E-ISSN: 2684-4230 ISSN: 2032-0418
Infertility management in patients with bowel endometriosis: the current landscape and the promise of randomised trials: a narrative review
PDF
Cite
Share
Request
Narrative Review
E-PUB
3 December 2025

Infertility management in patients with bowel endometriosis: the current landscape and the promise of randomised trials: a narrative review

Facts Views Vis ObGyn. Published online 3 December 2025.
Demetrio Larraín 1
Javier Caradeux 1
María D. Maisto 1,2
Fernanda Claure 2
Juan D. Villegas-Echeverry 3
Fernando Heredia 4
William Kondo 5
1. Clinic of Obstetrics and Gynecology Department, Clínica Santa María, Santiago, Chile
2. Department of Obstetrics and Gynecology, Hospital Barros Luco, Santiago, Chile 
3. Algia - Unidad de Laparoscopía Ginecológica Avanzada y Dolor Pélvico, Pereira, Colombia 
4. Department of Obstetrics and Gynecology, University of Concepción Faculty of Medicine, Concepción, Chile
5. Department of Obstetrics and Gynecology, Hospital das Nações, Curitiba, Brasil
No information available.
No information available
Received Date: 18.07.2025
Accepted Date: 11.10.2025
E-Pub Date: 03.12.2025
PDF
Cite
Share
Request

ABSTRACT

The management of infertility in women with bowel endometriosis remains a significant clinical challenge. The two primary therapeutic approaches include first-line medically assisted reproduction (MAR) and primary bowel surgery, with or without subsequent fertility treatments. While surgery can significantly improve fertility outcomes, the success of these interventions is influenced by several factors, and MAR may still be necessary for certain patients, especially those over 35 years or with complex disease patterns. In this narrative review, we assessed the outcomes of the main therapeutic strategies commonly offered to patients with bowel endometriosis-associated infertility and discussed the challenges inherent in evaluating reproductive outcomes in women with colorectal endometriosis.

Keywords:
Bowel endometriosis, colorectal endometriosis, infertility, pregnancy rates, reproduction

Introduction

Bowel endometriosis affects approximately 8-12% of patients with deep endometriosis (DE) and is associated with severe pain and infertility.1, 2 Although medical therapies can alleviate pain in symptomatic patients, they are not suitable for patients seeking to conceive due to their contraceptive effects.3 Thus, treatment must be individualised based on symptom severity and reproductive goals.

Several mechanisms have been proposed to explain endometriosis-associated infertility, including distorted pelvic anatomy, abnormal utero-tubal transport, immunological and peritoneal alterations, poor oocyte/embryo quality, impaired implantation,4 and reduced frequency of sexual intercourse due to dyspareunia.5

However, the mechanisms contributing to subfertility in patients with bowel DE remain poorly understood and seem related to the inflammatory environment produced by endometriotic nodules6, 7 and the presence of posterior cul-de-sac obliteration.8 Nevertheless, the usual coexistence of bowel endometriosis with other infertility factors such as endometriomas, hydrosalpinx, and adenomyosis complicates the attribution of subfertility to bowel lesions alone.

To date, the management of infertility in women with bowel endometriosis remains a significant clinical challenge. The two primary therapeutic approaches include first-line medically assisted reproduction (MAR) and primary surgical intervention, which may involve intestinal procedures.

Since patients with untreated colorectal endometriosis achieve similar fertility outcomes after in vitro fertilisation (IVF) compared with those without endometriosis,9 infertile patients with minimal pain are typically advised to pursue MAR first to avoid surgical risks. On the other hand, for patients with severe symptoms, the predominant indication of surgical resection is the severity of pain.

Long-term benefits of laparoscopic resection of bowel endometriosis in relieving pelvic pain, improving bowel function, and enhancing quality of life (QoL) are well established;8, 10, 11 however, its role in enhancing fertility remains uncertain. Observational data suggest that surgery may boost spontaneous conception and MAR success rates,12-15, but no randomised trials have addressed this specifically.

This review evaluates fertility outcomes after different treatment options in patients with bowel DE, highlighting challenges in measuring reproductive efficacy in this population.

Methods

Search Strategy

We conducted a narrative review of studies published between January 2009 and March 2025 in multiple databases, including PubMed, Google Scholar, Scielo, and ClinicalTrials.gov, to identify articles related to fertility and colorectal endometriosis. Only studies published in English, French, or Spanish were included.

Medical Subject Headings terms used included “colorectal endometriosis,” “bowel endometriosis,” and “intestinal endometriosis,” in combination with “fertility,” “infertility,” “pregnancy rate (PR),” “live birth rate, (LBR)” “in vitro fertilization (IVF),” “intracytoplasmic sperm injection (ICSI),” “assisted reproductive technology (ART),” “medically assisted reproduction (MAR),” and “intrauterine insemination (IUI).” The references of included studies were also screened to identify additional relevant publications.

Definitions

Definitions and outcomes were classified according to the 2017 International Glossary on Infertility and Fertility Care.4 “Infertility” was defined as the failure to achieve a clinical pregnancy after ≥1 year of regular, unprotected intercourse. The term “MAR” comprised ART (e.g., IVF, ICSI) and IUI, while “ART” refers exclusively to procedures involving the in vitro gamete handling (e.g., IVF and IVF ± ICSI).

Surgical procedures for bowel endometriosis were defined based on the updated terminology proposed in the International Endometriosis Terminology.16 “Shaving” refers to a partial-thickness excision without entry into the bowel lumen. “Discoid excision” indicated a full-thickness resection of the bowel wall with lumen entry. “Bowel resection” involved the removal of a bowel segment followed by re-anastomosis. Surgical complications were graded using the Clavien–Dindo classification.17

Study Selection

We considered observational, randomised, and review articles reporting reproductive outcomes in women with documented bowel DE who desired pregnancy (with or without proven infertility). Surgical videos and case reports were excluded. Both spontaneous and MAR-related outcomes were considered. Surgical techniques and patient fertility histories were also analysed. For review articles, methodological quality was assessed using the scale for the Assessment of Narrative Review Articles criteria (Supplementary Table 1).18

The following data were extracted from the included studies and entered into a datasheet: study characteristics (author, year of publication, study design, and whether data were collected prospectively or retrospectively), patient characteristics (definition of the included population and the total number of women initially included in the study), fertility outcomes [i.e., cumulative PR (CPR)] and the techniques used to achieve the pregnancies (spontaneous or MAR). Figure 1 depicts the review flow chart.

Optimising Fertility Outcomes in Women with Deep Endometriosis Affecting the Bowel

There are many challenges in understanding the best treatment options for patients desiring fertility affected by DE of the bowel. This is because assessing fertility outcomes in patients with bowel endometriosis is hindered by multiple confounding factors (Table 1).

Spontaneous Conception in Patients with Untreated Colorectal Endometriosis

In comparison to the fecundity rate of 15% to 20% per month in healthy couples, the spontaneous PR (SPR) in patients with untreated endometriosis is notably lower (2%-10%).19 Although previous studies have estimated SPR in patients with DE,20,21, these studies did not specifically focus on those with colorectal involvement.

