This article provides an overview of international developments in the area of infertility counseling. It informs about the development of international organizations and relevant professional standards and describes the need to make counseling accessible to all patients, especially those who experience great distress or display previous vulnerability. Whereas in previous years counseling focused on psychopathology; research shows that on average, men and women experiencing infertility are as healthy as others. Therefore, the aim of counseling is to reduce the emotional burden of infertility, help couples to consider the implication of family building alternatives and provide therapeutic care where relevant. In some instances, counselors also have the task to carry out psychological assessments. For the sake of transparency, it is important to clearly differentiate between these two interventions. Last but not least, this article argues that much of our current knowledge is based on research carried out in Western societies, therefore lacking understanding and appreciation for the meaning of infertility in other cultures. Therefore we need more international debate across cultures to further our understanding and to honor different cultural values.

There is still not enough evidence that endometriosis per se and infertility are causally related. While extensive pelvic adhesions or the loss of ovarian tissue clearly bears out the causative role of endometriosis this is more difficult in other patients. Several randomized controlled trials and observational studies have in fact reported almost uniform negative results:• spontaneous pregnancy rates were comparable in patients with unexplained infertility with and without pelvic endometriosis; • medical and surgical “suppressive” treatments in patients with pelvic endometriosis did not convincingly change their fecundity;• donor insemination and IVF cycles in women with and without endometriosis did not produce different outcomes. Only a small donor insemination study seems to show an impairment of the quality of the oocytes produced by women with endometriosis. Even patients with rectovaginal implants have apparently normal fertility.Endometriotic ovarian cysts are found in 20-40% of women with endometriosis and may greatly alter the ovarian cortex structure leading to a significant decline of spontaneous and induced ovulation. The most severe defects of ovarian function are seen in cases with bilateral endometriosis. Surgical treatment of the cysts is also associated with a decline in spontaneous and induced ovulation. Frequently endometrioma recurs after ablation but long-term use of oral contraceptives offers specific protection against this risk.

Before detailing the possibilities of laparoscopic surgical treatment a clear understanding of the energy modalities is required, ie electrosurgery, CO2 laser and harmonic scalpel. Secondly, especially in infertility, the ‘see and treat’ principle is important, ie during the diagnostic laparoscopy almost all surgical treatment should be feasible. Finally the relative advantages and disadvantages, of performing systematically a diagnostic laparoscopy early during infertility investigation, should be considered. We will not discuss the pro and con’s of performing systematically a laparoscopy or instead a THL in those women without suspicion of pathology.The preoperative work-up aims at identifying those women who need a bowel preparation and those women who need a ureter stent. When a deep nodule is suspected, clinically or by ultrasound, therefore a contrast enema and IVP are mandatory and a bowel preparation should be given. We also favor to give a bowel preparation for women who have been operated several times beforehand. During laparoscopic surgery any pathology will be treated. This varies from the treatment of the various forms endometriosis, to adhaesiolysis, myomectomy, salpingostomy and ovarian drilling. Endometriosis has already been discussed. Adhaesiolysis and adhaesion reformation is a controversial topic, for which none of the available antiadhaesive treatments has been validated. Yet today we expect that soon effective treatments will become available through additional pneumoperitoneum conditions ie adding small amounts of oxygen and cooling. The relationship between myoma’s and infertility is unclear. It is widely accepted however that submucoal myoma’s should be removed by hysteroscopy, and that the larger subserous or pedunculated myoma’s can cause mechanical infertility.Salpingostomy is the treatment of choice for hydrosalpinges with cumulative pregnancy rates around 60%. In women with thickwalled hydrosalpinges or with absence of mucosal folds at salpingoscopy of in case of tuberculosis, a salpingectomy should be performed. Ovarian drilling restores ovulation in some 80% of PCO women. Only 50% get pregnant and the drilling associated adhesions and infertility remains a topic of debate. Recently, drilling by THL has been introduced and initial data suggest that after ‘underwater’ drilling adhaesions are virtually absent . Finally surgery should be balanced with the IVF. Today however, surgery still is the method of choice provided performed adequately

