Surgery for Deep Endometriosis and Fertility Preservation: A Narrative Review

Abstract

Surgery for deep endometriosis may address pain, organ function, and reproductive goals, but these objectives are not equivalent. This critical narrative review examined the balance between reproductive outcomes, surgical extent, and functional consequences. Targeted PubMed searches were performed on October 15, 2026, together with consultation of official documents. Full texts informed the synthesis, which compared European, British, German-speaking countries’, and Canadian recommendations and identified studies shared across reviews and publications from the same cohort. Two meta-analyses comparing surgery with assisted reproduction as the initial approach shared six observational studies, showed high heterogeneity and very low certainty, and established neither superiority nor equivalence between strategies. An association between bowel resection and lower pregnancy rates in one meta-analysis does not demonstrate a causal disadvantage of the technique, given severity-related selection and heterogeneous comparators. For bowel function, differences in postoperative-only assessments diminished when changes from baseline were considered. The consulted guidelines support counselling, reproductive assessment, and consideration of ovarian surgery’s effects but use different development methods and classification systems; the European and Canadian guidelines do not support routine surgery for deep disease before assisted reproduction solely to increase live births. Findings do not establish a universal surgical technique for improving fertility. Counselling should distinguish symptom control, anatomical preservation, ovarian reserve, and live birth probability while retaining the uncertainty of available comparisons.