A Practical Approach to Fertility Considerations in Endometriosis Surgery

Endometriosis surgery requires thoughtful consideration and planning for those with infertility or those who wish to conceive in the future. Clinical history, examination, imaging, and fertility assessment can help plan, prepare and provide goal-directed surgical interventions when required. Further understanding of the benefits and limitations of surgery on future fertility outcomes is essential for those who provide care for patients with endometriosis. Endometriosis is a prevalent gynecologic condition, especially among patients with infertility. Studies demonstrate that, from a fertility perspective, surgery for endometriosis likely has a beneficial impact on the chance of spontaneous conception; however, selecting the appropriate surgical candidate can be challenging. To make a fully informed decision with regard to surgery, it is important to determine the patient's fertility goals and to conduct a thorough workup. Among patients with endometriosis-related infertility, first-line-assisted reproductive technology (ART) is generally preferred over surgery. Specific consideration in cases of minimal or mild endometriosis, ovarian endometrioma(s), and deep endometriosis (DE) are required for targeted counseling. Patients with symptoms significantly impacting their quality of life (QOL), or indications to proceed with surgery (ie, risk of malignancy, organ obstruction, or dysfunction) are best managed with surgical care by an experienced team. Surgery should be considered cautiously given the risks of damage to ovarian reserve, adhesions, and surgical complications. Risk of damage to ovarian reserve is a particularly important consideration among patients with endometrioma(s), with or without low ovarian reserve, and surgical complications are especially prevalent among patients undergoing surgery for bowel endometriosis. Goal-directed surgical treatment, as opposed to the traditional perspective of complete disease eradication, may be of particular importance among selected patients whereby fertility is a priority.