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



Endometriosis is associated with chronic pelvic inflammation. This generally results in formation of adhesions that may distort the anatomy of the internal genital organs. Infertility can be caused by adhesions around the ovaries, which may inhibit follicular growth and impair oocyte release, or from peritubal adhesions, which inhibit ovum capture or transport.[58,59]

Preoperative Diagnosis

A reliable preoperative diagnosis of pelvic adhesions is not feasible. At bimanual examination, adhesions between an ovarian endometrioma and the pelvic sidewall or the posterior aspect of the uterus may be hypothesized when the mobility of the ovary and/or the uterus is reduced.

Role of Surgery

There is a paucity of data supporting the effectiveness of adhesiolysis in improving fertility. A few studies were conducted soon after the introduction of laparoscopy in the 1980s. Pregnancy rates of between 38% and 52% were achieved after removal of adhesions in previously infertile women.[60–63] More recently, a RCT reported the pregnancy rates of 90 patients with adhesions and a mean duration of infertility of 7.2 years who underwent either one single laparoscopic salpingo-ovariolysis or two consecutive laparoscopic salpingo-ovariolysis, the second of which was performed to diagnose and treat reformed adhesions. Pregnancy rates were similar in both study groups, respectively, 27% and 19% in patients with moderate adhesions, 41% and 36% in patients with mild adhesions, and 57% and 43% in patients with minimal adhesions. No conceptions were observed in subjects with severe adhesions. The chance of early reformation of moderate and severe adhesion after laparoscopic salpingo-ovariolysis was ~40%.[64]

Based on the very limited available data, it seems that surgical adhesiolysis might enhance fertility only in patients with minimal to moderate adhesions and only in the short term. In the medium and long term, adhesion reformation is likely to reverse any initial benefit.[58,65,66]

Although surgery is the only available modality for removing adhesions, at the same time it is itself a major cause of adhesions formation. Therefore, physicians have put considerable efforts in the implementations of techniques specifically aimed at minimizing postsurgical adhesion formation. In this regard, it is generally accepted that laparoscopy appears to be associated with reduced adhesions formation or reformation than laparotomy, although comparative studies have provided conflicting results.[33,58,67]

Regardless of the type of surgical approach, the following surgical measures should always be applied: reduction of the extent of trauma through minimal tissue handling, avoidance of unnecessary dissection, prevention of desiccation, achievement of meticulous hemostasis, minimization of the infection risk, limitation in the introduction of foreign material into the abdomen, and irrigation of solutions at optimal temperature.[33,58] Other surgical strategies that have been shown to reduce postoperative adhesions include solid or liquid barrier agents, which prevent direct contact between two areas of injury,[33,58] and transient abdominal ovariopexy, that is, the suspension of one or both ovaries to the abdominal wall until the fifth postoperative day.[68] However, severe and dense adhesions between the ovaries and the anterior abdominal wall have been reported in association with the latter technique.[69]

In general, independently from hypothetical advantages and short-term follow-up laparoscopic findings, the only clinically meaningful outcome on which to base the judgment of any surgical measure aimed at prevention and treatment of pelvic adhesions in infertile women is medium-term reproductive performance assessed by RCTs. This information is unfortunately unavailable at present.