EC Gynaecology

Review Article Volume 14 Issue 8 - 2025

Endometriosis and Infertility: Medical Versus Surgical Approaches - A Systematic Review and Meta-Analysis

Francesco Maria Bulletti1, Elisabetta Coccia2, Maurizio Guido3, Evaldo Giacomucci4, Antonio Palagiano5 and Carlo Bulletti6*

1CHUV Lausanne - Département D'hôpital Maternité/Gynécologie et Obstétrique, Avenue Pierre Decker 2, 1011 Lausanne, Switzerland

2Associate Professor SSD: MEDS-21/A - Ginecologia e Ostetricia, Dipartimento di Scienze Biomediche, Sperimentali e Cliniche ‘Mario Serio’ Room 103, Pavillon 9, AOU Careggi, Italy

3Full Professor of Obstetrics and Gynecology, Università della Calabria (UNICAL) and Obstetrics and Gynecology Unit, Annunziata Hospital, Via Migliori 1, Cosenza, Italy

4Direttore Programma Dipartimentale Ginecologia dell'Infertilita' presso Ausl Bologna, Italy

5Antonio Palagiano CFA Naples, Italy

6Associate Professor Adjunct, Department of Obstetrics, Gynecology, and Reproductive Science, Yale University, New Haven, CT, USA and Past President of the Italian Society of Fertility, Sterility, and Reproductive Medicine (SIFE-MR), Italy

*Corresponding Author: Carlo Bulletti, Associate Professor Adjunct, Department of Obstetrics, Gynecology, and Reproductive Science, Yale University, New Haven, CT, USA and Past President of the Italian Society of Fertility, Sterility, and Reproductive Medicine (SIFE-MR), Italy.
Received: July 06, 2025; Published: July 27, 2025



Background: Endometriosis is a chronic inflammatory condition affecting reproductive-aged women, often associated with infertility. Medical and surgical treatments are widely used, but their relative effectiveness in restoring fertility remains debated.

Objective: To compare the impact of medical and surgical interventions on spontaneous pregnancy and IVF outcomes in women with endometriosis-associated infertility.

Methods: A systematic review and meta-analysis was conducted according to PRISMA 2020 guidelines. Databases searched included PubMed, Embase, Scopus, and Cochrane Library from January 2000 to June 2025. Eligible studies were comparative (prospective, retrospective, RCTs, meta-analyses) and evaluated fertility outcomes following medical or surgical treatment. Outcomes assessed were spontaneous pregnancy, IVF success, and surgical complications. Risk of bias was assessed with ROBINS-I and certainty of evidence with GRADE.

Results: Thirty-eight comparative studies met inclusion criteria: 12 evaluated medical treatments versus controls, 15 assessed surgical interventions versus controls, and 11 directly compared medical versus surgical approaches. Surgical treatment was associated with significantly higher odds of spontaneous pregnancy compared to controls (OR 1.71, 95% CI 1.41-2.08). Medical therapy had limited effect on natural conception, though in some studies GnRH agonist pretreatment before IVF modestly improved implantation rates. When directly compared, surgical interventions had superior outcomes in spontaneous pregnancy, whereas IVF results were similar between arms. Risk of bias was moderate in most studies. GRADE certainty ranged from low to moderate.

Conclusion: Surgical treatment offers significant benefits for spontaneous conception in women with early to moderate endometriosis. The role of medical therapy is more supportive, particularly in IVF protocols. Fertility treatment decisions should be individualized based on disease stage, ovarian reserve, and patient goals.

Keywords: Endometriosis; Infertility; Spontaneous Pregnancy; IVF; Medical Therapy; Laparoscopy; GnRH; Comparative Studies

