How can the fertility outcome in endometriosis patients be improved?

The general aim of this clinical PhD project (2011-2017) is to come to an evidence-based approach for fertility management in patients who have endometriosis-associated infertility, and to increase the success rate of these fertility treatments.

More specifically, the following research questions will be tackled:

1/ How strong is the association between endometriosis and infertility, and between adenomyosis (an often endometriosis-associated pathology with similar pathogenesis) and infertility? Two systematic literature reviews will be performed with the aim to identify a causal relationship between endometriosis/adenomyosis and infertility.

2/ Can patients be counselled correctly on their fertility prognosis after endometriosis surgery by means of the EFI? A validation study will be conducted to confirm its predictive potential.

3/ If patients have a good fertility prognosis (high EFI) after endometriosis surgery, is there an added value of IUI over expectant management to achieve a pregnancy? A randomized controlled clinical trial will be performed comparing spontaneous evolution with IUI, the study hypothesis being that patients in the IUI group will have a higher clinical pregnancy rate at the end of the study period.

4/ Is the presence of endometriosis truly a negative prognostic factor for the success rate of ART?     A large retrospective analysis will be performed of a 10-year period of ART in patients who all had a laparoscopy, comparing the results in patients with and without endometriosis, to assess the effect of endometriosis on ART performance.

5/ Will the success rate of ART be improved in postoperative endometriosis patients by using the ultralong downregulation protocol, as suggested by the Cochrane review of Sallam et al (14)?             A randomized trial will be performed, comparing the ultralong downregulation (at least 3 months of GnRH-agonist pretreatment) prior to ART stimulation with the conventional long agonist protocol.

6/ If an endometriotic ovarian cyst (endometrioma) is present prior to starting ART, is it then better to treat this cyst surgically before the start of ART, to pretreat with the ultralong downregulation protocol, or to proceed with ART without any further intervention? A randomized clinical trial will be performed (multicenter, global), to study the effect of these three options CPHB.