The optimal management approach to the infertile patient with endometriosis requires an evaluation of the extent of disease and the reproductive goals of the patient. The surgical approaches to endometriosis treatment are accomplished by laparotomy or laparoscopy. Surgical treatment for endometriosis-associated infertility employs techniques that are designed to minimize trauma, maintain hemostasis, and reduce operating time while facilitating the removal of all disease. The probability of conception may potentially be affected by other factors in addition to the outcome of surgery. In these patients, further assistance with ovulation induction or assisted reproductive technologies (ART) after surgery may be beneficial. Ovarian endometriomas are typically treated utilizing various techniques such as cyst stripping or ablation, drainage, and wide excision. The development of an endometriosis scoring system that has good correlation with the severity of reproductive impairment would contribute significantly to future studies.

When an appropriate follicular response to gonadotrophin stimulation has been achieved, the patient receives a subcutaneous injection of 5000 or 10000 iu of human chorionic gonadotrophin (HCG) to commence the final stage of oocyte maturation. Many women require more than one in vitro fertilisation (IVF) cycle and oocyte retrieval can be a painful procedure. Therefore, adequate sedation and analgesia is important for oocyte retrieval. The vacuum pressure for follicular aspiration should be less than 150 mmHg, since at pressures above this the rate of oocyte injury increases. Randomized controlled trials demonstrate that follicular flushing after aspiration does not significantly increase the number of oocytes retrieved or the pregnancy rate. During oocyte retrieval the aspiration needle should avoid endometriomas. This chapter discusses risks of oocyte retrieval, immature oocyte recovery and embryo transfer with embryo transfer procedures applicable in special circumstances.