inflammatory gynecologic condition with the presence of endometrial-like tissue outside the uterine cavity. It occurs in about 10% of women of reproductive age around the world and is known as one of the most frequent causes of chronic pelvic pain and infertility.¹ It has a significant physical, psychological, social and economic impact on impacted women and health systems.² Although it is common, its diagnosis is often delayed, as symptoms can be vague and mimic other pelvic problems.³

One of the most clinically important effects of endometriosis is infertility. Around 30-50% of women with endometriosis have a history of impaired fertility and up to half of women who seek evaluation for infertility have endometriosis.⁴ The association between endometriosis and infertility is complex, and includes anatomical distortion, pelvic adhesions, ovarian dysfunction, altered folliculogenesis, impaired oocyte quality, inflammatory changes in the peritoneal environment, progesterone resistance, and defective endometrial receptivity.⁵ These mechanisms can affect the processes of ovulation, fertilization, and development of the embryo, its implantation and the early maintenance of pregnancy.

The mechanisms underlying the pathogenesis of endometriosis are not fully known. The most popular theory is Sampson's retrograde menstruation hypothesis, which suggests viable endometrial cells reflux through the fallopian tubes and adhere to the pelvic surfaces.⁶ However, since retrograde menstruation is common in women who do not develop the disease, other mechanisms have been suggested, such as immune dysfunction, genetic susceptibility, epigenetic changes, involvement of stem cells, coelomic metaplasia, hormonal imbalance, oxidative stress, angiogenesis, and environmental factors.^7,8 All these make up a chronic inflammatory microenvironment with high levels of cytokines, prostaglandins, macrophages, and reactive oxygen species, which negatively impacts reproductive function.⁸

A number of biological mechanisms account for the decreased fertility of women with endometriosis. Chronic inflammation of the pelvic organs can result in dysfunction of the sperm, of the oocyte itself, of fertilization and either of embryo implantation.⁹ Moderate and severe disease may result in distortion of tubo-ovarian anatomy and interfere with the ova being collected by the fallopian tubes. Ovarian endometrioma can also impair fertility by decreasing normal ovarian tissue, changing the blood supply to the ovary, and creating an increased level of oxidant stress in the ovary. In women with minimal or mild endometriosis and no apparent anatomic defects, therefore, infertility can be a problem.

Endometriosis severity is usually defined by the revised American Society for Reproductive Medicine (rASRM) classification of the disease as minimal, mild, moderate and severe.¹⁰ This system is a standard approach to surgical reporting but does not have a strong correlation with symptom severity or reproductive outcome. Some women with minimal disease may be unable to conceive for a long time, while some women with advanced disease conceive spontaneously. Hence, nowadays, the initial emphasis on management is the individualized evaluation, taking into consideration age, ovarian reserve, reproductive aspirations, duration of infertility, pain symptoms, previous surgery, and associated infertility factors, not only on the stage of disease.

The management of endometriosis-associated infertile is still difficult. Medical therapies, including combined oral contraceptives, progestins, gonadotropin-releasing hormone (GnRH) agonists, antagonists, and aromatase inhibitors, all suppress pain levels, but have no beneficial effect on fertility during treatment because they inhibit ovulation.¹¹ For women of reproductive age who are trying to conceive, surgery and assisted reproductive technologies (ART) are the most important fertility preserving options.

Laparoscopic surgery is the recommended surgical option as it enables the diagnosis and treatment of endometriosis simultaneously, reduces the invasiveness of the surgery, and spares the patient from an abdominal incision. Surgical treatments involve the removal of peritoneal lesions or the ablation of these lesions, lysis of adhesions, restoration of normal pelvic structures, resection of deep infiltrating disease, and ovarian cystectomy in the case of endometrioma. Operative laparoscopy has been shown in randomized controlled trials to benefit women with mild to minimal endometriosis who have questionable spontaneous pregnancy rates when compared with diagnostic laparoscopy alone.¹²

Surgery's role in the management of endometriosis of the ovary is not well agreed upon. Cystectomy can improve the pelvic anatomy and decrease pain, in addition to making it easier to access the follicles during in vitro fertilization (IVF), but removing too much of the healthy ovarian cortex can decrease the ovarian reserve.¹³ Anti-Müllerian hormone (AMH) levels have been reported to decrease after surgery, especially bilateral (or repeat) ovarian surgery [13]. Thus, there is currently a careful patient selection and fertility-preserving surgical techniques recommended.¹⁴

Assisted reproductive technologies, especially IVF and intracytoplasmic sperm injection (ICSI), have significantly improved pregnancy outcomes for women with endometriosis-associated infertility, particularly in those with advanced disease, diminished ovarian reserve, tubal damage, or prolonged infertility.¹⁵ However, surgery may still be indicated before ART in selected cases, including symptomatic large endometriomas, severe pelvic pain, suspicion of malignancy, inaccessible follicles during oocyte retrieval, or extensive pelvic adhesions.

