Fertility after endometriosis surgery: a systematic review and meta-analysis comparison of primary versus multiple surgical interventions

Symptoms of endometriosis are often incompletely managed and recurrent surgeries are commonplace. The impact of re-operation on fertility remains unclear. This systematic review compares fertility outcomes in patients who underwent primary surgery versus re-operation for endometriosis. A systematic search of Embase, Medline, PubMed, and Web of Science was conducted, on publications between 2003 and 2023. Eligible studies included reproductive-aged women who underwent at least one surgery for endometriosis. Participants were divided into two groups: primary (one surgery) and re-operation (two or more surgeries). Outcomes included: rates of spontaneous pregnancy, live birth, miscarriage, pregnancy per embryo transfer (ET), and cumulative live birth. A meta-analysis was performed to calculate a combined estimate of the odds ratio (OR) across studies for selected outcomes. Seven retrospective cohort studies involving a total of 2101 participants met the inclusion criteria. The meta-analysis found that the odds of having spontaneous pregnancy were 2.1 times (95%CI, 1.5-2.8; P < 0.01) higher following a primary surgery compared to re-operation. The likelihood of having pregnancy per ET was 2.5 times (95% CI, 1.2---5.0; P = 0.01) higher following a primary surgery than with re-operation. Overall, for women attempting conception either naturally or via assisted reproductive technologies (ART), re-operation when compared to a single operation for endometriosis may negatively impact upon fertility and pregnancy outcomes, which has important implications for clinicians and patients when considering surgery.