A Practical Approach to Fertility Considerations in Endometriosis Surgery

Determining the role of surgery for endometriosis among those with related infertility or those with future fertility goals can be challenging. Endometriosis has a wide variety of clinical and pathologic presentations which makes it almost impossible to have a single approach for all patients and this is further reflected by the lack of high-quality evidence to guide decision making. In general, for patients with endometriosis-related infertility who wish to achieve pregnancy, ART is preferred over surgery. However, a personalized approach to care is necessary, and a thorough history, physical examination, and imaging will help inform the decision for surgery and counseling regarding the risks and benefits of surgery. The patient with significant pain, risk of malignancy, or disease resulting in organ obstruction or dysfunction is best managed with surgical care by an experienced team including consultation with a fertility specialist. Surgery should be considered cautiously among patients whereby fertility is a priority, given the risk of postoperative adhesions and damage to ovarian reserve. The classic surgical perspective that dictates mandatory radical excision of "all endometriosis" may be better replaced by goal directed surgical treatment of endometriosis in this population. If the goal is pregnancy in the future, then surgical care should enhance that outcome when possible.