Reproductive Outcomes Following Minimally Invasive Surgery for Deep Endometriosis: A Cohort Study

Objective: To evaluate reproductive outcomes following fertility-sparing surgery for deep endometriosis (DE), specifically assessing the impact of bowel resection on spontaneous conception rates and the predictive value of the Endometriosis Fertility Index (EFI). Design: Retrospective observational cohort study. Setting: High-volume tertiary referral center for endometriosis. Patients: A total of 507 women with histologically confirmed endometriosis and documented infertility or active desire for pregnancy, managed between 2018 and 2025. Patients undergoing hysterectomy were excluded. Interventions: Laparoscopic complete excision of endometriotic lesions using a nerve-sparing technique. The surgical strategy for bowel involvement was tailored to nodule characteristics: 194 patients (38.3%) underwent segmental colorectal resection, 38 (7.5%) underwent rectal shaving, and 9 (1.8%) were treated with advanced organ-sparing techniques (lateral rectal resection or extra-mucosal excision-EMEB). Main Outcome Measures: Postoperative pregnancy rate (PR), mode of conception (spontaneous vs. ART), and factors influencing fertility. Results: The cohort presented with severe disease (mean rASRM stage 3.4) and a high prevalence of primary infertility (79.3%). During the follow-up period, 310 patients achieved pregnancy, resulting in an overall pregnancy rate of 61.1%. Notably, 70.3% of these pregnancies were achieved spontaneously. Radicality did not compromise fertility: the segmental resection group achieved a pregnancy rate of 91.2% (177/194), while patients treated with rectal shaving achieved 100%. The EFI score was identified as a robust predictor of success (mean score 5.5 in pregnant vs. 4.9 in non-pregnant patients, p < 0.05). Conclusions: Comprehensive nerve-sparing excision of DE, including segmental bowel resection, is associated with high pregnancy rates and a predominant restoration of natural fertility. Surgery should be considered a first-line strategy to reduce dependency on assisted reproductive technologies.