To date, there is very limited data on spontaneous fertility outcomes in patients with untreated intestinal DE lesions (in situ) (Table 2).8, 22, 23 However, the presence of intestinal endometriosis has been associated with the lowest fertility rates (0.84% per month) and the longest time to conception among infertile patients attempting natural conception.8 Notably, Ferrero et al.22 reported a 38.9% spontaneous conception rate in women with untreated colorectal endometriosis, following proper patient selection for those with a good reproductive prognosis.

Given that most spontaneous pregnancies in patients with untreated colorectal endometriosis occur in those under 35 years of age and within the first year of trying to conceive,21, 23 expectant management could be considered as an initial approach for a limited period (6-12 months). In our opinion, this approach may be offered to younger patients (<35 years) with an adequate ovarian reserve (Anti Mullerian Hormone serum level >2 ng/mL), patent tubes, no evidence of adenomyosis, and normal semen analysis. In other cases, expectant management is discouraged.

Fertility Outcomes After “Medically Assisted Reproduction First” Approach in Patients with In Situ Colorectal Endometriosis

Current guidelines recommend that surgery should not be performed before ART in patients with colorectal endometriosis, with the primary goal of improving fertility.24 As a result, primary MAR is often the first-line treatment for infertile women with bowel endometriosis who experience little or no pain. Several reasons support this approach:

1) Avoidance of surgical risks, such as anastomotic leakage, pelvic abscesses, rectovaginal fistula formation, neurogenic bladder/bowel dysfunction, and anastomosis stenosis, without strong evidence supporting the role of surgery in improving reproductive outcomes.25

2) Patients with untreated colorectal endometriosis achieve similar fertility outcomes after IVF compared with non-endometriosis patients.9 In addition, first-line ART offers favourable CPR and cumulative LBR (CLBR). A large retrospective study, spanning 12 years, compared IVF-ICSI outcomes between 120 patients with bowel DE undergoing primary ART and 69 patients managed surgically. No significant differences in CPR (56.7% vs. 58%, P=0.47) and CLBR (50.8% vs. 52.2%, P=0.43) were found. The authors concluded that IVF-ICSI outcomes were similar regardless of prior surgical intervention, suggesting no additional benefit from surgery in these patients.26

3) Impact of uterine adenomyosis: The prevalence of adenomyosis in patients with bowel endometriosis ranges from 17% to 88%.15, 27-29 A systematic review identified adenomyosis as a strong predictor of reproductive failure in patients with colorectal endometriosis undergoing surgery,27 suggesting that adenomyosis may play a more significant role in infertility than the intestinal endometriotic lesions themselves. Since adenomyosis is not corrected surgically, the role of bowel surgery in asymptomatic patients solely to improve fertility may be overestimated.

4) Quality of evidence: Most available data on the impact of bowel surgery on fertility outcomes in infertile women with colorectal endometriosis come from uncontrolled cohorts where fertility was a secondary outcome. Given that non-randomised studies often report larger treatment effects than randomised controlled trials (RCTs), and cohort studies are prone to bias, the actual impact of bowel surgery on fertility may be overestimated.25

We identified eight studies8, 9, 22, 23, 26, 28-30 involving 363 women with documented colorectal endometriosis and pregnancy intention undergoing primary MAR without prior bowel surgery (Table 3). Among these women, 170 became pregnant, resulting in a PR of 46.8 %. Time to pregnancy after MAR was reported in two studies8, 22 and was considerably longer than the time reported for patients who conceived naturally.

Prognostic factors impacting reproductive outcomes in patients with bowel endometriosis undergoing first-line fertility treatments.

Adenomyosis

In a prospective multicentre study involving 75 patients with in situ colorectal endometriosis, Ballester et al.28 demonstrated that CPR were significantly lower after IVF-ICSI in women with concomitant adenomyosis (19%) compared to those with a healthy uterus (82.4%) (P=0.01). However, the detrimental impact of adenomyosis was not observed in a larger prospective study involving 89 patients with documented adenomyosis undergoing primary IVF.29

History of Prior Surgery for Deep Endometriosis

Prior observational studies have suggested that a history of surgery for endometriosis negatively affects ART outcomes in patients with DE.5, 29, 31 However, only two studies have specifically evaluated this effect in patients with bowel endometriosis. One study found no association between prior surgery for DE and worse IVF outcomes,8 while another study reported significantly lower LBR for patients with a history of endometriosis surgery compared to those without prior surgery (64.4% vs. 41.3%, respectively; P=0.009).29 Despite surgery may impair ovarian reserve and reduce IVF.

Diminished Ovarian Reserve

Low ovarian reserve, as indicated by low AMH levels (<2 ng/mL) and an antral follicle count <10, has been identified as an independent negative predictive factor for ART success in patients with in situ bowel endometriosis.28, 29 In these studies, low ovarian reserve parameters were associated with a significantly lower CPR (P=0.02)28 and lower LBR (P=0.001).29 However, it is noteworthy that the authors included in their analysis patients with and without concomitant endometrioma.

Other Factors

Other prognostic factors have been inconsistently associated with worse reproductive outcomes in patients with bowel endometriosis undergoing ART, including age over 35 years28 and a duration of infertility exceeding 30 months.29

Bowel Endometriosis-Related Complications in Women Undergoing First-Line Medically Assisted Reproduction

Although rare, infertile patients with bowel endometriosis who delay surgery should be informed about the potential complications that may arise after discontinuing hormonal therapies,32, 33 as well as during ovarian stimulation,22 oocyte retrieval,34 pregnancy, and even the postpartum period.35 Theoretically, the resulting hyperestrogenism could stimulate the growth of intestinal nodules, leading to exacerbation of symptoms and even bowel obstruction or perforation.32, 36

The estimated risk of developing occlusive symptoms during primary MAR in patients with bowel endometriosis ranges from 5% to 11.8%,36, 37 and the risk is higher in patients with undiagnosed bowel stenosis (>60%).37 Consequently, bowel imaging to assess stenosis is strongly recommended before advising patients with bowel DE to prioritise primary MAR.

Fertility Outcomes After Primary Surgical Resection of Bowel Endometriosis

Observational studies conducted by experienced surgical teams have suggested the beneficial impact of complete resection of bowel DE on reproductive outcomes. In addition to improving the chances of natural pregnancy and LBR,31, 38 surgery may also enhance the MAR success rate,14, 30 while preventing potential complications associated with disease progression during ovarian stimulation. Surgery is also recommended after failed IVF,39, 40 and several studies have reported spontaneous conception following surgery in patients with previously failed IVF.15, 41, 42 Studies reporting postoperative reproductive outcomes are summarised in Supplementary Table 2.43-76

Determinant Factors of Fertility Outcomes After Surgery in Patients Undergoing Surgical Excision of Bowel Endometriosis

Even though the results published by experienced surgeons may not be fully generalizable to all surgical teams, several key factors must be considered to maximise the chances of reproductive success (either naturally or through MAR) in patients with bowel endometriosis undergoing surgery.

Surgical Route

A randomised trial comparing fertility outcomes after laparoscopic and open colorectal resection for bowel endometriosis reported significantly higher SPR in patients who underwent laparoscopic surgery.41 In another study by the same team, the authors demonstrated that conversion to open surgery negatively impacted PR in patients undergoing colorectal resection for DE.42 Based on these findings, laparoscopy is considered the gold standard for treating bowel DE in patients wishing to conceive, and the procedure must be carried out in a specialised centre with a multidisciplinary team available.

