The treatment of endometriosis: a review of the evidence.

The treatment of endometriosis focuses upon amelioration of two symptoms: pain and infertility. The treatment of endometriosis-associated pain has been well studied and all major medical therapies appear to be superior to placebo. In addition, none seems to be drastically better than another. Surgical therapy also appears to be efficacious, albeit with a relatively high rate of recurrence of symptoms following conservative surgical intervention. There are no trials comparing the relative value of medical versus surgical therapy. Combination surgery/medical therapy has several high-quality trials for evaluation, but its value remains unclear. The treatment of endometriosis-associated infertility presents a different picture: medical therapy has not been shown to be of any value and may prove detrimental to fertility. Surgical treatment does improve fertility, probably for all stages of disease. Assisted reproduction also seems to be efficacious, with both controlled ovarian hyperstimulation and intrauterine insemination as well as in vitro fertilization shown to be of benefit. Finally, the combination of in vitro fertilization and either medical or surgical therapy may be beneficial with advanced endometriosis, but further study is required.