SURGICAL-TREATMENT OF ENDOMETRIOSIS-ASSOCIATED INFERTILITY - METAANALYSIS COMPARED WITH SURVIVAL ANALYSIS

OBJECTIVE: Our purpose was to evaluate the role of surgery in the trea tment of endometriosis associated with infertility. STUDY DESIGN: We u sed a prospective cohort analysis of pregnancy rates and variables aff ecting pregnancy rates for surgical, medical, and no treatment. Our st udies were combined with those reported by Hughes et al. (Fertil Steri l 1993;59:963-70), and the meta-analysis was expanded to include addit ional comparisons. Treatment was performed by a single surgeon in a re ferral reproductive endocrinology and surgery private practice. Result s from 579 women with endometriosis and infertility in our study and t he meta-analysis of 25 studies by Hughes et al. were examined. Interve ntions consisted of no treatment, medical treatment, or surgical treat ment by laparoscopy or laparotomy. The main outcome measure was pregna ncy rates. RESULTS: For minimal and mild disease, no treatment, laparo scopy, and laparotomy had equivalent 3-year estimated cumulative life- table pregnancy rates (67% +/- 12%, 68% +/- 4%, and 74% +/- 8%, respec tively) that were higher than medical treatment pregnancy rates (Bresl ow p = 0.003). For moderate and severe disease, all but II patients we re treated surgically. The 3-year estimated cumulative life-table preg nancy rates were 44% +/- 6% for 120 laparoscopy cases and 62% +/- 6% f or 102 laparotomy cases (Breslow p = 0.054). For endometriomas, 48 lap aroscopy patients had a 3-year estimated cumulative life-table pregnan cy rate of 52% +/- 9% and 52 laparotomy patients had a 3-year estimate d cumulative life-table pregnancy rate of 46% +/- 9% (Breslow p = 0.48 ). For 28 patients with complete cul-de-sac obliteration, the 3-year e stimated cumulative life-table pregnancy rates were 30% +/- 14% after laparoscopy and 24% +/- 12% after laparotomy (Breslow p = 0.084). Comp arison of our results with the expanded meta-analysis revealed deficie ncies in the design of meta-analysis studies and the impact of our usi ng life-table pregnancy rates controlled for factors influencing outco me (survival analysis with fixed covariates) rather than the simple pr egnancy rates used in the meta-analysis. Benefits of sophisticated sta tistical techniques, including propensity scores, to adjust for noncom parability of groups in prospective cohort studies were identified. CO NCLUSION: Both our study and the meta-analysis show that either no tre atment or surgery is superior to medical treatment for minimal and mil d endometriosis associated with infertility. For moderate and severe d isease, surgery is usually used. In these patients experienced surgeon s utilizing good clinical judgment can achieve results at operative la paroscopy at least equivalent to those at laparotomy, even in cases in volving endometriomas and complete cul-de-sac obliteration. Prospectiv e randomized trials should be performed to confirm these findings.