Scientific studies show that laparoscopic treatment of endometriosis offers women higher chances of conception and improved fertility.
One in three women becomes pregnant within the first nine months after the laparoscopic treatment of endometriosis. In contrast, the number of women who conceive without surgical management of their gynecological condition is significantly lower.
For this reason, gynecologists recommend that endometriosis be treated before pregnancy.
What is endometriosis?
Endometriosis is a very common condition in which cells from the endometrium (the inner lining of the uterus) grow in other areas, usually outside the uterus. It is not an infection, nor is it any form of malignancy.
The most common sites where endometriosis appears are:
- the peritoneum
- the ovaries
- the fallopian tubes
- the bladder
In rare cases, endometriosis can develop in the intestine or even in other organs (lungs, kidneys).
Symptoms
The main symptoms of endometriosis include abdominal or pelvic pain, pain during or after sexual intercourse, and painful periods (dysmenorrhea). Heavy bleeding and painful urination during menstruation may also occur. Some women with endometriosis may have no symptoms at all.
Diagnosis and treatment
Clinical examination can only provide indications of the presence of endometriosis. Endometriosis can be diagnosed only through laparoscopy, followed by histological examination of the tissue. In addition, the extent of the condition can be determined, and the disease can be treated surgically at the same time. Other examinations, such as MRI or transrectal ultrasound, may also be performed to identify endometriosis lesions with greater accuracy.
Infertility
One in two women with infertility problems is diagnosed with endometriosis. A woman with mild endometriosis has a 2–4.5% chance per month of conceiving naturally (while in fertile couples this rate is 15–20%). However, if a woman has endometriosis, it does not necessarily mean she will experience infertility.
It is not entirely clear how endometriosis affects fertility, especially in women who do not have adhesions. The prevailing theory is that endometriosis causes small but significant changes in the pelvis: inflammation, alterations in the immune system, hormonal imbalances, changes in the function of the fallopian tubes, or problems with fertilization and embryo implantation. In more severe cases of endometriosis, adhesions play a significant role and can cause infertility, as they may prevent the release of the egg or the entry of sperm into the fallopian tube. Adhesions may also affect the mobility of the fallopian tube and its ability to capture the egg during ovulation.
When laparoscopy is recommended for a woman who wants a child
The decision is not the same for everyone. Surgery mainly has a role when:
- pain is not controlled with medication and affects daily life,
- there is a large endometrioma (chocolate cyst) or one with suspicious features,
- tests show adhesions that distort the fallopian tubes,
- the woman is young, has a good ovarian reserve and wants to conceive naturally.
On the other hand, over the age of 35 to 38, with low AMH, when there is also a male factor, or when ovarian surgery has already been done, the preferred option is often to go straight to in vitro fertilization. Every repeat operation on the ovary can reduce the egg reserve.
What happens during the procedure
With laparoscopy the surgeon removes or destroys the lesions, frees adhesions and restores the anatomy of the pelvis. With endometriomas, the cyst wall is removed while preserving as much healthy ovarian tissue as possible. At the same time, tubal patency is checked by injecting dye. Tissue samples are sent for pathology examination, which confirms the diagnosis.
Excision or ablation of lesions: the surgical techniques
Superficial lesions on the peritoneum are treated in two main ways. In excision the surgeon cuts out and removes the lesion together with a thin margin of healthy tissue, so there is material for pathology examination. In ablation the lesion is destroyed on the spot with diathermy, laser or plasma energy. For mild forms, the European ESHRE guidelines state that operative laparoscopy, with excision or ablation of the lesions, increases the chances of pregnancy compared with diagnostic laparoscopy alone. The choice between the two techniques depends on the depth and location of the lesion. Near sensitive organs, such as the ureter or bowel, excision gives more control.
At the same time, adhesions that tie the ovaries or fallopian tubes to nearby organs are released. The goal is simple: the tubes should move freely and be able to “catch” the egg at the moment of ovulation.
Endometrioma: cystectomy, drainage or waiting?
A chocolate cyst is the most delicate surgical issue in a woman who wants a child, because it sits inside the tissue that contains the eggs.
- Cystectomy: the entire cyst wall is removed. Compared with simple drainage and cauterization, studies show fewer recurrences and better pain control. The trade-off is a possible reduction in ovarian reserve, which is why the technique must be delicate, with minimal use of thermal energy.
- Drainage and cauterization: the contents are emptied and the inner wall is cauterized. It may spare more healthy tissue, but recurrences are more common.
- Combined techniques: partial removal of the wall and destruction of the rest with energy, when the cyst is close to the hilum of the ovary.
- No surgery: if the woman does not have significant pain and the next step is IVF anyway, guidelines do not recommend routine removal of an endometrioma just to improve birth rates. Surgery before IVF mainly has a role when the cyst blocks access to the follicles during egg retrieval, when the pain is severe or when the ultrasound appearance is not typical.
With bilateral or recurrent endometriomas, doctors often discuss egg freezing before surgery as a backup.
Deep infiltrating endometriosis: when surgery involves several organs
In the deep form, lesions penetrate more than five millimeters below the peritoneum and may involve the uterosacral ligaments, the rectovaginal septum, the bowel, the bladder or the ureters. Here surgery is on a different scale:
- Detailed mapping is needed beforehand, with specialized ultrasound or MRI.
