Desire for fertility should guide endometriosis Tx. (Expert Opinion).

BALTIMORE -- Medical management of patients with endometriosis may be worth considering for the woman whose chief compliant is pain, but not if she's interested in preserving or regaining her fertility, Dr. Nikos Vlahos warned.

At least three studies now show that treatment with a laparoscopic laser or laparotomy confers anywhere from a threefold to a fivefold improved chance of-pregnancy compared with medical therapy, he said at a reproductive endocrinology meeting sponsored by Johns Hopkins University.

For medical therapy, oral contraceptives and progestins cause decidualization and shedding of the endometrial tissue, inducing a kind of pseudopregnancy state; GnRH analognes cause atrophy of the endometrial tissue, or a pseudomenopausal state.

When these therapies are used temporarily and then discontinued, a woman's chances of becoming pregnant are the same as if she had no treatment at all, Dr. Vlahos explained.

There doesn't appear to be much difference between laparoscopy and laparotomy in terms of subsequent pregnancy rates. Physicians therefore should perform whichever procedure they are most comfortable with, advised Dr. Vlahos of the department of ob.gyn. at Johns Hopkins.

If the patient's principal concern is pain, a first-line treatment that Dr. Vlahos frequently tries is continuous low-dose oral contraceptives. "It's interesting because I have patients who tell me that they didn't respond to birth control pills, and they are pretty adamant about not using them again. But when you put them on a continuous regimen and you talk with them and explain the theory behind it, it often works well.

"I might use Lupron [leuprolide acetate] in the woman who comes to me with a diagnosis of endometriosis when I don't ...