Fertility outcomes after conservative versus radical surgery in moderate to severe endometriosis with deep endometriosis

OBJECTIVE: Does laparoscopic radical excision of deep endometriosis (DE) and enucleation of endometrioma improve fertility outcomes and reduce recurrence rates in patients with moderate to severe endometriosis? METHODS AND RESULTS: All patients (n = 77) with moderate to severe endometriosis and DE underwent either partial or radical excision as part of their treatment. Patients were divided into two groups. Group 1 (conservative treatment, n = 22) underwent laparoscopic enucleation of endometrioma and ablation of DE. Group 2 (radical excision, n = 55) underwent laparoscopic enucleation of endometrioma with radical excision of extra-ovarian endometriosis. Group 2 showed significantly higher surgical complexity, higher revised American Fertility Society classification scores, a more severe form of endometriosis, multiple endometriotic lesion sites, and longer surgical time. Group 2 also tended to have a higher pregnancy rate (84 % vs. 67 %, p = .56) and live birth rate (80 % vs. 67 %, p = .59). In stage IV endometriosis cases, Group 2 showed significantly reduced recurrence (9 % vs. 50 %, p = .04). Overall recurrence rates were not significantly different between groups (HR = 1.90, 95 % CI: 0.47-7.59, p = 0.37). Radical surgery was associated with significantly higher cumulative pregnancy rates and a shorter median time to pregnancy (38.7 vs. 49.5 months). Cox regression showed a 3.75-fold increased likelihood of pregnancy after radical surgery (HR = 3.75, 95 % CI: 1.25-11.29, p = 0.01). CONCLUSION: The group that underwent laparoscopic radical excision resulted in more complex surgeries and was associated with significantly improved fertility outcomes, while recurrence rates were comparable between radical and conservative surgery, particularly in Stage IV disease. Radical surgery is advisable to limit disease progression and ensure complete symptom resolution. Additionally, the laparoscopic radical excision group had a higher rate of natural conception, indicating benefits for fertility in patients with moderate to severe endometriosis with DE. This study also confirmed significantly higher cumulative pregnancy rates and a shorter median time to pregnancy, with a 3.75-fold increase in the likelihood of conception following radical excision of deep endometriosis. TRIAL REGISTRATION NUMBER: None.