Surgical measures for endometriosis-related infertility: a plea for research

The precise relationship between endometriosis and infertility is debated. Surgery is considered to play a role within the framework of the therapeutic options to cure infertile women with the disease even though its effectiveness is generally modest. In fact, there is unquestionably the need to improve surgical techniques in this area. Specifically, two main aspects require optimization: 1) preventing the injury to the follicular reserve that follows surgical excision of ovarian endometriomas and 2) preventing post-surgical formation and re-formation of adhesions. The comparison between the excision/stripping and the vaporization/coagulation techniques represents the main point of debate on what is the best procedure to remove ovarian endometrioma. Randomized controlled trials showed that the excision technique is associated with a higher pregnancy rate and a lower rate of recurrence although it may determine severe injury to the ovarian reserve. Improvements to this latter aspect may be represented by a combined excisional-vaporization technique or by replacing diathermy coagulation with surgical ovarian suture. Barrier agents reduce but not eliminate the post-surgical adhesion formation in women with endometriosis. Encouraging evidence has been reported with Interceed, Oxiplex/AP gel and Adept solution. However, available studies are mainly based on II look laparoscopies performed few weeks after the intervention and data on fertility is lacking. Clinical trials including pregnancy rate as a specific outcome are warranted.