Endometriosis: surgical management for fertility enhancement

Endometriosis is a common, chronic inflammatory condition characterized by the presence of endometrium-like tissue outside of the uterus that can impact fertility through multiple mechanisms. In this review, the diagnosis, classification, staging, and surgical management of endometriosis for fertility enhancement is discussed. Surgery for patients seeking to optimize fertility or for whom infertility is the only symptom is complex. In patients with superficial endometriosis, laparoscopy may enhance fertility for unassisted pregnancy, but current guidelines recommend against routine surgery prior to ART. In patients with deep endometriosis, surgical intervention depends on multiple factors, including patient age, ovarian reserve, fertility goals, and the presence of other infertility factors. While there may be potential improvements in fertility-related outcomes, this must be weighed against potential impacts to ovarian reserve. Surgical techniques that minimize damage to the ovaries, fallopian tubes, and uterus are essential when fertility is the goal. While there is increasing interest in regenerative therapies for treatment of endometriosis (e.g., stem-cell based therapies, platelet-rich plasma, or extracellular vesicles), these remain investigational and are not yet utilized clinically for fertility enhancement in patients with endometriosis.