IVF/ICSI or surgery as first approach for the treatment of infertility associated with ovarian and deep infiltrating endometriosis? A systematic review and meta-analysis

This systematic review and meta-analysis (CRD42024588171) compared the effectiveness of surgery followed by IVF/intracytoplasmic sperm injection (IVF/ICSI) with direct IVF/ICSI (i.e. without previous surgery) on the reproductive outcomes of infertile women with ovarian endometriomas (OMA) and deep infiltrating endometriosis (DIE), analysing 22 studies with 3590 participants. Surgery followed by IVF/ICSI did not improve the live birth rate significantly in patients with OMA (OR 0.89, 95% CI 0.68–1.16) or DIE (OR 1.82, 95% CI 0.70–4.77). The clinical pregnancy rate was also unaffected by surgery (OMA: OR 1.13, 95% CI 0.80–1.59; DIE: OR 1.28, 95% CI 0.71–2.31). The pregnancy loss rate remained comparable between the surgical and non-surgical groups. In the OMA subgroup, surgery reduced the concentration of anti-Müllerian hormone (mean difference -0.57, 95% CI -1.02 to -0.12) and number of retrieved oocytes (mean difference -1.24, 95% CI -1.70 to -0.77) significantly. These findings highlight the importance of careful consideration of the ovarian reserve when opting for surgical intervention. Consequently, IVF/ICSI should be prioritized as the initial treatment for infertility in patients with endometriosis, reserving surgery for symptom management, patient-specific factors, or clearly defined clinical indications to optimize reproductive outcomes and patient safety. However, the very low certainty of evidence, the available study designs, and their inherent limitations warrant caution when interpreting such findings.