Randomized trials, systematic review, meta-analyses and international guidelines have built up knowledge and evidence over the last decade, which have further clarified the circumstances in which surgery is likely to offer a significant reproductive benefit and when ART should be favoured. However, there are significant controversies on the best timing of the surgery, treatment of recurrent disease, preservation of ovarian reserve, and the combination of surgery with assisted reproductive technologies.¹⁶ Thus, this review will focus on the indications and efficacy of surgery in endometriosis-related infertility, as well as the reproductive outcomes of surgery, its limitations, and its role in today's fertility treatment.

This study was a narrative review of the literature to assess surgical management of women with endometriosis-related infertility. A systematic search of the published literature was performed using four major electronic databases: PubMed/MEDLINE, Scopus, Web of Science, and the Cochrane Library. Studies published in English from January 2000 to April 2026 were searched, which included both the key and more recent evidence. A combination of Medical Subject Headings (MeSH) and free-text terms was used in the search strategy with the use of Boolean operators. These were the top search terms: Endometriosis, Infertility, Endometriosis-associated infertility, Laparoscopy, Surgical management, Excision, Ablation, Endometrioma, Ovarian cystectomy, Deep infiltrating endometriosis, Fertility outcomes, Spontaneous pregnancy, in vitro fertilization (IVF), Assisted reproductive technology (ART), and Reproductive surgery. Furthermore, relevant articles were manually searched from reference lists of identified studies to find additional eligible studies. Studies were included which evaluated the reproductive results of surgical treatment of endometriosis in women of childbearing age who were infertile. Randomized controlled trials, prospective and retrospective cohort studies, case-control studies, systematic review, meta-analysis, evidence-based clinical practice guidelines and consensus statements from internationally recognized organizations (European Society of Human Reproduction and Embryology (ESHRE), American Society for Reproductive Medicine (ASRM), European Society for Gynaecological Endoscopy (ESGE), National Institute for Health and Care Excellence (NICE)) were eligible for publication. Articles that studied only pain management without reporting fertility data, used animal studies, conference abstracts, editorials, letters to the editor, unpublished manuscripts, duplicate publications or articles with inadequate methodological quality or outcome data were excluded from the review. Duplicates and titles and abstracts were reviewed for relevance to the research objective. Full text articles that fulfilled the eligibility criteria were retrieved, and selected independently by predefined selection criteria. Studies on spontaneous pregnancy, live birth rates, clinical pregnancy rates after assisted reproductive technologies (ART), ovarian reserve parameters (anti-Müllerian hormone [AMH] and antral follicle count [AFC]), recurrence rates, postoperative complications, and overall reproductive outcome after laparoscopic surgery were emphasized. High-quality evidence, such as random controlled trials, systematic reviews, meta-analyses, and recent international guidelines was given priority. Details from each study were included as follows: the first author's name, year published, country of study, study design, sample size, patient characteristics, severity of endometriosis (where provided) by the revised American Society for Reproductive Medicine (rASRM) classification, type of surgical intervention performed, comparator group, duration of follow-up, measures used for fertility outcomes, and principle findings. Due to the significant heterogeneity in patient populations, severity of disease, surgical procedures, endpoints of fertility and length of follow-up, the collected evidence was pooled narratively. The results were critically evaluated to assess the effectiveness of the surgery in restoring fertility, the subset of patients for whom surgery may be beneficial, the possibility that surgery may affect the ovarian reserve, and to summarize what available evidence-based recommendations are for using surgery in conjunction with ART for the management of endometriosis-related infertility.

The literature search was conducted and 1,248 records were retrieved from the PubMed, Scopus, Web of Science and Cochrane Library. After removing 312 duplicate records, 936 titles and abstracts were screened for relevance. Of that number, 781 studies were excluded due to not assessing fertility outcomes after surgical procedures, non-human studies, and only studies about pain management. The remaining 155 full-text articles were screened for eligibility. Of these 48 studies that fulfilled the inclusion and exclusion criteria, 13 studies were randomized controlled trials, 16 were cohort studies, 11 were systematic reviews, 3 were meta-analyses, and 5 were international clinical guidelines.

