JBRA Assisted Reproduction 2025;29(Suppl.2 SBRA 2025):33
Poster Presentation
29^th Annual Congress of the SBRA. São Paulo/SP - Brazil, 2025
doi: 10.5935/1518-0557.20263557

P-021. Assisted Reproduction in the fight against infertility caused by endometriosis

Vinícius Machado Salles¹, Amanda de Alevir¹, Leticia Ferreira¹, Marcelo Cavalcante¹, Marina Pinheiro Bezerra de Menezes¹

¹ UNIFOR - Universidade de Fortaleza - Fortaleza - CE - Brasil

Objective: Endometriosis is a chronic, multifactorial inflammatory disease that affects many women of reproductive age and is frequently associated with infertility. Several morphological, inflammatory, endocrine, and immunological alterations related to the disease compromise spontaneous fertility, interfering with processes from ovulation to embryo implantation. In this context, assisted reproductive technologies (ART) have proven to be an important therapeutic strategy to restore the reproductive potential of these patients. This study aims to conduct a narrative review of the literature on the role of ART in the treatment of endometriosis-associated infertility.
Methods: A literature review was carried out in the PubMed database using the descriptors “endometriosis,” “infertility,” and “assisted reproductive technique”. Only studies conducted in humans, published in the last 10 years, in English or Portuguese, were included. Observational studies, systematic reviews, and meta-analyses addressing endometriosis-related infertility and ART approaches were prioritized.
Results: Across the reviewed literature, ART, particularly in vitro fertilization (IVF), have proven to be essential in the treatment of endometriosis-associated infertility, especially when surgical or medical treatments yield suboptimal results. Women with minimal or mild endometriosis (ASRM I/II) may present lower fertilization rates compared to controls, although implantation and pregnancy outcomes are generally preserved. In contrast, moderate to severe stages (ASRM III/IV) are consistently linked with reduced implantation, clinical pregnancy, and live birth rates. Endometriomas, present in up to 44% of cases, are associated with decreased ovarian reserve and a reduced number of oocyte retrievals, particularly when treated bilaterally or surgically. Despite this, studies show that oocyte and embryo quality, as well as euploidy rates, remain virtually unchanged, suggesting that ART may overcome some of the mechanical and inflammatory barriers imposed by the disease. Notably, the success of ART appears to be more compromised by surgical damage to ovarian tissue than by the endometrioma itself. Regarding endometrial receptivity, although some molecular studies indicate altered expression of implantation markers (e.g., HOXA10, integrins), large retrospective cohort studies using euploid embryo transfers report no significant differences in implantation or live birth rates between women with and without endometriosis. Extended GnRH agonist pretreatment prior to IVF has been proposed to reduce inflammatory activity and improve ART outcomes, though recent meta-analyses show mixed results. Similarly, there is no robust evidence supporting the systematic surgical removal of endometriomas before ART, unless they impair follicular access or cause significant pain. Overall, the literature emphasizes a personalized approach: IVF remains the most effective treatment, especially when tubal function is compromised or when infertility persists after surgery. The Endometriosis Fertility Index (IFI) can help identify early on which patients would benefit from ART.
Conclusion: ART, particularly IVF, stands out as the main therapeutic alternative for restoring fertility in women with endometriosis. Evidence shows that, although the disease can compromise ovarian reserve and endometrial receptivity, the quality of oocytes and embryos is generally preserved. The rational use of surgery and individualized treatment based on clinical and reproductive parameters are essential to maximize results. Recent literature emphasizes that the main limiting factor for ART success is the ovarian damage caused by surgery, especially in endometriomas larger than 4 cm. Moreover, large-scale analyses using euploid embryo transfers and donor oocytes indicate that implantation potential remains virtually intact in most cases. However, in more advanced stages of the disease or in the presence of adenomyosis, results may vary and require more detailed evaluation. Given the heterogeneity of the disease, early identification of candidates for fertility preservation strategies is essential, considering the trend toward delayed motherhood in modern society. Therefore, ART offers a technically effective solution and plays a strategic role in reproductive planning for women with endometriosis.