Role of Surgery in Endometriosis-Associated Subfertility

Nicola Berlanda, MD; Paolo Vercellini, MD; Edgardo Somigliana, MD, PhD; Maria Pina Frattaruolo, MD; Laura Buggio, MD; Umberto Gattei, MD


Semin Reprod Med. 2013;31(2):133-143. 

In This Article

Rectovaginal Endometriosis


The effect of rectovaginal endometriosis on fertility is uncertain because burial of foci beneath rectouterine adhesions with exclusion of the deepest part of the pouch of Douglas may limit interference with fertilization processes.[43] The concomitant presence of other forms of endometriosis such as superficial implants, ovarian endometriomas, and pelvic adhesions, and not the deep form itself, might be actually involved in determining the subfertility condition.[28,44]

Preoperative Diagnosis

A tender nodule or plaque of the posterior cul-de-sac infiltrating the anterior rectal wall and the posterior vaginal fornix is often palpated at rectovaginal examination. Bluish nodules and reddish papules are usually visible at speculum examination of the retrocervical area and of the proximal (cranial) third of the posterior vaginal wall. These lesions can be biopsied in an office setting.[45] The diagnosis can often be confirmed at transvaginal sonography, which has been demonstrated to be highly accurate and reliable in the identification of deep pouch of Douglas lesions.[46,47,48,49]

When rectovaginal endometriotic plaques are present, the performance of urinary tract ultrasonography is always indicated, with the aim of ruling out ureteral stenosis with secondary hydronephrosis. Rectosigmoidoscopy is recommended to evaluate potential stenosis of the rectosigmoid junction. The role of pelvic computed tomography and magnetic resonance imaging is controversial, and these techniques should be used only in selected circumstances.

Role of Surgery

No RCTs evaluating the effect of surgery in subfertile patients with rectovaginal endometriosis are available. Only one prospective study has compared surgically treated patients with patients who sought spontaneous pregnancy without treatment. In this study, including 105 infertile patients with rectovaginal endometriosis and no other associated infertility factors, the 24-month cumulative probabilities of becoming pregnant were comparable between women who underwent resection of rectovaginal endometriosis at laparotomy and women who choose expectant management (44.9% versus 46.8%, respectively).[50] Accordingly, the mean pregnancy rates after excision of rectovaginal endometriosis, as reported in three relatively recent comprehensive literature reviews, varies between 42% and 44%.[14,28,51]

However, similarly to surgery for ovarian endometriomas, the specific effect of rectovaginal endometriosis excision on fertility is best estimated by excluding from the analysis patients who did not seek a pregnancy before surgery (i.e., whose fertility status is not known), as well as those who conceived by assisted reproductive techniques (ART) after surgery. A systematic literature review according to these inclusion criteria demonstrated a mean postoperative pregnancy rate of 24% (range: 10 to 41%; Fig. 3).[43] Consistently, Douay-Hauser et al[52] showed that the addition of extensive surgery for deep endometriosis to the treatment of intraperitoneal lesions did not increase the 24-month cumulative pregnancy rate compared with surgery limited to intraperitoneal lesions only (23.2% versus 24.8%, respectively). In this study, extensive surgery was associated with a higher rate of major perioperative complications (6 of 41 versus 0 of 34).

Figure 3.

Percentages of spontaneous conception in infertile women at the end of follow-up in studies on the effect of radical surgery for rectovaginal and rectosigmoid endometriosis on reproductive performance. The diamonds represents percentage point estimates and the horizontal lines the 95% confidence intervals. SD, standard deviation. (From Vercellini P, Barbara G, Buggio L, Frattaruolo MP, Somigliana E, Fedele L. Effect of patient selection on estimate of reproductive success after surgery for rectovaginal endometriosis: literature review. Reprod Biomed Online 2012;24:389–395. Reprinted by permission.)

Bianchi and colleagues[53] reported that laparoscopic excision of deep endometriosis improved IVF outcome, thus questioning the notion that rectovaginal endometriosis affects ART results marginally. However, this isolated observation must be reproduced and confirmed.

As for the surgical technique, it has been shown that avoidance of rectosigmoid resection and adoption of the so-called shaving of bowel lesions ameliorates the prognosis in terms of both postoperative conception and pain recurrence rates.[54] Moreover, the risk of major complications following surgery for rectovaginal endometriosis is substantially increased when rectosigmoid resection is performed in addition to excision of the posterior vaginal fornix.[55,56,57]

Because it is still uncertain whether or not, and to what extent, rectovaginal endometriosis per se affects fertility, the best clinical management of infertile patients with this disease form and without bowel or ureteral stenosis must be tailored for each woman according to the presence of concomitant pain, the coexistence of endometriosis at other sites, and the patient's preference, after extensive counseling on the uncertainty regarding the potential benefit of surgery, as well as the risks associated with rectovaginal plaque excision, including the probability of rectovaginal fistula formation and the development of neurogenic bladder.