All of the studies included in this analysis showed laparoscopic surgery resulted in better spontaneous pregnancy than diagnostic laparoscopy alone in women with minimal-to-mild (Stage I–II) endometriosis. Evidence for the moderate-to-severe group of patients (Stage III–IV) was more variable, with some reports that assisted reproductive technologies (ART) may offer better reproductive outcomes in some patients. Pelvic anatomy and pain relief were improved with surgical treatment of ovarian endometrioma, however the risk existed of compromising ovarian reserve, especially if the surgeries were bilateral and/or repeat cystectomy.

Table 1. Characteristics of Included Studies

Figure 1. PRISMA Flow Diagram of Study Selection

The fertility outcomes were different depending on the severity of the disease, age of the patient, ovarian reserve and previous treatment time for infertility. For women with stage I–II endometriosis, those who had the laparoscopy procedure for removal or destruction of the endometriosis had greater spontaneous conception rates. However, women in Stage III–IV disease typically had to undergo surgery and ART to achieve optimal pregnancy outcome.

Table 2. Summary of Fertility Outcomes Following Surgical Management

One of the most controversial topics was the treatment of ovarian endometriomas. Most studies indicated that there was a reduced recurrence rate and improved spontaneous conception with laparoscopic cystectomy than with drainage alone or coagulation. Other studies, however, showed a measurable decrease in ovarian reserve after surgery, evidenced by a decrease of the serum anti-Müllerian hormone (AMH) levels postpartum.

Figure 2. Reported Benefits and Risks of Surgical Management

Different surgical procedures were compared and showed that the laparoscopic removal of the lesions generally resulted in a better rate of fertility compared with the removal of the lesions alone. Adhesiolysis resulted in the restoration of the normal relations between the tubes and the ovary and thus made it easier for a natural conception to take place.

Table 3. Comparison of Common Surgical Procedures

The individual treatment planning was a key principle highlighted in international clinical guidelines. Surgery was recommended mostly for women with either minimal-to-mild disease, or symptomatic endometriomas, severe pelvic pain, distorted pelvic anatomy, and/or lesions interfering with IVF oocyte retrieval. Early referral for ART was generally recommended over repeated surgery for women older than 35 years, those with diminished ovarian reserve or long-standing infertile women or women with recurrent endometriosis.

Figure 3. Clinical Decision Pathway for Endometriosis-Related Infertility

Based on the collective evidence, laparoscopy continues to be a good fertility-enhancing surgical procedure for the well-targeted woman with endometriosis-related infertility, especially when the disease is minimal to mild. Women with advanced disease, very limited ovarian reserve, recurrent endometriosis or advanced reproductive age have generally better reproductive outcomes with personalized combination of surgery and ART. Patient selection and the use of care to preserve fertility during surgery continue to be important to maximize reproductive outcomes with minimal impact on ovarian reserve.

This review will assess the existing evidence on the value of surgery for women with endometriosis who are trying to conceive. The results show that laparoscopy is a significant therapeutic option for well-selected patients, especially those with or without any pain symptoms from ovarian endometriomas and with minimal-to-mild endometriosis and/or abnormal pelvic anatomy. However, it can be affected by a number of factors such as the severity of the disease, patient age, ovarian reserve, length of infertility and history of previous surgeries. The evidence also indicates that surgery has the potential to greatly improve spontaneous pregnancy rates in selected women; however, in women with advanced disease or limited ovarian reserve, assisted reproductive technologies (ART) may yield better cumulative pregnancy outcomes.

This review reveals one of the main findings is that the surgical removal of endometriotic lesions laparoscopically or by ablation improves spontaneous pregnancy rates among women with stage I–II disease (minimal to mild). Re-establishment of normal pelvic anatomy, removal of inflammatory implants, and reduction of the inflammatory environment within the peritoneal cavity are suggested as the major mechanisms involved in the improvement of fertility post-surgery. Surgical treatment in appropriately selected infertile women with early-stage disease was supported by a recent network meta-analysis by Hodgson et al. which showed that the operative laparoscopy group had a higher natural conception rate than the diagnostic laparoscopy group.¹⁷ Likewise, Leonardi et al. have found that surgery offers significant reproductive benefits when tailored to specific patients and not administered as a universal treatment to all women with endometriosis-related infertility.¹⁸

Although these are promising results, the advantages of surgery seem to be less consistent for women who have moderate to severe endometriosis. As the disease advances, there are often extensive adhesions in the pelvis, ovarian endometriomas, deep infiltrating lesions and irreversible damage to reproductive anatomy. Even if surgery restores normal tubo-ovarian relationships and the pain is cured, the spontaneous pregnancy rates will be less than those of women with early-stage disease. Many international experts have called for the early referral to IVF instead of repeated conservative surgery for women with endometriosis at advanced age, advanced maternal age and/or prolonged infertility.¹⁹ This customized method decreases the number of unnecessary delays in pregancy while at the same time reducing repeated operative procedures.