Following an old ancient belief in different societies and cultures, having children has been a female duty. Accordingly, physicians considered infertility treatment as a mere gynecological problem. The various infertility treatment techniques were also originally directed and designed towards women’s complication. Long after the ART techniques were developed for treatment of women's infertility, they were made useful to cover men's problems too. Dissemination and development of laboratory techniques along with the innovation of the sperm intracytoplasmic injection (ICSI) method, has since 1993 resulted in enabling the spermatozoa, which were not able to fertilize spontaneously, to be used for fertilization. Since 1995, it was made possible to retrieve spermatozoa from epididimis and also from testis biopsy material for use in ICSI and in this way infertility treatment in azoespermic men with abstractive or non-abstractive etiology was materialized. It was thus necessary for a close cooperation between gynecologists, embryologists and andrologists. With specialization of infertility treatment and the necessity of involvement of after basic and clinical specialties, like endocrinology, genetics, immunology, biochemistry, infectious diseases, internal medicine, psychiatry, prenatology and neonatology, higher rate of success in treatment of multifactoral infertility complications have been achieved. The necessity of inter disciplinary cooperation among different specialties in ART treatment of infertility is further emphasized by the need in precise control of ovulation, prevention of hyper stimulation, treatment of immunologic factor variations in management of recurrent spontaneous abortion and ART failure, recognition of the role of STI and after infections in fertilization and fertility, analysis of effect of psycho-social consequences of infertility in different cultural backgrounds. Indeed, successful diagnosis and treatment of infertility seem impossible if these elements are disregarded it has now been revealed that this professional team work action is not provided unless by a comprehensive management. The most logical way is entire concurrent treatment in the form of presentation a package of infertility treatment to infertile couples by the professional specialists.

The quantity of Infertility in woman reproductive age suffering from endometriosis in Russia is from 15% (V.Baskakov) to 38% (Popov A). But the treatment success not exceeding 45-48% (not randomized). And the correlation between prevalence endometriosis rate and PR is absent.Is There a Role For Hormonal Treatment in Endometriosis- Associated Infertility? Suppression of ovarian function to improve fertility in minimal–mild endometriosis is not effective and should not be offered for this indication alone. There is no evidence of its effectiveness in more severe disease.Does Surgery for Minimal–Mild Disease Improve Pregnancy Rates? Ablation of endometriotic lesions plus adhesiolysis to improve is effective compared with diagnostic laparoscopy alone. Does Surgery for Moderate– Severe Disease Improve Pregnancy Rates? The fertility in minimal–mild endometriosis role of surgery in improving pregnancy rates for moderate-severe disease is uncertain. The effect of surgery for peritoneal disease is small. Excision of rectovaginal lesions is of doubtful value and associated with severe morbidity. First-line surgery for the large ovarian endometriomas seems to be the procedure with the most favorable balance between benefits, harm and costs (http://www.guideline. gov). A practical advantage of surgery is temporary pain relief in symptomatic patients. This may render feasible spontaneous attempts at conception in women who refuse or prefer to postpone IVF (Vercellini P). There are the pitfalls of surgical treatment of endometrios; there are non-adequate surgery for diagnosis and staging and non-adequate first operative procedure. We shouldn’t use high energy to remove the endometriomas, bipolar coagulation (max 30 Watt) and/or suture are more safety. Is In Vitro Fertilisation (IVF) Indicated? IVF is appropriate treatment, especially if tubal function is compromised, if there is also male factor infertility, and/or other treatments have failed. Treatment with a GnRH agonist for 3 to 6 months before IVF in women with endometriosis increases the rate of clinical pregnancy. Diphereline 3,75 mg in Russian clinical practice – effective alternative daily forms medications (immediate release). But IVF PR (pregnancy rate) are lower in women with endometriosis than in those with tubal infertility (I-II st. - 16,6%, III-IV st. - 14,9%, tubal Infertility - 37,4%). According our date (not RCT) SL (super long) Protocol of IVF in case of deep endometriosis increased PR (14% vs 25%). Conclusion: ● The effective of surgery for endometriosis-associated infertility may be overvalued.● The second surgery for infertility treatment is not effective.It should be better to do IVF.● Complete and detailed information on risk and benefits of treatment alternatives must be offered to patients, in order to allow unbiased choices between different possible options (Vercellini P. et al, 2009).