A 32-year-old woman with stage IV endometriosis (deep infiltrating endometriosis, bilateral endometriomas) and infertility is counselled regarding treatment. The ESHRE 2022 guideline recommends which FIRST-LINE approach for endometriosis-associated infertility?

• A GnRH agonist suppression for 6 months followed by natural conception
• B Laparoscopic surgical excision of endometriomas >3 cm before ART
• C Dienogest suppressive therapy for 12 months before IVF
• D Direct IVF without prior surgery for moderate-severe endometriosis ✓

Explanation

For moderate-severe (stage III-IV) endometriosis-associated infertility, ESHRE 2022 guidelines recommend direct IVF without mandatory prior surgical excision of endometriomas (provided they are <4 cm and the patient is adequately counselled about ovarian reserve impact). Surgery does not improve IVF outcomes for moderate-severe disease and may reduce ovarian reserve due to damage to healthy ovarian tissue. Medical suppression (GnRH agonist, dienogest) delays fertility treatment without improving outcomes.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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Written and medically reviewed by the StethoPrep medical team.