Completeness of Surgery

Four studies have evaluated the impact of incomplete surgical resection in infertile women with DE. In one study, patients with documented colorectal endometriosis underwent complete eradication of non-bowel DE lesions, but intestinal nodules were left behind.8 The authors reported both lower spontaneous and ART-induced PR in patients with residual bowel disease compared to those who had complete disease resection. Additionally, patients who underwent incomplete surgery had longer intervals to conception (P<0.05) and lower monthly fecundity rates (P<0.05).8 Similarly, a large retrospective study involving 230 patients with posterior DE compared three groups: complete surgery, incomplete surgery, and no surgery before ART. After logistic regression analysis, the presence of a recto-uterine nodule was associated with a significantly lower chance of pregnancy after IVF.77

Other studies have shown no difference in fertility outcomes among patients with DE undergoing postoperative ART, regardless of whether surgery was complete or not. However, these studies included both colorectal and non-colorectal cases and did not specifically analyse fertility outcomes in the subgroup of patients with bowel disease.31, 78, 79

Therefore, for patients with colorectal endometriosis, a complete macroscopic resection should be attempted, as it is associated with better fertility outcomes and pain relief compared to incomplete procedures, especially in patients with multiple DE lesions.31, 80

However, in selected cases, incomplete resection may be justified (e.g., low rectal lesions, nerve supply involvement) to avoid complications.31 Centini et al.31 found no significant impact on fertility outcomes (P=0.37) when small retroperitoneal nodules were left in place. Based on these data, the current recommendation is to aim for the complete removal of all macroscopic DE lesions when feasible, maintaining a balance between radical excision and functional preservation.

Other Factors

Other prognostic factors have been inconsistently associated with worse postoperative fertility outcomes in patients with bowel endometriosis, like age over 35 years, higher American Society for Reproductive Medicine (ASRM) scores, and the presence of concomitant adenomyosis.27, 30, 42

The Impact of Bowel Endometriosis Resection on Spontaneous Fertility

To accurately evaluate whether surgery improves fertility in patients with bowel DE, the preferred outcome should be the postoperative SPR. Theoretically, DE excision restores normal anatomy and significantly increases the chance of spontaneous conception,31, 81 enabling patients to avoid ART and minimise associated healthcare costs. However, assessing the impact of bowel DE excision on spontaneous pregnancy is challenging because ART is often indicated immediately after surgery (without allowing time for spontaneous conception to occur). In addition, comparative studies evaluating postoperative spontaneous fertility in patients with DE have not focused on patients with bowel involvement.21, 82

To date, postoperative spontaneous fertility in patients with colorectal endometriosis wishing to conceive (with or without documented infertility) has been evaluated in four systematic reviews. Iversen et al.83 reported a 21% SPR among 490 patients from three prospective studies, and 49% SPR from four retrospective studies involving 415 women. Daraï et al.39 reported a 31.4% SPR among 855 patients wishing to conceive from 24 studies published between 1990 and 2015. Cohen et al.84 reviewed 1320 patients with bowel DE who underwent surgery. They identified 171 spontaneous pregnancies among 597 women, resulting in a SPR of 28.6%.

Recently, a comprehensive review by Daniilidis et al.85 estimated a 24.9% postoperative SPR in patients with bowel endometriosis. However, this estimate included two studies focusing solely on ART outcomes (which reported 0% spontaneous pregnancies), making the reported SPR potentially inaccurate.

In our study, spontaneous fertility after bowel surgery for DE was reported in 35 studies published from 2009 to the present, involving 2405 patients with pregnancy intention (with or without infertility diagnosis).12, 13, 15, 41, 43-74 We identified 783 spontaneous pregnancies, resulting in a 32.6% SPR. Most available studies were observational and failed to report how many patients underwent surgery due to pain, infertility, or both. Three RCTs were identified,41, 43, 86 though their primary outcomes were not fertility-related.

Selecting Candidates for Attempting Natural Conception After Surgery

Several factors have been associated with a lower postoperative chance of spontaneous pregnancy in patients with bowel DE, emphasising the importance of patient selection in estimating postoperative reproductive success.87 These factors should always be considered during perioperative counselling.

Preoperative Infertility Diagnosis

Although satisfactory postoperative SPRs are reported in patients with bowel DE wishing to conceive, when only patients with documented infertility are analysed, the estimated SPR is significantly lower. A systematic review by Vercellini et al.,87 aimed at defining SPR specifically in patients with documented infertility before surgery, reported a mean postoperative SPR of 24% among 510 infertile women with rectovaginal endometriosis from 11 studies. However, this review was not restricted to patients with bowel DE. We identified sixteen studies reporting SPR in patients with colorectal DE according to their preoperative fertility status. Among 824 infertile women undergoing digestive surgery (shaving, disc excision, segmental resection), 190 achieved a spontaneous pregnancy, resulting in an SPR of 23.1% (Table 4). It is important to note that in most studies, limited information is available on the duration of infertility and the coexistence of additional infertility factors other than endometriosis. Indeed, duration of preoperative infertility may be a determining factor of postoperative SPR after colorectal resection for endometriosis.44

Age at the Time of Surgery

Patient age has been consistently associated with postoperative SPR in patients with bowel DE. Stepniewska et al.45 reported a cumulative SPR after laparoscopic segmental resection of 58% for patients younger than 30 years, and 45% for those aged 30-34 years. No pregnancies were achieved in patients older than 35 years. This result aligns with findings from Daraï et al.,41 who observed no spontaneous pregnancies after colorectal resection in women older than 35 years. Based on these data, IVF may be prioritised for women over 35 years. Since fertility outcomes after IVF in women under 35 years were similar to those of women trying to conceive naturally,45 postoperative natural conception should be attempted in young women with normal tubal function and normal semen analysis.

Endometriosis Fertility Index

The Endometriosis Fertility Index (EFI) is a validated tool to predict the likelihood of natural conception after endometriosis surgery.88 Although the EFI score has been demonstrated to correlate well with the chance of live birth and fertility prognosis after surgical resection of moderate to severe endometriosis (ASRM stage III-IV),89 it has not been explicitly validated among women with bowel endometriosis. Then, the place of the EFI in the decision-making process after surgery in patients with bowel DE remains to be established.

Fertility Outcomes According to the Surgical Procedure Performed for Bowel Endometriosis

Postoperative SPR after rectal “shaving” has been evaluated in six retrospective studies.13, 46-50 Among 654 women with pregnancy wishes or proven infertility, 295 spontaneous pregnancies were observed, resulting in a 45.1% SPR. The mean time to pregnancy after surgery was reported in two studies12, 51 and varied from 9.4 to 14 months.

Seven studies, including 348 patients desiring pregnancy (with or without documented infertility), specifically reported fertility outcomes after “disc excision” of colorectal endometriosis.12, 50, 52-56 In the entire group, 109 spontaneous pregnancies were observed after surgery, resulting in a 31.3% SPR. Time to pregnancy was reported in three studies,12, 52, 55 ranging from 5 to 20.6 months.

“Segmental resection” remains the most widely performed procedure for the surgical treatment of colorectal endometriosis. Fertility outcomes were retrieved from eighteen studies,41, 43, 44, 46, 47, 50, 52, 55, 57-66 including 675 patients with pregnancy intention in whom segmental resection was the only technique performed to treat colorectal endometriosis. In the entire group, 207 spontaneous pregnancies were observed after surgery, resulting in a 30.7% SPR.

