Comprehensive review of the latest evidence available on endometriosis and subfertility

Endometriosis is a chronic inflammatory condition affecting women of reproductive age group, often resulting in subfertility and chronic pelvic pain. The multifactorial nature of endometriosis-associated infertility is influenced by a complex interplay of genetic, hormonal, menstrual, inflammatory and immunological factors, which together define the phenotypic presentation of the disease. These factors complicate natural conception and impact the success of Assisted Reproductive Technology (ART) cycles. While medical management, typically contraceptive, offers symptomatic relief, it may not address the underlying issues that impede natural conception. Surgical intervention, particularly for ovarian endometriosis, has the potential to enhance spontaneous conception rates but also carries the risk of reducing ovarian reserve. This presents a dilemma in fertility preservation, especially when considering assisted reproductive technologies (ART). The current evidence on the efficacy of surgery in improving ART outcomes remains inconclusive, underscoring the need for an individualized and holistic approach in treatment planning. Such an approach is crucial in optimizing reproductive outcomes for women with endometriosis. A systematic search of the literature was conducted to gather the latest evidence on endometriosis and subfertility. Databases searched included PubMed, Scopus, Web of Science and Cochrane Library. While excising endometriomas may help restore pelvic anatomy and increase spontaneous pregnancy rates, there is also a substantial risk of reducing ovarian reserve due to damage caused during the procedure. In particular, cystectomy has been associated with a significant reduction in anti-Müllerian hormone (AMH) levels, a key marker of ovarian reserve.