Exploring the Impact of Surgery for Deep Infiltrating Endometriosis on Fertility Outcomes

Plain and simple, women with endometriosis ARE affected by infertility. 50% of all infertility cases are caused by a form of endometriosis. For women who suffer from deep infiltrating endometriosis, their fertility rate can range from 2 to 10%. This can be extremely difficult and disheartening for those seeking to become pregnant. But there is hope.


We have explored what the literature says on the impact of endometriosis surgeries on reproductive outcomes and pregnancy rates in women with and without prior infertility. We found that surgery may improve fertility outcomes, although due to variability in the studies, there is concern that doctors may be exaggerating the magnitude of the overall benefit. It is also noted that surgeons with suboptimal outcomes will not publish these outcomes i.e., publication bias.


We want to highlight this key concept as you read forward. Numerous surgeons in the field have stated the same. Evidence-based statements such as surgery being an ultimately successful tool have unreliable studies to back them up. It is estimated that 10-25% of surgeries have successful conception rates.


Assisted reproduction should be considered if conception is desired.


What is Endometriosis?


Endometriosis is a common gynecological condition characterized by the presence of endometrial-like tissue outside of the uterus. It affects approximately 10% of women worldwide (our stance here at ENDOLLS says 30%). It can cause significant pain and other symptoms such as infertility and heavy menstrual bleeding. Numerous experts have stated various mechanisms, but one hasn't been found yet (we have a unifying theory we go over in our book, which based on the studies done, may be closer than the rest), a widely supported theory is retrograde menstruation—when menstrual blood flows back up into the Fallopian tubes instead of out through the vagina— this is one possible cause.


How Does Surgery Help?


Surgery, excisions specifically, can and are used as the Golden Standard to diagnose and treat endometriosis. Depending on where it’s located, doctors may use laparoscopy (a minimally invasive procedure) or laparotomy (an open abdominal procedure).


If conception is the goal, a CO2 laser vaporization-based surgery (this is a form of ablation) is recommended for stage I and II endometriosis, as the data does show a higher accumulative pregnancy rate. Monopolar coagulation-based surgery is more commonly used. However, it has statistically lesser rates of pregnancy thereafter. For stages III and IV, any sort of specialist-done procedure will almost double the overall pregnancy rate.


Ovarian endometriomas also have a favorable profile when vaporization of plasma energy ablation is used.


Now, I understand where most people's dilemma comes into play here. The endometriosis community has come to believe that excisions are a must and that nothing else works. Please understand that this article is geared explicitly at increasing pregnancy outcomes and not so much long-term benefit. Excision-based surgeries lead to reduced pregnancy outcomes. This is primarily due to cystectomies (excisions) which result in reduced ovarian volume and damage to the ovarian reserve when compared to ablations.


Reduced ovarian volume or damage to the ovarian reserve can affect overall egg quantity and quality as well as egg release. There is a significant difference in all of these factors when comparing ablations to excisions. Ablations generally have less of an impact to ovarian volume when compared to excisions. Statistically, having high conception rates. If damage to the ovarian reserve is experienced, it can take up to 1 year before a baseline can be regained.


So if you're goal is pregnancy, then the opposite of what is typically recommended is the ideal choice here. 


Regardless, in both of these procedures, doctors will remove any visible implants or lesions from your reproductive organs as well as scar tissue that has built up due to endometriosis. So relief will still be a part of both scenarios. Longevity and the desired ultimate outcome is the only thing that changes.


As a last resort, doctors may also recommend a hysterectomy if necessary. However, this procedure is generally avoided at all costs to preserve fertility.



As previously mentioned, the goal of all of these procedures is to reduce or eliminate symptoms so that you can get back to living your life normally again. While surgery isn't a guaranteed cure for endometriosis, many women report an improvement in their symptoms after treatment, spontaneous pregnancy rates almost double as well, with properly done ablations. The return period for endometriotic lesions after properly done ablations seems to average a 2-year rate. Moreover, research suggests that surgical treatment is associated with improved fertility outcomes in women with deep infiltrating endometriosis—especially when combined with assisted reproductive technologies such as IVF (in vitro fertilization).


A study published in 2019 reported that among 814 patients undergoing surgery for deep infiltrating endometriosis before attempting conception via IVF/ICSI (intracytoplasmic sperm injection), 52 percent became pregnant within one year of follow-up (compared to 44 percent among those who only underwent IVF/ICSI).


Deep infiltrating endometriosis can have a devastating effect on a woman's ability to conceive children naturally. However, this review suggests that surgery may improve fertility outcomes in women suffering from deep infiltrating endometriosis—especially when combined with assisted reproductive technologies such as IVF or ICSI.


While more research needs to be done regarding optimal management strategies for deep endometriosis patients seeking fertility treatments, these findings offer hope for those struggling with this condition who wish to become parents someday soon. Ultimately, it’s important for all women suffering from this condition to speak with their doctor about their options so they can make an informed decision about how best to proceed with treatment and care tailored specifically towards their individual needs.



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