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

Recurrent Endometriosis


Surgical treatment does not eliminate the causes of endometriosis. The persistence of pathogenetic mechanisms and the recent tendency toward delaying pregnancy[70–72] appear to act synergistically, leading to a considerable rate of postoperative endometriosis recurrences that gradually increases throughout the years. Moreover, recurrent endometriosis may constitute a biologically more aggressive disease subgroup with an adverse prognosis.[73]

Based on literature data, Evers et al[74] argue that 10% of patients have redeveloped signs and symptoms of endometriosis after a 1-year follow-up period, 25% after 3 years, and 45% after 5 years. According to DeCherney, the endometriosis annual recurrence rate may be as high as 15%, and cumulative rates approximate 40% after 3 to 5 years.[75] Guo[76] calculated that the disease relapse rate is >20% at 2 years and 40 to 50% at 5 years. Even in young women ≤21 years of age, the 5-year recurrence rate was as high as 56%, irrespectively of site and stage of endometriosis.[77]

These figures must be kept in mind by clinicians when planning the management of women with primary endometriosis.

Role of Surgery

The consequences of endometriosis recurrence on reproductive performance may be particularly detrimental, resulting from the combination of a patient's increasing age and repeated peritoneal as well as gonadal damage caused by both recurrent disease and surgical trauma.[30,78]

According to a systematic literature review, among women undergoing repetitive surgery for recurrent endometriosis associated with infertility, the mean conception rate was significantly reduced as compared with that of women undergoing a primary procedure (26% versus 41%, respectively).[79] In particular, reproductive performance after first- and second-line surgery in the same patient population was reported in three studies.[73,80,81] A pregnancy was achieved by 41% of the women in the former group but only in 23% of those in the latter, demonstrating halving of the likelihood of reproductive success after second- compared with first-line surgery (Fig. 4).

Figure 4.

Results of studies comparing repetitive surgery for recurrent endometriosis with first-line surgery for primary disease. The horizontal lines indicate 95% confidence intervals, boxes show the study-specific weight, rhombi represent combined effect sizes, and dashed line indicates the overall estimate. Breslow-Day test for heterogeneity: χ2 2 = 0.45, p = 0.799. (From Vercellini P, Somigliana E, Viganò P, et al. The effect of second-line surgery on reproductive performance of women with recurrent endometriosis: a systematic review. Acta Obstet Gynecol Scand 2009;88:1074–1082. Reprinted by permission.)

Moreover, in two small randomized studies comparing pregnancy rate between IVF and repeat surgery for recurrent endometriosis, a conception was achieved in 30% of the infertile women who had undergone IVF, and in 20% of the women who had undergone repeat surgery, which does not suggest that second-line surgery is better than IVF. In particular, the probability of conception in the IVF group was lower than repeat surgery when only one cycle was performed[82] but higher after two IVF cycles.[83] There seems to be general agreement that for infertile women who have moderate to severe endometriosis and have previously had one or more infertility operations, IVF is often a better therapeutic option than another infertility operation.[9,14]