Does surgery for deep infiltrating bowel endometriosis improve fertility? A systematic review

Abstract

Introduction. Reduced fertility is a major concern in women with endometriosis. The influence of surgery of deep infiltrating endometriosis (DIE) affecting the bowel wall on fertility is controversial and the literature on this field is heterogeneous. In this review we addressed whether surgery for bowel DIE improves the spontaneous pregnancy rate, and the results of in vitro fertilization (IVF), and the potential risk of such surgery. Material and methods. We conducted a literature search including the terms "deep", "deep infiltrating", "bowel", rectovaginal", "endometriosis", "fertility", "infertility" and "IVF" in PubMed. Results. No randomized controlled studies were found. Other publications of relevance included four retrospective and three prospective observational studies. Moreover, one retrospective study compared results of IVF treatment with or without previous surgery for bowel DIE. All studies reported detailed data on surgical complications. The poor data quality precluded firm conclusions. The results indicate, however, the possibility that surgery for bowel DIE may improve the spontaneous pregnancy rate, and positive effects on IVF outcome cannot be excluded. Such surgery will be associated with risk of major complications. Conclusion. The lack of proper data precludes conclusions on the potential role for bowel DIE surgery to improve the spontaneous pregnancy rate and results of IVF treatment. Positive effects cannot be excluded, but the definite risk of major complications must be taken into account.

Pain and fertility outcomes of nerve‐sparing, full‐thickness disk or segmental bowel resection for deep infiltrating endometriosis—A prospective cohort study

“…There is increasing but still limited evidence that infertile women with advanced stage DIE do benefit from radical surgery regarding altered postsurgical spontaneous and IVF PRs . However, the situation is complex in this patient group because multiple additional influencing factors such as age, ovarian reserve, and the presence or absence of adenomyosis do influence postoperative fertility outcomes and must be taken into account in the light of the possible severe complications of radical surgery .…”

“…Deep infiltrating endometriosis (DIE) is defined as infiltrative growth of extrauterine endometrial glands and stroma extending below the peritoneal surface >5 mm . DIE affecting the colon and/or rectum has been associated with severe pain symptoms, altered digestive function, and decreased fertility, consequently leading to impaired quality of life in these patients. Medical treatment does offer a valuable therapeutic option in the majority of women affected with colorectal DIE .…”

“…In addition, spontaneous and in vitro fertilization (IVF) rates have been demonstrated as being decreased in women with advanced disease and colorectal endometriosis . These issues may, to a significant extent, be overcome by surgical removal of DIE lesions, which thereby offers an effective alternative treatment strategy to these patients . Several studies have demonstrated a significant drop in pain scores and amelioration of impaired sexual functioning in women following surgical resection of colorectal endometriosis .…”

“…Several studies have demonstrated a significant drop in pain scores and amelioration of impaired sexual functioning in women following surgical resection of colorectal endometriosis . Furthermore, there is increasing evidence demonstrating overall pregnancy rates (PR) ranging from 42% up to 80% in women with resected colorectal disease . There is an ongoing discussion on how to optimally resect bowel endometriosis.…”

Medical treatment in the management of deep endometriosis infiltrating the proximal rectum and sigmoid colon: a comprehensive literature review

“…However, several investigators observed substantial improvements of bowel symptoms during hormonal treatment (10)(11)(12)(13)(14). Disentangling the uncertainties of the role of medical therapy in women with infiltrating bowel endometriosis seems exceedingly important, as excisional procedures with opening of the bowel lumen are generally effective in relieving intestinal symptoms but are also associated with severe short-and long-term complications in about one of 10 patients (for example, intestinal leakage, anastomosis dehiscence, septic peritonitis, rectovaginal fistula formation, bowel anastomosis stenosis, iatrogenic neurologic bladder dysfunction with need for long periods of selfcatheterization, and postoperative constipation and de novo rectal dysfunction) (16)(17)(18)(19)(20)(21)(22)(23)(24)(25). The incidence of some complications is associated also with the distance between the lower margin of resection and the anal verge (9,26).…”