Total pregnancy rates according to the surgical procedure performed for bowel endometriosis.

Seven studies,13, 14, 47, 52, 55, 86, 90 and one meta-analysis91 evaluated postoperative PR (both spontaneous and after MAR) by surgical approach among patients with pregnancy intention.

• Lapointe et al.13 compared fertility outcomes of patients undergoing shaving with those undergoing digestive resection (discoid or segmental). While there was no difference in the overall PR between groups, spontaneous conception was significantly higher in the resection group than in the shaving group (73.6% vs. 33.3%, P=0.0086).

• In a prior prospective study, Ballester et al.14 assessed fertility outcomes after IVF in infertile women following the complete removal of colorectal endometriosis. A decreased CPR was observed for women who required segmental resection compared to those who underwent shaving or disc excision (P=0.04). Additionally, all patients who underwent more conservative bowel surgery (n=18) became pregnant after two IVF cycles, suggesting that patients requiring shaving or disc excision may be good candidates for first-intention surgery.

• Conversely, Bourdel et al.47 reported no differences between groups when comparing shaving to segmental resection in terms of fertility. These findings were corroborated by Roman et al.,86 who reported similar PR in patients undergoing segmental resection compared to those who underwent shaving or disc excision (P=0.99) after a 7-year follow-up.

• In a previous study, Hudelist et al.55 evaluated fertility results as a secondary outcome among 102 patients who underwent segmental resection and 32 women undergoing disc excision. No differences were found between groups. Similar results were obtained in more recent studies.52, 90

• In a recent systematic review and meta-analysis including 13 studies and 2131 patients with pregnancy information,91 colorectal resection was associated with a lower PR compared with the other surgical techniques [35.5% vs. 42.6%, odds ratio (OR): 0.64 (95% confidence interval (CI): 0.52-0.79), P<0.001]. There was a similar result when comparing colorectal resection with shaving [n=952, 17.3% vs. 38.8%, OR: 0.51 (95% CI: 0.36-0.73), P<0.001] and no differences were found when comparing colorectal resection with disc excision [n=432, 29.2% vs. 35.8%, OR: 0.65 (95% CI: 0.37-1.13), P=0.13]. However, when SPR was specifically evaluated, there was no difference between colorectal resection and the other techniques.

Nevertheless, the question of which approach is best for removing bowel DE to improve reproductive outcomes in these women remains difficult to answer. Most of the aforementioned studies used fertility outcome as a secondary result, and the decision to perform one technique over another is largely based on the characteristics of the endometriotic bowel lesions.1

Complications After Surgery and Their Impact on Fertility Outcomes

Although surgical resection of bowel endometriosis exposes patients to serious complications, the impact of such complications (Clavien-Dindo III-IV) on fertility outcomes is not well-defined. Kondo et al.92 evaluated fertility outcomes in 23 patients who experienced major postoperative complications following DE resection. Although the study was not specifically focused on patients with bowel involvement, overall PR was significantly lower among women who experienced intestinal complications, compared with those who presented urinary complications (33.3% vs. 83.3%, P=0.04).

Specifically, the reproductive outcome of patients who underwent colorectal surgery for bowel endometriosis and experienced severe complications has been reported in four studies.12, 42, 50, 67 In a recent study by Raos et al.,67 16.6% of patients experienced Clavien-Dindo grade III complications. Notably, the presence of such complications did not affect the chances of pregnancy, time-to-pregnancy, or LBR. These findings align with previous reports on women who developed severe surgical complications after bowel endometriosis resection.12, 42, 50 However, the occurrence of postoperative complications was associated with a longer delay in achieving pregnancy.12, 50

Ferrier et al.93 retrospectively analysed reproductive outcomes in 48 patients who experienced major complications (Clavien-Dindo ≥ grade III) after colorectal surgery for endometriosis. After a median follow-up of 5 years, the CPR was 46%, and the LBR was 29.2%. Although the occurrence of such complications seemed to have little impact on fertility outcomes, a significantly lower CPR was observed in patients who developed septic complications such as deep pelvic abscesses (P=0.04) and anastomotic leakage (P=0.02). Additionally, the median time between surgery and the first pregnancy was longer than that observed in patients without complications.

Hence, surgery should not be avoided due to the risk of complications affecting pregnancy chances. However, efforts should be made to achieve pregnancy during the first postoperative year. For patients experiencing septic complications, rapid ART may be a good option.

First-line Surgery Followed by Assisted Reproductive Technologies

The potential influence of surgical excision of bowel endometriosis before IVF on fertility outcomes has been evaluated in three studies,14, 26, 30 and one systematic review,94 providing conflicting results.

Casals et al.94 reported a benefit of surgery before ART in patients with colorectal endometriosis (OR: 2.43, 95% CI: 1.13-5.52). However, this result was based on a single retrospective study.30 This study compared the impact of first-line ART versus first-line colorectal surgery followed by ART on fertility outcomes in 110 women with proven infertility and documented bowel DE using propensity score matching analysis to reduce bias. Patients were allocated into two groups: 55 in the first-line IVF arm and 55 in the first-line colorectal surgery arm. The authors reported significantly higher PR (21.8% vs. 49%, P=0.003), CPR (56.6% vs. 79.7%, P=0.037), and CLBR after 3 IVF cycles (54.9% vs. 70.6%, P=0.008) in women who underwent first-line surgery. Additionally, a subgroup of patients with a worse reproductive prognosis (those over 35 years old, with AMH ≥ 2 ng/mL, and with concomitant adenomyosis) was identified. For patients with at least one negative factor, first-line surgery resulted in significantly higher PR (P=0.01). However, no significant differences were found between the two strategies in patients over 35 years or those with adenomyosis.

In a separate analysis from the same cohort (n=60), Ballester et al.14 reported a 78.1% CPR after 3 IVF cycles. However, a trend toward a decreased CPR was observed for women who received their first IVF cycle more than 18 months following surgery (P=0.07). Interestingly, a 44% (4/9 patients) postoperative PR was found after the first IVF cycle in a group of patients with previous IVF failure. Similarly, prior data indicated no benefit after three IVF cycles in patients with in situ colorectal endometriosis, reinforcing the indication for colorectal surgery after IVF failure.28

A third study,26 not included in the meta-analysis, was published in 2024. The authors retrospectively compared fertility outcomes in 189 patients with colorectal endometriosis and proven infertility: 120 patients undergoing IVF alone and 69 patients undergoing surgery followed by IVF. Both the CPR and CLBR were similar between the groups.

Ongoing Trials

The ENDOFERT study (NCT0294897) is an open, multicentre, parallel-group, controlled trial aimed to evaluate the impact of complete surgery of colorectal DE on IVF outcomes. Patients are randomised into two groups: one group undergoing complete surgery of colorectal DE before IVF and the other group undergoing IVF alone (ratio 1:1). The Primary outcome will be the occurrence of a clinical pregnancy (6 weeks of gestation with ultrasound confirmation) after 2 IVF cycles.

