Woman with severe endometriosis who are hoping to get pregnant typically face of a choice of surgery to remove deep lesions prior to in vitro fertilization (IVF). But in the absence of rigorous studies comparing surgery followed by IVF to fertility treatments alone, neither approach is clearly favored — leaving women and their physicians in a difficult position.

In the editorial “Swimming Against the Stream: is Surgery Worthwhile in Women with Deep Infiltrating Endometriosis and Pregnancy Intention?”, published in The Journal of Minimally Invasive Gynecology, investigators at Rouen University Hospital’s endometriosis center, in France, reviewed what is known about this issue, and offered their thoughts on it.

They note, citing their center’s database, that “conservative surgery” in younger women with severe endometriosis “results in high postoperative pregnancy rates, the majority of which are the result of spontaneous conception, as well as a low complication rate.” In contrast, delays in such surgery based on “a fragile scientific basis” supporting contraception first carry risks.

The European Society of Human Reproduction and Embryology (ESHRE) compiled a series of recommendations in 2013, that were reviewed by specialists in an attempt to improve endometriosis management and patient care.

In a clinical setting, women with fertility problems related to their disease are often offered a choice between trying to become pregnant using assisted reproductive techniques (ART),  versus symptom improvement by surgery. This decision process implies that it is not possible to achieve both goals easily, the researchers note.

“Young women fearful of never being able to conceive might choose pregnancy as first priority,” they wrote, despite “painful symptoms related to deep infiltrating intestinal endometriosis and is therefore offered first-line IVF treatment. In the best conditions, she will benefit from IVF early in treatment. When treatment fails, which statistically occurs in more than two-thirds of cases, a second IVF cycle will be scheduled after a few months.”

Previous studies noted that delaying surgery in favor of fertility treatments can lead to disease progression and severe complications, such as bowel stenosis (narrowing). The researchers think these cases may be under-evaluated in the literature.

Surgery for deep infiltrating endometriosis can lead to severe post-operative complications, although greater specialization among surgeons and advanced surgical techniques have reduced their incidence. Laparoscopic surgery, which can be performed in more than 90% of the cases, the study notes, can significantly reduce surgery-associated risks, and allows spontaneous conception. Indeed, the researchers observed that 65% of patients with colorectal endometriosis and ovarian endometriomas who underwent surgical treatment before fertility therapies were able to conceive, and most of these pregnancies were “spontaneous.”

“The low risk of severe postoperative complications should be weighed against the positive results in terms of postoperative fertility,” they wrote.

According to the authors, endometriosis management cannot follow rigid rules, and should take into account several factors:

• severity of the infiltrations
• risk of disease evolution
• time until menopause as an indication of disease recurrence
• ovarian reserve
• tubal permeability restoration
• spermatic parameters of the spouse
• symptom severity

“The aim of this editorial is not to plead for first-line surgery in all women with deep endometriosis and pregnancy intention. We defend the principles of conservative surgery to reduce the risk of postoperative complications and functional sequelae,” they wrote.

And, they added, “delay in surgical management reduces the feasibility of conservative surgery, particularly in diseases that evolve and result in bowel obstruction, ureteral stenosis, or irreversible renal atrophy. When this delay is the result of a questionable management strategy for infertility based on a fragile scientific basis, the questioning of such a strategy is not only a right, but rather a duty.”