Surgical Intervention in Submocosal Myoma Grade II and III

Endometriosis is present in approximately 5 to 15% of infertile couples. However, the best treatment approach and the place of surgery for these patients are still in dispute. Detecting infertile women who are at risk for endometriosis and optimal imaging evaluation are now replacing the use of laparoscopic surgery to diagnose pelvic endometriosis.Laparoscopic surgery for patients with minimal and mild peri-toneal superficial endometriosis (SUP) improves the chance of spontaneous conception and live birth rate. This treatment ef-fect before IVF is relatively small, and thus, it may not be a cost-effective intervention.The ovaries with endometrioma (OMA) ovulate spontaneously and do respond to stimulation with gonadotropin. The size of OMAs not requiring surgical intervention tends to rise, espe-cially if the infertility is present. Removing the OMAs does not improve the ART outcome; furthermore, the procedure may significantly decrease the ovarian reserve and previous surgery for OMA is a significant prognostic factor for a reduced ART success rate. It is of great importance to maintain the ovarian re-serve and to start ART before ovarian reserve is compromised. Surgery for deep infiltrating endometriosis (DIE) is complex and carries certain risks and does not improve fertility and ART outcome. Data does not support the use of surgery before ART for infertile patients with DIE. IVF is the first line treatment for these patients.Today, for infertile patients with endometriosis, ART is the first line and surgery is the final treatment. Surgery prior to ARTmust be carefully considered regarding factors such as patient’s age, t duration of infertility, other infertility factors such as the presence of hydrosalpinx, severity of pain, previous surgery for OMAs, and most importantly ovarian reserve. Young patients with short infertility duration and pelvic pain might be good candidates for primary surgery. If surgery is used to treat en-dometriosis, the conception should be attempted shortly after surgery.The main goals are to do surgery -if required- only once in a life time for the patients with endometriosis, to postpone surgery to the closest time to pregnancy attempt or ART, and to maintain a good ovarian reserve for future spontaneous conception or ART.