The TOSCA study (NCT05677269)95 is a multicentre prospective observational cohort study that will compare surgery (potentially combined with IVF/ICSI) versus IVF/ICSI-only treatment in women with colorectal endometriosis and subfertility, in order to provide evidence on the value of surgery as a fertility-enhancing procedure. The duration of time to allow natural conception will be determined based on the EFI score. The primary outcome will be the cumulative ongoing PR resulting in a live birth, measured by CLBR. The total follow-up time per patient will include 40 months unless the study endpoint is achieved earlier. The endpoint criteria of the study are: 1) live birth or 2) no live birth after 40 months of follow-up despite IVF/ICSI (maximum three cycles), colorectal resection surgery, or a combination of both treatments. The choice between surgery and IVF/ICSI treatment will be determined through shared decision-making while considering the patient’s current QoL.

The EFFORT study (NCT 04610710)96 is a multicentre, parallel-group, controlled trial aimed at determining the CPR and LBR after first-line surgery compared with first-line IVF for women with colorectal endometriosis and pregnancy intention. Patients are randomised 1:1 to either surgical management or IVF (at least two cycles if not pregnant after the first cycle). Women in the surgical intervention group will attempt to get pregnant after surgery, by either spontaneous conception or ART, depending on the EFI score.

Conclusion

Bowel endometriosis-associated infertility remains a complex condition requiring individualised management. Laparoscopic surgical excision can improve fertility outcomes - especially in younger patients, those without adenomyosis, and those with minimal additional infertility factors.

Completeness of resection, surgical expertise, and proper candidate selection are key determinants of reproductive success. However, the evidence base is primarily observational. The benefit of surgery in improving outcomes - especially when performed before ART - remains uncertain. In patients with a good reproductive prognosis (age <35, no adenomyosis, patent tubes, normal ovarian reserve), natural conception after surgery is a reasonable goal. Conversely, for older patients or those with diminished ovarian reserve or prior ART failures, IVF should not be delayed (Figure 2).

Surgical complications, though infrequent, may delay conception but do not necessarily reduce LBRs - except in cases of septic events. Notably, the timing between surgery and ART initiation appears to impact outcomes, with earlier treatment yielding better results.

First-line ART remains a viable option in patients without obstructive bowel disease or pain, although fertility outcomes are influenced by adenomyosis and prior surgeries.

Ongoing trials are expected to provide needed clarity. Until randomised trials are published, the choice between surgery-first or ART-first must be guided by shared decision-making, individual clinical profiles, and a balance between fertility goals, surgical risk, and symptom burden.

Acknowledgements

None.

Contributors

Concept: D.L., J.C., J.D.V.E., F.H., W.K., Design: D.L., F.H., Data Collection or Processing: D.L., J.C., M.D.M., F.C., J.D.V.E., Analysis or Interpretation: D.L., J.C., F.H., Literature Search: D.L., M.D.M., F.C., Writing: D.L., J.D.V.E., W.K.
Funding: None.
Competing interests: No conflict of interest was declared by the authors.
Ethical approval: Not required.
Informed consent: Not applicable.
Data sharing: Not applicable.
Transparency: The authors affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

