Design:

Systematic review and meta-analysis.

Setting: Tertiary medical center.

Patients or Participants: 120 reviewed abstracts.

Interventions: Following PRISMA guidelines, MEDLINE, Embase, and Cochrane databases were searched for studies investigating the effects of surgical treatments on fertility in patients with moderate to severe endometriosis.

Comprehensive meta-analysis software was used for meta-analysis and heterogeneity assessment. The risk of bias in non-randomized studies was evaluated using the Newcastle-Ottawa Scale (NOS).

Measurements and Main Results:

Out of 120 reviewed abstracts, we screened 86 full-text articles. Five studies comparing surgical treatment to IVF met the inclusion criteria for the meta-analysis. Although the results of the meta-analysis suggested a higher likelihood of pregnancy post-surgery compared to IVF alone, statistical significance was not achieved (RR, 1.34 [95% CI, 0.91-1.57, p= 0.24). High heterogeneity among studies was observed. Four studies preferred surgery pre-IVF, while one indicated no benefit and had the lowest NOS score.

In a separate analysis including 49 observational studies, spontaneous pregnancy rate post-surgery was compared with IVF treatment outcomes. The event rate for spontaneous pregnancies after surgery was 0.315 (95% CI, 0.274-0.358), whereas the event rate for IVF pregnancies after surgery was 0.264 (95% CI, 0.234-0.296).

Conclusion:

While a meta-analysis of comparative studies did not reveal statistically significant differences in pregnancy rates between surgical treatment and IVF, a meta-analysis of observational studies demonstrated higher rates of spontaneous pregnancies after surgery compared to pregnancies after IVF. Randomized Controlled Studies are needed to better understand the effect of surgery on spontaneous and IVF conception for women with advanced stage endometriosis.