title: Surgery for endometriosis-associated infertility: do we exaggerate the magnitude of effect?
abstract: OBJECTIVE
  Surgery remains the mainstay in the diagnosis and management of endometriosis. The number of surgeries performed for endometriosis worldwide is ever increasing, however do we have evidence for improvement of infertility after the surgery and do we exaggerate the magnitude of effect of surgery when we counsel our patients? The management of patients who failed the surgery could be by repeat surgery or assisted reproduction. What evidence do we have for patients who fail assisted reproduction and what is their best chance for achieving pregnancy?
  
  
  METHODS
  In this study we reviewed the evidence-based practice pertaining to the outcome of surgery assisted infertility associated with endometriosis. Manuscripts published in PubMed and Science Direct as well as the bibliography cited in these articles were reviewed. Patients with peritoneal endometriosis with mild and severe disease were addressed separately. Patients who failed the primary surgery and managed by repeat or assisted reproduction technology were also evaluated. Patients who failed assisted reproduction and managed by surgery were also studied to determine of the best course of action.
  
  
  RESULTS
  In patients with minimal and mild pelvic endometriosis, excision or ablation of the peritoneal endometriosis increases the pregnancy rate. In women with severe endometriosis, controlled trials suggested an improvement of pregnancy rate. In women with ovarian endometrioma 4 cm or larger ovarian cystectomy increases the pregnancy rate, decreases the recurrence rate, but is associated with decrease in ovarian reserve. In patients who have failed the primary surgery, assisted reproduction appears to be significantly more effective than repeat surgery. In patients who failed assisted reproduction, the management remains to be extremely controversial. Surgery in expert hands might result in significant improvement in pregnancy rate.
  
  
  CONCLUSIONS
  In women with minimal and mild endometriosis, surgical excision or ablation of endometriosis is recommended as first line with doubling the pregnancy rate. In patients with moderate and severe endometriosis surgical excision also is recommended as first line. In patients who failed to conceive spontaneously after surgery, assisted reproduction is more effective than repeat surgery. Following surgery, the ovarian reserve may be reduced as determined by Anti Mullerian Hormone. The antral follicle count is not significantly reduced. In women with large endometriomas > 4 cm the ovarian endometrioma should be removed. In women who have failed assisted reproduction, further management remains controversial in the present time.
authors.affiliation: Division of reproductive medicine and infertility, Department of Obstetrics and Gynecology, University of South Alabama, Mobile, Alabama, U.S.A.
authors.forename: B
authors.initials: B
authors.lastname: Rizk
authors.affiliation: Division of reproductive medicine and infertility, Department of Obstetrics and Gynecology, University of South Alabama, Mobile, Alabama, U.S.A. ; Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia.
authors.forename: R
authors.initials: R
authors.lastname: Turki
authors.affiliation: Division of reproductive medicine and infertility, Department of Obstetrics and Gynecology, University of South Alabama, Mobile, Alabama, U.S.A. ; Department of Obstetrics and Gynecology, Tanta University, Egypt.
authors.forename: H
authors.initials: H
authors.lastname: Lotfy
authors.affiliation: Division of reproductive medicine and infertility, Department of Obstetrics and Gynecology, University of South Alabama, Mobile, Alabama, U.S.A.
authors.forename: S
authors.initials: S
authors.lastname: Ranganathan
authors.affiliation: Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia.
authors.forename: H
authors.initials: H
authors.lastname: Zahed
authors.affiliation: Division of reproductive medicine and infertility, Department of Obstetrics and Gynecology, University of South Alabama, Mobile, Alabama, U.S.A.
authors.forename: A R
authors.initials: AR
authors.lastname: Freeman
authors.affiliation: Division of reproductive medicine and infertility, Department of Obstetrics and Gynecology, University of South Alabama, Mobile, Alabama, U.S.A.
authors.forename: Z
authors.initials: Z
authors.lastname: Shilbayeh
authors.affiliation: IVF Michigan, Rochester Hills, Michigan, U.S.A.
authors.forename: M
authors.initials: M
authors.lastname: Sassy
authors.affiliation: LSU School of Medicine, New Orleans, Louisiana.
authors.forename: M
authors.initials: M
authors.lastname: Shalaby
authors.affiliation: Division of reproductive medicine and infertility, Department of Obstetrics and Gynecology, University of South Alabama, Mobile, Alabama, U.S.A. ; Department of Obstetrics and Gynecology, University of Indiana, Indianapolis, Indiana, U.S.A.
authors.forename: R
authors.initials: R
authors.lastname: Malik
keywords: Assisted reproductive technology; endometrioma; endometriosis; intrauterine insemination; ovarian; repeat surgery