- Ideally, the operation is done by a team with a gynecologist, a colorectal surgeon and a urologist, at an experienced center.
- The magnification and dexterity of robotic surgery help in selected cases.
- The risks are greater than with simple laparoscopy and include injury to the bowel or ureter and problems with urination.
Deep surgery is done mainly for pain and for symptoms from the affected organs. Whether it improves the chances of pregnancy on its own has not been adequately established, so in women without severe pain who want a child, the decision is weighed very carefully.
Laparoscopy findings and the Endometriosis Fertility Index
Laparoscopy does not only treat. It also provides information that no ultrasound can give with the same accuracy. The surgeon records the extent of the disease using the classic four-stage classification, but for fertility, particular value lies in the Endometriosis Fertility Index (EFI).
The EFI combines age, years of infertility, whether there has been a previous pregnancy, the severity of the disease and, above all, how well the tubes, fimbriae and ovaries function at the end of surgery. The result is a score that estimates the chance of natural conception over the next few years.
- High score: it is reasonable to allow time for natural conception, with or without simple assistance.
- Low score: waiting costs valuable time, and the next step is usually to go directly to IVF.
Ask your surgeon to include the EFI details in the operative report. They will be very useful to the doctor who follows you afterward.
Preparing for laparoscopy for endometriosis
- Mapping the disease: specialized transvaginal ultrasound and, where needed, MRI, so that it is known in advance whether there is deep infiltration.
- Assessing ovarian reserve: AMH and an ultrasound follicle count, especially if surgery on the ovaries is planned.
- Partner's semen analysis: if there is a severe male factor, the strategy changes.
- Bowel preparation: only when surgery near or on the bowel is expected.
- Consent covering different scenarios: discuss beforehand what will happen if more disease is found than expected, so the surgeon knows how far to go.
Hormone therapy around surgery: when yes and when no
Many women ask whether they should take medication before or after surgery. When the goal is pregnancy, the answer is usually no. Hormonal suppression before laparoscopy does not improve fertility. And suppression after surgery simply delays trying to conceive, without increasing the chances of natural conception. The picture changes when you will not start trying right away, for example because you want to wait: then treatment after surgery helps reduce the risk of recurrence until it is time for a baby.
When you have already had surgery for endometriosis
Many women come to the fertility discussion having already had one or more operations. In that case the balance changes. Adhesions from previous surgery make a new operation more difficult, and every repeat operation on the ovaries takes away a little more of the reserve. That is why, without severe pain or a new finding that needs investigation, a second laparoscopy is rarely the best route to pregnancy. Bring the reports of your previous operations and the pathology results to your appointment. They are invaluable for planning.
What surgery can and cannot offer
- It can: confirm the diagnosis, reduce pain, restore anatomy and improve the chances of natural conception in selected women.
- It cannot: correct egg quality, reverse age or guarantee that the disease will not come back.
- It should not: be repeated lightly. A second operation for infertility is less effective than the first and puts more strain on the ovaries.
After surgery: when to start trying
The first postoperative visit is when everything comes together: the findings, the pathology results and the plan for the coming months.
You go home the same day or the next day, and you are fully back to your daily routine within one to two weeks. The first 6 to 12 months are considered the most favorable window for conception, so you start trying as soon as your doctor allows, without delay. If pregnancy does not occur in this period, the next step is discussed, usually intrauterine insemination (IUI) or IVF.
To learn how the disease affects conception overall, read our guide Endometriosis and Fertility.
For a personalized assessment of your case, book an appointment with Dr. Panagiotis Polyzos at his office in Athens or Volos.
Frequently Asked Questions
Does laparoscopy improve the chances of pregnancy with endometriosis?
In mild and moderate disease, removing the lesions increases the chances of natural conception. In severe endometriosis it restores the anatomy, but IVF is often needed as well.
How soon can I try for a baby after surgery?
Usually from the first or second cycle after surgery, as long as your doctor allows it. The first twelve months are the most fertile period.
Does removing an endometrioma affect ovarian reserve?
It can reduce it, especially with surgery on both ovaries or repeat operations. That is why AMH is measured before surgery and, where needed, egg freezing is discussed.
Can endometriosis come back?
Yes, the disease comes back in a significant percentage of women over the following years. This is one more reason not to delay trying to conceive after surgery.
Surgery or IVF first?
It depends on age, pain, ovarian reserve, the fallopian tubes and the semen analysis. There is no single right answer for everyone, and the decision is made after a full evaluation.
Should I take hormone therapy after surgery if I want a child?
No, if you plan to start trying right away. Hormonal suppression after laparoscopy does not increase the chances of natural conception and simply delays trying. It has a role when pregnancy will be postponed for a long time.
How long does laparoscopy for endometriosis take?
From about an hour for mild disease to several hours for deep infiltrating endometriosis involving the bowel or bladder. The duration depends on the extent of the lesions and adhesions.
Will I need bowel surgery?
Only if there is deep endometriosis infiltrating the bowel wall, which is usually seen in advance on specialized ultrasound or MRI. In that case the operation is planned together with a colorectal surgeon.
What is the EFI score my surgeon mentions?
It is the Endometriosis Fertility Index, a score calculated at the end of laparoscopy based on age, history and the function of the tubes and ovaries. It estimates the chance of natural conception and helps decide whether to allow time or move on to IVF.