References

1
Abrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C. Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update. 2015;21:329-39.
CrossRef PubMed Google Scholar
2
De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, Koninckx P. Bowel resection for deep endometriosis: a systematic review. BJOG. 2011;118:285-91.
CrossRef PubMed Google Scholar
3
Vercellini P, Sergenti G, Buggio L, Frattaruolo MP, Dridi D, Berlanda N. Advances in the medical management of bowel endometriosis. Best Pract Res Clin Obstet Gynaecol. 2021;71:78-99.
CrossRef PubMed Google Scholar
4
Zegers-Hochschild F, Adamson GD, Dyer S, Racowsky C, de Mouzon J, Sokol R, et al. The International Glossary on Infertility and Fertility Care, 2017. Fertil Steril. 2017;108:393-406.
5
Maignien C, Santulli P, Bourdon M, Korb D, Marcellin L, Lamau MC, et al. Deep Infiltrating Endometriosis: a Previous History of Surgery for Endometriosis May Negatively Affect Assisted Reproductive Technology Outcomes. Reprod Sci. 2020;27:545-54.
6
Yin W, Li X, Liu P, Li Y, Liu J, Yu S, et al. Digestive system deep infiltrating endometriosis: What do we know. J Cell Mol Med. 2023;27:3649-61.
7
Habib N, Centini G, Lazzeri L, Amoruso N, El Khoury L, Zupi E, et al. Bowel endometriosis: current perspectives on diagnosis and treatment. Int J Womens Health. 2020;12:35-47.
8
Stepniewska A, Pomini P, Bruni F, Mereu L, Ruffo G, Ceccaroni M, et al. Laparoscopic treatment of bowel endometriosis in infertile women. Hum Reprod. 2009;24:1619-25.
9
Mathieu d’Argent E, Coutant C, Ballester M, Dessolle L, Bazot M, Antoine JM, et al. Results of first in vitro fertilization cycle in women with colorectal endometriosis compared with those with tubal or male factor infertility. Fertil Steril. 2010;94:2441-3.
CrossRef PubMed Google Scholar
10
Bassi MA, Podgaec S, Dias JA, D’Amico Filho N, Petta CA, Abrao MS. Quality of life after segmental resection of the rectosigmoid by laparoscopy in patients with deep infiltrating endometriosis with bowel involvement. J Minim Invasive Gynecol. 2011;18:730-3.
CrossRef PubMed Google Scholar
11
Riiskjær M, Forman A, Kesmodel US, Andersen LM, Ljungmann K, Seyer-Hansen M. Pelvic pain and quality of life before and after laparoscopic bowel resection for rectosigmoid endometriosis: a prospective, observational study. Dis Colon Rectum. 2018;61:221-9.
CrossRef PubMed Google Scholar
12
Dabi Y, Ebanga L, Favier A, Kolanska K, Puchar A, Jayot A, et al. Discoid excision for colorectal endometriosis associated infertility: a balance between fertility outcomes and complication rates. J Gynecol Obstet Hum Reprod. 2024;53:102723.
13
Lapointe M, Pontvianne M, Faller E, Lodi M, Futcher F, Lecointre L, et al. Impact of surgery for colorectal endometriosis on postoperative fertility and pregnancy outcomes. J Gynecol Obstet Hum Reprod. 2022;51:102348.
14
Ballester M, Roman H, Mathieu E, Touleimat S, Belghiti J, Daraï E. Prior colorectal surgery for endometriosis-associated infertility improves ICSI-IVF outcomes: results from two expert centres. Eur J Obstet Gynecol Reprod Biol. 2017;209:95-9.
CrossRef PubMed Google Scholar
15
Hezer S, Chauvin G, Klein C, Bernard V, Brun JL, Launay-Savary MV, et al. Fertility outcomes after surgical management of colorectal endometriosis: a single-center retrospective study. J Minim Invasive Gynecol. 2023;30:230-9.
CrossRef
16
International working group of AAGL, ESGE, ESHRE and WES, Tomassetti C, Johnson NP, Petrozza J, Abrao MS, Einarsson JI, et al. An International Terminology for Endometriosis, 2021. J Minim Invasive Gynecol. 2021;28:1849-59.
CrossRef
17
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205-13.
18
Baethge C, Goldbeck-Wood S, Mertens S. SANRA-a scale for the quality assessment of narrative review articles. Res Integr Peer Rev. 2019;4:5.
CrossRef PubMed Google Scholar
19
Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility: a committee opinion. Fertil Steril.
20
Vercellini P, Pietropaolo G, De Giorgi O, Daguati R, Pasin R, Crosignani PG. Reproductive performance in infertile women with rectovaginal endometriosis: is surgery worthwhile? Am J Obstet Gynecol. 2006;195:1303-10.
CrossRef PubMed Google Scholar
21
Leone Roberti Maggiore U, Scala C, Tafi E, Racca A, Biscaldi E, Vellone VG, et al. Spontaneous fertility after expectant or surgical management of rectovaginal endometriosis in women with or without ovarian endometrioma: a retrospective analysis. Fertil Steril. 2017;107:969-76.
CrossRef PubMed Google Scholar
22
Ferrero S, Scala C, Biscaldi E, Racca A, Leone Roberti Maggiore U, Barra F. Fertility in patients with untreated rectosigmoid endometriosis. Reprod Biomed Online. 2021;42:757-67.
CrossRef PubMed Google Scholar
23
Acién P, Núñez C, Quereda F, Velasco I, Valiente M, Vidal V. Is a bowel resection necessary for deep endometriosis with rectovaginal or colorectal involvement? Int J Womens Health. 2013;5:449-55.
CrossRef PubMed Google Scholar
24
Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, et al. ESHRE guideline: endometriosis. Hum Reprod Open. 2022;2022:hoac009.
CrossRef
25
Vercellini P, Viganò P, Frattaruolo MP, Borghi A, Somigliana E. Bowel surgery as a fertility-enhancing procedure in patients with colorectal endometriosis: methodological, pathogenic and ethical issues. Hum Reprod. 2018;33:1205-11.
CrossRef PubMed Google Scholar
26
Rubod C, De Prémare C, Kerbage Y, Kyheng M, Plouvier P, Chossegros C, et al. Does surgery for colorectal endometriosis prior to IVF±ICSI have an impact on cumulative live birth rates? Reprod Biomed Online. 2024;48:103649.
CrossRef
27
Vercellini P, Consonni D, Barbara G, Buggio L, Frattaruolo MP, Somigliana E. Adenomyosis and reproductive performance after surgery for rectovaginal and colorectal endometriosis: a systematic review and meta-analysis. Reprod Biomed Online. 2014;28:704-13.
CrossRef PubMed Google Scholar
28
Ballester M, d’Argent EM, Morcel K, Belaisch-Allart J, Nisolle M, Daraï E. Cumulative pregnancy rate after ICSI-IVF in patients with colorectal endometriosis: results of a multicentre study. Hum Reprod. 2012;27:1043-9.
CrossRef PubMed Google Scholar
29
Maignien C, Santulli P, Marcellin L, Korb D, Bordonne C, Dousset B, et al. Infertility in women with bowel endometriosis: first-line assisted reproductive technology results in satisfactory cumulative live-birth rates. Fertil Steril. 2021;115:692-701.
30
Bendifallah S, Roman H, Mathieu d’Argent E, Touleimat S, Cohen J, Darai E, et al. Colorectal endometriosis-associated infertility: should surgery precede ART? Fertil Steril. 2017;108:525-31.
31
Centini G, Afors K, Murtada R, Argay IM, Lazzeri L, Akladios CY, et al. Impact of laparoscopic surgical management of deep endometriosis on pregnancy rate. J Minim Invasive Gynecol. 2016;23:113-9.
CrossRef
32
Barra F, Mikhail E, Villegas-Echeverri JD, Ferrero S. Infertility in patients with bowel endometriosis. Best Pract Res Clin Obstet Gynaecol. 2021;71:161-71.
CrossRef PubMed Google Scholar
33
Roman H, Friederich L, Khalil H, Marouteau-Pasquier N, Hochain P, Marpeau L. [Treating severe endometriosis by pregnancy: a risky business]. Gynecol Obstet Fertil. 2007;35:38-40.
CrossRef PubMed Google Scholar
34
Melado L, Ata B. Chapter 11. Endometriosis-related complications in women undergoing in-vitro fertilization. Best Pract Res Clin Obstet Gynaecol. 2024;93:102456.
CrossRef PubMed Google Scholar
35
