves the outcome of ART. When age, ovarian reserve, and male and tubal status permit, surgery should be considered immediately so that time is dedicated to attempts to conceive naturally. In other cases, the preference is for administration of gonadotropin-releasing hormone analogues before ART, and no surgery beforehand. The strategy of early surgery, however, seems counterintuitive because of beliefs that milder non-surgical options should be offered first and surgery last (only if initial treatment attempts fail). Weighing up the relative advantages of surgery, medical treatment and ART are the foundations for a global approach to infertility associated with endometriosis.
子宫内膜异位症和不孕在临床上是相关的。子宫内膜异位症的医疗和手术治疗对女性自然受孕或通过辅助生殖技术（ART）受孕的机会有不同的影响。子宫内膜异位症的医疗治疗是避孕的。大多是非对照的数据表明，在子宫内膜异位症的任何阶段进行手术都能提高自然受孕的机会。保留卵巢子宫内膜异位囊肿的标准为：双侧囊肿、既往手术史和卵巢储备功能改变。担心手术会改变已经受损的卵巢功能，这一顾虑导致了在进行 ART 之前不进行手术的规则。对这一指导方针的例外情况是疼痛、输卵管积水和非常大的卵巢子宫内膜异位囊肿。医学治疗——例如，3-6 个月的促性腺激素释放激素类似物治疗——可以改善 ART 的结果。当年龄、卵巢储备功能以及男性和输卵管状况允许时，应立即考虑手术，以便有时间自然尝试受孕。在其他情况下，更倾向于在 ART 之前给予促性腺激素释放激素类似物治疗，而不进行手术。然而，早期手术的策略似乎有违直觉，因为人们认为应该首先提供较温和的非手术选择，最后才是手术（只有在初始治疗尝试失败时才进行手术）。权衡手术、药物治疗和 ART 的相对优势是解决与子宫内膜异位症相关不孕的整体方法的基础。