  1. Vercellini P., et al. “Endometriosis: pathogenesis and treatment”. Nature Reviews Endocrinology 5 (2014): 261-275.
  2. Brosens I., et al. “Endometriosis: a life cycle approach?” American Journal of Obstetrics and Gynecology 4 (2013): 307-316.
  3. As-Sanie S., et al. “Endometriosis: A review”. Journal of the American Medical Association1 (2025): 64-78.
  4. Giudice LC. “Clinical practice. Endometriosis”. New England Journal of Medicine25 (2010): 2389-2398.
  5. American Society for Reproductive Medicine. “Endometriosis and infertility: a committee opinion”. Fertility and Sterility 3 (2012): 591-598.
  6. European Society of Human Reproduction and Embryology. “ESHRE guideline: management of women with endometriosis”. Human Reproduction 3 (2014): 400-412.
  7. Royal College of Obstetricians and Gynaecologists. The Investigation and Management of Endometriosis. Green-top Guideline No. 24 (2017).
  8. Harada T., et al. “Long-term efficacy and safety of dienogest in the treatment of endometriosis”. Fertility and Sterility 2 (2014): 291-298.
  9. Sutton CJ., et al. “Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis”. Fertility and Sterility6 (1997): 1070-1074.
  10. Abbott J., et al. “Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial”. Fertility and Sterility4 (2004): 878-884.
  11. Garcia-Velasco JA and Somigliana E. “Management of endometriosis in patients who require IVF”. Current Opinion in Obstetrics and Gynecology 3 (2009): 300-304.
  12. Sallam HN., et al. “Long-term pituitary down-regulation before in vitro fertilization (IVF) for women with endometriosis”. Cochrane Database of Systematic Reviews 1 (2006): CD004635.
  13. Page MJ., et al. “The PRISMA 2020 statement: an updated guideline for reporting systematic reviews”. British Medical Journal 372 (2021): n71.
  14. Sterne JA., et al. “ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions”. British Medical Journal 355 (2016): i4919.
  15. Sterne JAC., et al. “RoB 2: a revised tool for assessing risk of bias in randomized trials”. British Medical Journal 366 (2019): l4898.
  16. Guyatt GH., et al. “GRADE: an emerging consensus on rating quality of evidence and strength of recommendations”. British Medical Journal7650 (2008): 924-926.
  17. Bulletti C., et al. “Uterine contractility during the menstrual cycle”. Human Reproduction 1 (2000): 81-89.
  18. Dunselman GAJ., et al. “ESHRE guideline: management of women with endometriosis”. Human Reproduction 3 (2014): 400-412.
  19. Leyendecker G., et al. “Uterine peristalsis and sperm transport: the missing link”. Reproductive BioMedicine Online3 (2002): 7-9.
  20. K M Moss., et al. “Delayed diagnosis of endometriosis disadvantages women in ART: a retrospective population linked data study”. Human Reproduction 12 (2021): 3074-3082.
  21. Chapron C., et al. “Ovarian endometrioma: severe pelvic pain is associated with deeply infiltrating endometriosis”. Human Reproduction 3 (2012): 702-711.
  22. Dunselman GAJ., et al. “ESHRE guideline: management of women with endometriosis”. Human Reproduction 3 (2014): 400-412.
  23. Vercellini P., et al. “Surgery for endometriosis-associated infertility: a pragmatic approach". Human Reproduction 2 (2013): 251-259.
  24. Nirgianakis K., et al. “Obstetric complications after laparoscopic excision of deep infiltrating endometriosis”. Fertility and Sterility2 (2020): 299-306.
  25. Marcoux S., et al. “Laparoscopic surgery in infertile women with minimal or mild endometriosis”. New England Journal of Medicine4 (1997): 217-222.
  26. Abbott J., et al. “Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial”. Fertility and Sterility4 (2004): 878-884.
  27. Somigliana E., et al. “The use of ovarian reserve testing before and after surgery for endometriomas”. Human Reproduction Update6 (2012): 525-536.
  28. Garcia-Velasco JA., et al. “Long-term pituitary down-regulation before in vitro fertilization in women with endometriomas: a randomized controlled trial”. Reproductive BioMedicine Online4 (2006): 602-607.
  29. Bianchi PHM., et al. “Ovarian endometrioma: a marker of severity of the disease?” Journal of Minimally Invasive Gynecology 2 (2009): 167-172.
  30. Somigliana E., et al. “Surgical versus expectant management before assisted reproduction in women with endometriosis-associated subfertility: a review”. Reproductive BioMedicine Online 4 (2015): 402-406.
  31. Vercellini P., et al. “The effect of surgery for symptomatic endometriosis: the other side of the story”. Human Reproduction Update2 (2009): 177-188.
  32. Nezhat C., et al. “Laparoscopic treatment of deeply infiltrating endometriosis: retrospective study evaluating pain, quality of life and complications”. Journal of Minimally Invasive Gynecology 6 (2018): 1045-1052.
  33. Somigliana E., et al. “The presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotropins”. Fertility and Sterility1 (2006): 192-196.
  34. Raffi F., et al. “The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis”. Journal of Clinical Endocrinology and Metabolism 9 (2012): 3146-3154.
  35. Abbott J., et al. “The effects and effectiveness of laparoscopic excision of endometriosis: a prospective study with 2-5 year follow-up”. Human Reproduction 9 (2003): 1922-1927.
  36. Timmerman D., et al. “ESGO/ISUOG/IOTA/ESGE consensus statement on preoperative diagnosis of ovarian tumors”. Ultrasound in Obstetrics and Gynecology 5 (2021): 735-753.
  37. Jacobson TZ., et al. “Laparoscopic surgery for subfertility associated with endometriosis”. Cochrane Database of Systematic Reviews 1 (2010): CD001398.
  38. Bafort C., et al. “Laparoscopic surgery for endometriosis”. Cochrane Database of Systematic Reviews 10 (2020): CD011031.
  39. Vercellini P., et al. “Endometriosis: current therapies and new pharmacological developments”. Reproductive BioMedicine Online 3 (2009): 29-34.
  40. Bulletti C., et al. “Endometriosis and infertility”. Journal of Assisted Reproduction and Genetics 8 (2010): 441-447.
  41. Sanchez AM., et al. “Is the oocyte quality affected by endometriosis? A review of the literature”. Journal of Ovarian Research 1 (2017): 43.
  42. Bulletti FM., et al. “Endometriosis: a century of unresolved pathogenesis - it’s time for decisive action”. Biomedical Journal of Scientific and Technical Research 5 (2024): BJSTR.MS.ID.009214.
  43. Bulletti C., et al. “Uterine contractility during menses in women with mild to moderate endometriosis”. Fertility and Sterility6 (2002): 1156-1161.

Carlo Bulletti., et al. “Endometriosis and Infertility: Medical Versus Surgical Approaches - A Systematic Review and Meta-Analysis”. EC Gynaecology  14.8 (2025): 01-14.

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