Setúbal A, Sidiropoulou Z, Torgal M, Casal E, Lourenço C, Koninckx P. Bowel complications of deep endometriosis during pregnancy or in vitro fertilization. Fertil Steril. 2014;101:442-6.
CrossRef PubMed Google Scholar
36
Seyer-Hansen M, Egekvist A, Forman A, Riiskjaer M. Risk of bowel obstruction during in vitro fertilization treatment of patients with deep infiltrating endometriosis. Acta Obstet Gynecol Scand. 2018;97:47-52.
CrossRef PubMed Google Scholar
37
Roman H, Puscasiu L, Lempicki M, Huet E, Chati R, Bridoux V, et al. Colorectal endometriosis responsible for bowel occlusion or subocclusion in women with pregnancy intention: is the policy of primary in vitro fertilization always safe? J Minim Invasive Gynecol. 2015;22:1059-67.
38
Grigoriadis G, Daniilidis A, Merlot B, Stratakis K, Dennis T, Crestani A, et al. Surgical treatment of deep endometriosis: Impact on spontaneous conception. Best Pract Res Clin Obstet Gynaecol. 2024;93:102455.
CrossRef
39
Daraï E, Cohen J, Ballester M. Colorectal endometriosis and fertility. Eur J Obstet Gynecol Reprod Biol. 2017;209:86-94.
CrossRef PubMed Google Scholar
40
Breteau P, Chanavaz-Lacheray I, Rubod C, Turck M, Sanguin S, Pop I, et al. Pregnancy rates after surgical treatment of deep infiltrating endometriosis in infertile patients with at least 2 previous in vitro fertilization or intracytoplasmic sperm injection failures. J Minim Invasive Gynecol. 2020;27:1148-57.
CrossRef PubMed Google Scholar
41
Daraï E, Lesieur B, Dubernard G, Rouzier R, Bazot M, Ballester M. Fertility after colorectal resection for endometriosis: results of a prospective study comparing laparoscopy with open surgery. Fertil Steril. 2011;95:1903-8.
CrossRef PubMed Google Scholar
42
Daraï E, Carbonnel M, Dubernard G, Lavoué V, Coutant C, Bazot M, et al. Determinant factors of fertility outcomes after laparoscopic colorectal resection for endometriosis. Eur J Obstet Gynecol Reprod Biol. 2010;149:210-4.
43
Dobó N, Márki G, Hudelist G, Csibi N, Brubel R, Ács N, et al. Laparoscopic natural orifice specimen extraction colectomy versus conventional laparoscopic colorectal resection in patients with rectal endometriosis: a randomized, controlled trial. Int J Surg Lond Engl. 2023;109:4018-26.
44
Ferrero S, Anserini P, Abbamonte LH, Ragni N, Camerini G, Remorgida V. Fertility after bowel resection for endometriosis. Fertil Steril. 2009;92:41-6.
CrossRef PubMed Google Scholar
45
Stepniewska A, Pomini P, Scioscia M, Mereu L, Ruffo G, Minelli L. Fertility and clinical outcome after bowel resection in infertile women with endometriosis. Reprod Biomed Online. 2010;20:602-9.
CrossRef PubMed Google Scholar
46
Marty N, Touleimat S, Moatassim-Drissa S, Millochau JC, Vallee A, Stochino Loi E, et al. Rectal shaving using plasma energy in deep infiltrating endometriosis of the rectum: four years of experience. J Minim Invasive Gynecol. 2017;24:1121-7.
CrossRef
47
Bourdel N, Comptour A, Bouchet P, Gremeau AS, Pouly JL, Slim K, et al. Long-term evaluation of painful symptoms and fertility after surgery for large rectovaginal endometriosis nodule: a retrospective study. Acta Obstet Gynecol Scand. 2018;97:158-67.
CrossRef
48
Donnez J, Squifflet J. Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules. Hum Reprod Oxf Engl. 2010;25:1949-58.
49
Roman H, Moatassim-Drissa S, Marty N, Milles M, Vallée A, Desnyder E, et al. Rectal shaving for deep endometriosis infiltrating the rectum: a 5-year continuous retrospective series. Fertil Steril. 2016;106:1438-45.
50
Abo C, Moatassim S, Marty N, Saint Ghislain M, Huet E, Bridoux V, et al. Postoperative complications after bowel endometriosis surgery by shaving, disc excision, or segmental resection: a three-arm comparative analysis of 364 consecutive cases. Fertil Steril. 2018;109:172-8.
CrossRef PubMed Google Scholar
51
Roman H, Chanavaz-Lacheray I, Ballester M, Bendifallah S, Touleimat S, Tuech JJ, et al. High postoperative fertility rate following surgical management of colorectal endometriosis. Hum Reprod. 2018;33:1669-76
52
Hudelist G, Pashkunova D, Darici E, Rath A, Mitrowitz J, Dauser B, et al. Pain, gastrointestinal function and fertility outcomes of modified nerve-vessel sparing segmental and full thickness discoid resection for deep colorectal endometriosis - a prospective cohort study. Acta Obstet Gynecol Scand. 2023;102:1347-58.
CrossRef
53
Roman H, Abo C, Huet E, Bridoux V, Auber M, Oden S, et al. Full-thickness disc excision in deep endometriotic nodules of the rectum: a prospective cohort. Dis Colon Rectum. 2015;58:957-66.
54
Fanfani F, Fagotti A, Gagliardi ML, Ruffo G, Ceccaroni M, Scambia G, et al. Discoid or segmental rectosigmoid resection for deep infiltrating endometriosis: a case-control study. Fertil Steril. 2010;94:444-9.
CrossRef PubMed Google Scholar
55
Hudelist G, Aas-Eng MK, Birsan T, Berger F, Sevelda U, Kirchner L, et al. Pain and fertility outcomes of nerve-sparing, full-thickness disk or segmental bowel resection for deep infiltrating endometriosis-A prospective cohort study. Acta Obstet Gynecol Scand. 2018;97:1438-46.
CrossRef PubMed Google Scholar
56
Ceccaroni M, Ceccarello M, Clarizia R, Fusco E, Roviglione G, Mautone D, et al. Nerve-sparing laparoscopic disc excision of deep endometriosis involving the bowel: a single-center experience on 371 consecutives cases. Surg Endosc. 2021;35:5991-6000.
57
Turco LC, Scaldaferri F, Chiantera V, Cianci S, Ercoli A, Fagotti A, et al. Long-term evaluation of quality of life and gastrointestinal well-being after segmental colo-rectal resection for deep infiltrating endometriosis (ENDO-RESECT QoL). Arch Gynecol Obstet. 2020;301:217-28.
58
Kavallaris A, Chalvatzas N, Hornemann A, Banz C, Diedrich K, Agic A. 94 months follow-up after laparoscopic assisted vaginal resection of septum rectovaginale and rectosigmoid in women with deep infiltrating endometriosis. Arch Gynecol Obstet. 2011;283:1059-64.
CrossRef PubMed Google Scholar
59
Malzoni M, Di Giovanni A, Coppola M, Iuzzolino D, Casarella L, Rasile M, et al. Total laparoscopic segmental resection with transanal natural orifice specimen extraction for treatment of colorectal endometriosis: descriptive analysis from the TrEnd study database. J Minim Invasive Gynecol. 2025;32:240-7.
CrossRef
60
Meuleman C, Tomassetti C, Wolthuis A, Van Cleynenbreugel B, Laenen A, Penninckx F, et al. Clinical outcome after radical excision of moderate—severe endometriosis with or without bowel resection and reanastomosis: a prospective cohort study. Ann Surg. 2014;259:522-31.
CrossRef PubMed Google Scholar
61
Meuleman C, Tomassetti C, D’Hoore A, Buyens A, Van Cleynenbreugel B, Fieuws S, et al. Clinical outcome after CO 2 laser laparoscopic radical excision of endometriosis with colorectal wall invasion combined with laparoscopic segmental bowel resection and reanastomosis. Hum Reprod. 2011;26:2336-43.
62
Malzoni M, Di Giovanni A, Exacoustos C, Lannino G, Capece R, Perone C, et al. Feasibility and safety of laparoscopic-assisted bowel segmental resection for deep infiltrating endometriosis: a retrospective cohort study with description of technique. J Minim Invasive Gynecol. 2016;23:512-25.
CrossRef
63
Meuleman C, D’Hoore A, Van Cleynenbreugel B, Beks N, D’Hooghe T. Outcome after multidisciplinary CO2 laser laparoscopic excision of deep infiltrating colorectal endometriosis. Reprod Biomed Online. 2009;18:282-9.
CrossRef PubMed Google Scholar
64
Rocha AM, Albuquerque MMD, Schmidt EM, Freitas CD, Farias JP, Bedin F. Late impact of the laparoscopic treatment of deep infiltrating endometriosis with segmental colorectal resection. Arq Bras Cir Dig. 2018;31:1406.