Treatment of ovarian endometriomas is one of the most controversial issues in fertility treatments. Based on the available literature surveyed in this review, laparoscopy in cystectomy has several clinical advantages such as better visualization of the retrieval of the oocytes, decreased disease recurrence, restoration of the ovarian anatomy, and relief of pain symptoms. However, current evidence shows that ovarian surgery can have a negative impact on ovarian reserve as a result of unintentional removal of normal ovarian cortex and heat damage during hemostasis. Deckers et al. showed that the ovarian reserve was reduced more following electrocoagulation of the endometrioma cyst during surgery than following non-thermal methods of hemostasis.²⁰ Similarly, Nankali et al. found that AMH levels significantly decreased in the postoperative period after both unilateral and bilateral laparoscopic surgery, with greater decreases after bilateral surgery.²¹ These results highlight the need for the preservation of fertility surgery techniques and patient selection prior to ovarian surgery.

Another significant finding from the reviewed literature is the role of the Endometriosis Fertility Index (EFI) in clinically predicting reproductive outcomes following surgery. The EFI takes into account patient age, period of infertility, previous pregnancy history, the state of the Fallopian tubes, the condition of the ovary and surgical findings to estimate the probability of spontaneous pregnancy after surgery. In a systematic review and metaanalysis, Vesali et al. showed that there was a consistent correlation between high EFI and high natural pregnancy rates after surgical treatment, indicating that EFI is a useful tool to use in the counselling of patients about their post-surgical possibilities for natural pregnancy.²² The use of EFI in routine clinical practice could help in optimizing individualized treatment planning and help the clinician decide whether the patient needs surgery or whether early ART should be recommended.

Surgery is playing a more significant role in modern-day fertility care, especially when combined with other assisted reproductive techniques. IVF can overcome many of the causes of endometriosis infertility, such as poor functioning of the fallopian tubes and changes in pelvic structure. The evidence reviewed suggests that regular surgical intervention prior to IVF is not always a good thing. Rather, surgery should only be performed in carefully selected patients, including those with large endometriomas with symptoms, those with suspicion of malignancy, severe pelvic pain, recurrent infection, or lesions that affect the ability to retrieve oocytes. Lee et al. reported that individualized clinical decision making, which takes into account patient's age and ovarian reserve, disease severity and previous treatment history, results in better reproductive outcomes than the standardized treatment algorithms.²³ Likewise, Muzii et al. suggested that IVF should be considered as the first-line treatment for women with advanced disease, recurrent endometriosis and/or low ovarian reserve, while surgery should be used in specific clinical situations.²⁴

The present review also emphasizes the importance of fertility preservation in women who need surgical treatment. Previous ovarian surgery has consistently been linked with a progressive loss of ovarian reserve and of the ovarian reproductive potential. As a result, emphasis has shifted to the development of fertility-saving procedures, such as the cryopreservation of oocytes and embryos, preservation of ovarian tissue and careful microsurgical applications and reducing bipolar coagulation during surgery. Before surgery, it is important to discuss fertility preservation before surgery, especially in women who have desired future pregnancy or reduced ovarian reserve or have bilateral endometriomas, as emphasized by the systematic review performed by Calagna et al. .²⁵ These recommendations are being incorporated into international clinical practice guidelines and are a significant progress in patient-centered reproductive health care.

All the evidence is in favor of surgery in the carefully selected patient, but there are some limitations. There is significant variability in the published literature in terms of patient selection, disease classification, surgical experience, surgical technique, assessment of fertility outcomes and follow-up duration. The number of study subjects is often small and evidence is limited in many studies, which are largely retrospective. Moreover, endometriosis can recur after conservative surgery and can be a major clinical problem that can have adverse long-term reproductive outcomes. The recent network meta-analysis of Hodgson et al. underscored the requirement for further high-quality RCTs to determine evidence-based management algorithms for various groups of patients, when considering surgery alone, ART alone and combined approaches.²⁶

Based on the available evidence, laparoscopic surgery remains a valuable treatment option for endometriosis associated infertility especially in women with mild endometriosis and favorable reproductive characteristics. The treatment options should be personalized, however, based on the disease severity, previous surgery, patient age and reproductive objectives, as well as ovarian reserve. The ideal timing of surgical procedures and the use of assisted reproductive technologies that preserve the woman's potential for pregnancy represents the highest potential for maximizing pregnancy rates and minimizing any negative impact on her ovarian function.

