Despite intense clinical interest, increasing numbers of infertile couples with endometriosis-associated infertility and ever more sophisticated diagnostic technology, optimal treatment of the infertility remains frustrating. In the absence of mechanical compromise of the pelvic viscera, there is no treatment directed towards the endometriosis itself, medical or surgical, which alleviates the infertility experienced by these couples. The reason for this lack of therapeutic progress is most likely related to the lack of consensus regarding the mechanism(s) by which the endometriosis or its pathophysiology may cause infertility. The possibility that infertility from another, as yet unidentifiable, cause(s) results in repetitive, nonconceptive, ovulatory menstrual cycles and leads to the development of endometriosis remains just as viable a hypothesis. The most useful current therapeutic approach is to consider these couples as having ‘unexplained’ infertility and utilize nonspecific cycle fecundity enhancement such as controlled ovarian hyperstimulation with intrauterine insemination or IVF. Since the fecundity of women with endometriosis in the later reproductive years continues to rapidly decline, this represents their most cost-effective option. While these nonspecific treatments may normalize the cycle fecundity, they are expensive and fraught with the hazards of multiple gestation and ovarian hyperstimulation. While efforts to reduce the risks of this approach are being made, improved therapeutic success with less hazard and cost will continue to remain elusive until the mechanism(s) of the infertility associated with endometriosis is conclusively defined.
