Laparoscopic Treatment and Pregnancy Outcomes in Endometriosis-Associated Infertility

High pregnancy rates after laparoscopic treatment of endometriosis in women with infertility, regardless of prior fertility treatment

Key Points

Highlights: 

• Laparoscopic treatment of endometriosis is associated with high postoperative pregnancy rates in women with infertility.
• A substantial proportion of pregnancies occur spontaneously after surgery in fertility-treatment–naïve patients.

Importance:

• Endometriosis is a major and often underrecognized cause of infertility, yet the optimal role and timing of surgery in fertility care remain debated.
• Fndings of study support the integration of surgical treatment into individualized fertility management pathways for women with endometriosis.

What’s done here:

• Researchers conducted a retrospective cohort analysis of 95 infertile women who underwent laparoscopic treatment of endometriosis between 2015 and 2023.
• Patients were stratified based on whether they had experienced prior fertility enhancement treatment failure.
• Postoperative pregnancy outcomes and clinical predictors of conception were systematically evaluated.

Key results:

• 82% of women with prior failed fertility enhancement conceived after endometriosis surgery, most through assisted reproductive technologies.
• 78% of women without prior fertility enhancement conceived after surgery, with 31% achieving spontaneous pregnancy.
• Younger age was significantly associated with pregnancy in women who had not undergone prior fertility enhancement.
• Endometriosis stage was not significantly associated with pregnancy outcomes.
• Women with endometriomas were more likely to undergo surgery before fertility enhancement, and many achieved pregnancy postoperatively.

Strength and Limitations:

• Strenghts are；All surgeries performed by a highly experienced endometriosis surgeon using standardized techniques, ensuring procedural consistency; pathologic confirmation of endometriosis strengthened diagnostic accuracy; the study reflects real-world fertility practice by including both spontaneous and ART-assisted pregnancies; stratification by prior fertility treatment provides clinically relevant insight into surgical timing.
• Limitations are; the retrospective design and relatively small sample size may introduce selection bias; single-center, single-surgeon data limit generalizability to broader clinical settings; the absence of a non-surgical control group prevents definitive assessment of the causal effect of surgery on fertility outcomes; perioperative morbidity and long-term reproductive outcomes were not assessed.

From the Editor-in-Chief – EndoNews

"The optimal role and timing of surgery in endometriosis-associated infertility remain among the most debated topics in reproductive medicine. This study contributes valuable real-world evidence suggesting that laparoscopic excision of endometriosis is associated with high postoperative pregnancy rates, both in patients with prior failed fertility enhancement technology (FET) and in those undergoing surgery before assisted reproductive treatment.

The findings reinforce the concept that surgical restoration of pelvic anatomy and removal of inflammatory disease burden may enhance reproductive potential beyond symptom control. Notably, the observation that pregnancy rates were not significantly influenced by disease stage supports the growing recognition that even early-stage endometriosis may negatively affect fertility through mechanisms extending beyond anatomic distortion, including inflammatory and microenvironmental alterations.

The study also highlights clinically relevant nuances in treatment sequencing. Patients undergoing surgery prior to FET demonstrated a meaningful rate of spontaneous conception, whereas those with prior FET failure largely required assisted reproductive technologies despite surgical intervention. These findings underscore the importance of individualized treatment planning, particularly when counseling patients regarding the potential reproductive benefits of early surgical management.

However, interpretation of these results should be tempered by several methodological considerations. The retrospective design, limited cohort size, and reliance on a single high-volume surgeon may introduce selection and performance bias. Additionally, the absence of a non-surgical comparison group restricts definitive conclusions regarding the independent contribution of surgery to fertility outcomes. Referral patterns from reproductive endocrinology practices may also influence patient selection and observed success rates.

Despite these limitations, the study contributes to the evolving discussion regarding integration of minimally invasive surgery within fertility treatment algorithms. As endometriosis is increasingly recognized as a complex systemic and inflammatory disorder, multidisciplinary strategies combining surgical expertise with reproductive technologies will likely remain essential. Future prospective studies evaluating cost-effectiveness, optimal surgical timing, and long-term reproductive outcomes are needed to better define patient-centered management pathways."

Lay Summary

A new study published in the Journal of the Society of Laparoscopic & Robotic Surgeons by Nezhat group and colleagues reports that many women with endometriosis-related infertility became pregnant after laparoscopic surgery, regardless of whether they had previously used fertility treatments.

The research team, led by Dr. Camran Nezhat, reviewed the medical records of 95 women aged 18 to 45 who had infertility and underwent laparoscopic surgery for endometriosis between 2015 and 2023.

Some women had surgery before trying fertility treatments, while others had surgery after fertility treatments had not been successful. The researchers also examined how factors such as age, body mass index, disease stage, previous pregnancies, and the presence of ovarian endometriomas affected pregnancy outcomes.

Among women who had previously tried fertility treatments without success, 82% became pregnant after surgery, mostly with the help of assisted reproductive technologies. Among those who had not used fertility treatments before surgery, 78% became pregnant, and nearly one-third conceived naturally without medical assistance.

Younger age was linked to a higher chance of pregnancy in women who had not previously used fertility treatments. The stage of endometriosis, however, did not appear to significantly affect pregnancy outcomes. Women with ovarian endometriomas were more likely to be referred for surgery before fertility treatments, reflecting current clinical decision-making.

Overall, the findings suggest that laparoscopic surgery may play an important role in fertility care for women with endometriosis, especially when treatment plans are tailored to individual clinical features. The authors note that further studies are needed to determine the best timing of surgery and to compare surgical and non-surgical approaches in improving fertility outcomes.

Research Source: https://pubmed.ncbi.nlm.nih.gov/41334485/