65
Neme RM, Schraibman V, Okazaki S, Maccapani G, Chen WJ, Domit CD, et al. Deep infiltrating colorectal endometriosis treated with robotic-assisted rectosigmoidectomy. JSLS. 2013;17:227-34.
CrossRef
66
Tuominen A, Saavalainen L, Tiitinen A, Heikinheimo O, Härkki P. Pregnancy and delivery outcomes in women with rectovaginal endometriosis treated either conservatively or operatively. Fertil Steril. 2021;115:406-15.
CrossRef PubMed Google Scholar
67
Raos M, Mathiasen M, Seyer-Hansen M. Impact of surgery on fertility among patients with deep infiltrating endometriosis. Eur J Obstet Gynecol Reprod Biol. 2023;280:174-8.
CrossRef PubMed Google Scholar
68
Gordts S, Puttemans P, Campo R, Valkenburg M, Gordts S. Outcome of conservative surgical treatment of deep infiltrating endometriosis. Gynecol Surg. 2013;10:137-41.
69
Wills H, Tsaltas J, Cooper MJW, Reid GD, Morgan M, Woods R, et al. Laparoscopic surgery for colorectal endometriosis and its impact upon fertility: an updated australian series of 307 cases. J Endometr Pelvic Pain Disord. 2017;9:193-9.
CrossRef
70
Bafort C, Van Elst B, Neutens S, Meuleman C, Laenen A, d’Hoore A, et al. Outcome after surgery for deep endometriosis infiltrating the rectum. Fertil Steril. 2020;113:1319-27.
71
Millochau JC, Stochino-Loi E, Darwish B, Abo C, Coget J, Chati R, et al. Multiple nodule removal by disc excision and segmental resection in multifocal colorectal endometriosis. J Minim Invasive Gynecol. 2018;25:139-46.
CrossRef
72
Jelenc F, Ribič-Pucelj M, Juvan R, Kobal B, Šinkovec J, Šalamun V. Laparoscopic rectal resection of deep infiltrating endometriosis. J Laparoendosc Adv Surg Tech. 2012;22:66-9.
CrossRef PubMed Google Scholar
73
Koh CE, Juszczyk K, Cooper MJW, Solomon MJ. Management of deeply infiltrating endometriosis involving the rectum. Dis Colon Rectum. 2012;55:925-31.
CrossRef PubMed Google Scholar
74
Parra RS, Feitosa MR, Camargo HPD, Valério FP, Zanardi JVC, Rocha JJRD, et al. The impact of laparoscopic surgery on the symptoms and wellbeing of patients with deep infiltrating endometriosis and bowel involvement. J Psychosom Obstet Gynecol. 2021;42:75-80
75
Juhasz-Böss I, Lattrich C, Fürst A, Malik E, Ortmann O. Severe endometriosis: laparoscopic rectum resection. Arch Gynecol Obstet. 2010;281:657-62.
CrossRef PubMed Google Scholar
76
Minelli L, Fanfani F, Fagotti A, Ruffo G, Ceccaroni M, Mereu L, et al. Laparoscopic colorectal resection for bowel endometriosis: feasibility, complications, and clinical outcome. Arch Surg. 2009;144:234-9.
77
Rubod C, Fouquet A, Bartolo S, Lepage J, Capelle A, Lefebvre C, et al. Factors associated with pregnancy after in vitro fertilization in infertile patients with posterior deep pelvic endometriosis: a retrospective study. J Gynecol Obstet Hum Reprod. 2019;48:235-9.
78
Capelle A, Lepage J, Langlois C, Lefebvre C, Dewailly D, Collinet P, et al. [Surgery for deep infiltrating endometriosis before in vitro fertilization: no benefit for fertility?]. Gynecol Obstet Fertil. 2015;43:109-16.
79
Douay-Hauser N, Yazbeck C, Walker F, Luton D, Madelenat P, Koskas M. Infertile women with deep and intraperitoneal endometriosis: comparison of fertility outcome according to the extent of surgery. J Minim Invasive Gynecol. 2011;18:622-8.
CrossRef
80
Ballester M, Roman H. [Surgical management of deep endometriosis with colorectal involvement: CNGOF-HAS Endometriosis Guidelines]. Gynecol Obstet Fertil Senol. 2018;46:290-5.
CrossRef PubMed Google Scholar
81
Vidal F, Guerby P, Simon C, Lesourd F, Cartron G, Parinaud J, et al. Spontaneous pregnancy rate following surgery for deep infiltrating endometriosis in infertile women: The impact of the learning curve. J Gynecol Obstet Hum Reprod. 2021;50:101942.
82
Nguyen AD, Marshall HL, Sidle MW, Galaviz VD, Sticco PL, Downing KT. Factors associated with spontaneous conception leading to live birth in infertility patients after endometriosis surgery. J Minim Invasive Gynecol. 2025;32:718-24.
CrossRef PubMed Google Scholar
83
Iversen ML, Seyer-Hansen M, Forman A. Does surgery for deep infiltrating bowel endometriosis improve fertility? A systematic review. Acta Obstet Gynecol Scand. 2017;96:688-93.
CrossRef PubMed Google Scholar
84
Cohen J, Thomin A, Mathieu D’Argent E, Laas E, Canlorbe G, Zilberman S, et al. Fertility before and after surgery for deep infiltrating endometriosis with and without bowel involvement: a literature review. Minerva Ginecol. 2014;66:575-87.
85
Daniilidis A, Angioni S, Di Michele S, Dinas K, Gkrozou F, D’Alterio MN. Endometriosis and infertility: what is the impact of surgery? J Clin Med. 2022;11:6727.
86
Roman H, Huet E, Bridoux V, Khalil H, Hennetier C, Bubenheim M, et al. Long-term outcomes following surgical management of rectal endometriosis: seven-year follow-up of patients enrolled in a randomized trial. J Minim Invasive Gynecol. 2022;29:767-75.
CrossRef
87
Vercellini P, Barbara G, Buggio L, Frattaruolo MP, Somigliana E, Fedele L. Effect of patient selection on estimate of reproductive success after surgery for rectovaginal endometriosis: literature review. Reprod Biomed Online. 2012;24:389-95.
CrossRef PubMed Google Scholar
88
Adamson GD, Pasta DJ. Endometriosis fertility index: the new, validated endometriosis staging system. Fertil Steril. 2010;94:1609-15.
CrossRef PubMed Google Scholar
89
Maheux-Lacroix S, Nesbitt-Hawes E, Deans R, Won H, Budden A, Adamson D, et al. Endometriosis fertility index predicts live births following surgical resection of moderate and severe endometriosis. Hum Reprod. 2017;32:2243-9.
90
Alborzi S, Roman H, Askary E, Poordast T, Shahraki MH, Alborzi S, et al. Colorectal endometriosis: Diagnosis, surgical strategies and post-operative complications. Front Surg. 2022;9:978326.
91
Vallée A, Ceccaldi PF, Carbonnel M, Horsman S, Murtada R, Moawad G, et al. Comparative pregnancy rate after colorectal resection versus other surgical procedures for deep infiltrating rectal endometriosis: a systematic review and meta-analysis. Sci Rep. 2025;15:9369.
CrossRef PubMed Google Scholar
92
Kondo W, Daraï E, Yazbeck C, Panel P, Tamburro S, Dubuisson J, et al. Do patients manage to achieve pregnancy after a major complication of deeply infiltrating endometriosis resection? Eur J Obstet Gynecol Reprod Biol. 2011;154:196-9.
93
Ferrier C, Roman H, Alzahrani Y, d’Argent EM, Bendifallah S, Marty N, et al. Fertility outcomes in women experiencing severe complications after surgery for colorectal endometriosis. Hum Reprod Oxf Engl. 2018;33:411-5.
94
Casals G, Carrera M, Domínguez JA, Abrão MS, Carmona F. Impact of surgery for deep infiltrative endometriosis before in vitro fertilization: a systematic review and meta-analysis. J Minim Invasive Gynecol. 2021;28:1303-12.
CrossRef PubMed Google Scholar
95
de Koning R, Cantineau AEP, van der Tuuk K, De Bie B, Groen H, van den Akker-van Marle ME, et al. The (cost-) effectiveness Of Surgical excision of Colorectal endometriosis compared to ART treatment trAjectory (TOSCA study) - a study protocol. Reprod Fertil. 2024;5:e230048.
96
Raos M, Roman H, Seyer-Hansen M, Kesmodel US, Knudsen UB. EFFORT study: Comparing impact of operation and assisted reproductive technologies on fertility for women with deep infiltrating endometriosis - study protocol for a multicentre randomised trial. BMJ Open. 2022;12:e052877.
CrossRef PubMed Google Scholar

Suplementary Materials

2024 ©️ Galenos Publishing House