Endometriosis is still a major cause of female infertility, and its harmful effects are the result of a complex process involving chronic inflammation, the distortion of pelvic anatomy, dysfunction of the ovary, loss of endometrial receptivity, and disrupted reproductive physiology. Based on the conclusions of this review, surgery has a significant role to play in the improvement of fertility outcome in suitable cases. Laparoscopic endo-excision or ablation of endometriotic lesions has been shown to have considerable benefit in improving spontaneous pregnancy rates in women with little-to-mild endometriosis by improving pelvic anatomy and decreasing the inflammatory burden. Surgical removal can also offer symptom relief and enable women with ovarian endometrioma and some cases of deep infiltrating endometriosis to plan for their reproduction. But not all women who have endometriosis related infertility will benefit from surgery. For older women, those with low ovarian reserve, recurrent disease or severe endometriosis, multiple surgeries can negatively affect ovarian reserve without providing a significant benefit to fertility. During such times, assisted reproductive technologies, such as in vitro fertilization (IVF), may yield better total rates of pregnancy and births. Hence, the treatment should be tailored according to patient age, duration of infertility, ovarian reserve, severity of the disease, surgery history, symptoms and patient's reproductive aims. There is current evidence that a multidisciplinary and patient centred way of working with integrating surgery and assisted reproductive technologies rather than competing therapies. Surgical techniques that preserve fertility, careful selection of patients, and the application of predictive tools such as the Endometriosis Fertility Index (EFI) can help to optimize clinical decision making and avoid unnecessary surgical risks. Further well-performed multicenter randomized controlled trial with standardized fertility outcome measures and long-term follow-up would help clarify the optimal timing of surgery, to improve patient selection criteria and to establish the most effective surgery/assisted reproductive interventions combination. In conclusion, the individualized management of women with endometriosis-related infertility based on their ovarian reserve and pregnancy potential should be the main principle for maximizing reproductive success without compromising ovarian function. Recommendations The treatment of endometriosis-related infertility should be tailored on a case-by-case basis, and be multidisciplinary and evidence-based, taking into account patient age, ovarian reserve, disease severity, duration of infertility, symptom burden, and reproductive goals. Laparoscopic surgery should be indicated in women with a small or mild amount of endometriosis, symptomatic ovarian endometria, pelvic adhesions and/or abnormal pelvic anatomy in which surgical correction is likely to increase spontaneous conception. If at all possible, repeated ovarian surgery should be avoided as it can have a negative effect on ovarian function, especially if a woman has bilateral endometriomas or low ovarian reserve. For women over age 35, with prolonged (longer than 12 months) infertility, advanced stage disease, recurrent endometriosis, or diminished ovarian reserve, early referral for assisted reproductive technologies (ART) is recommended to maximize pregnancy outcomes and minimize treatment delay. Routinely used, careful fertility-preserving surgical procedures, such as limited thermal coagulation and careful handling of tissues should be used to preserve ovarian function. Standardized and validated prognostic factors like the Endometriosis Fertility Index (EFI) should be used in clinical decision making and to advise patients about their postoperative fertility prospects. Additionally, the multidisciplinary approach with gynecologists, reproductive endocrinologists, fertility specialists, radiologists and fertility counselors should be encouraged to create personalized treatment plans. Finally, long-term prospective and comparative studies of surgery, ART and combined treatment methods in endometriosis-associated infertility are needed in the future in a multicenter randomized controlled trial with standardized outcome measures for solid evidence and further optimization of clinical guidelines for the best treatment of endometriosis-associated infertility. Authors’ Contributions Dr. Nasreen Rehmatullah conceived and designed the study, supervised the overall research process, interpreted the findings, critically revised the manuscript for important intellectual content, and provided overall guidance throughout the study. Dr. Iqra Mushtaq contributed to the literature review, data collection, evidence synthesis, manuscript drafting, and interpretation of the findings. Dr. Noorehira participated in the literature search, data extraction, critical appraisal of the included studies, manuscript writing, and revision of the scientific content. Dr. Haleema Abbas contributed to the preparation of the methodology and results sections, development of the tables and figures, interpretation of the findings, and manuscript editing. Dr. Wajeeha Abbas contributed to the study methodology, literature review, data interpretation, reference management, and critical revision of the manuscript. Dr. Asma Khalil contributed to the critical review of the manuscript, validation of the scientific content, final editing, and coordination of the manuscript preparation and ensured the overall quality of the work. All authors made substantial intellectual contributions to the study, reviewed and approved the final version of the manuscript, and agree to be accountable for all aspects of the work, ensuring the accuracy and integrity of the research.

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