Pregnancy Rates After Surgical Resection of Deep Infiltrating Endometriosis - A Systematic Review and Meta-Analysis

Study Objective Assess pregnancy rates after surgery for deep infiltrating endometriosis (DIE) in infertile patients, and in women without proven infertility, and whether ART was necessary to achieve pregnancy. Design meta-analysis. Setting N/A. Patients or Participants Electronic-based search performed on Pubmed, Embase, Scopus, Web of Science, and Cochrane Database. Studies including both surgical resection of DIE (>5mm depth confirmed on pathology) and pregnancy rates in the last 10 years were reviewed. Patients with ovarian involvement only were excluded. Interventions Meta-analysis was applied to calculate pooled pregnancy rates using random-effects model with inverse-variance weighting. 95% confidence intervals (95% CIs) calculated using Agresti-Coull method. Studies with extreme heterogeneity were excluded. Measurements and Main Results 32 studies were included (1,110 patients). DIE locations included intestinal tract, genitourinary tract, and other non-visceral locations. Patients with preoperative infertility undergoing surgery for DIE (n=758) were analyzed separately. The pooled pregnancy rate in 1,100 patients who underwent surgical resection of DIE was 53.7% (95% CI 47.7-59.5%): spontaneous in 36.5% (95% CI 30.9-42.6%) and with ART in 23.7% (95% CI 17.6-31.1%). The live birth rate for all pregnancies was 47.1% (95% CI 40-54.3%). Follow up time ranged from 12-96 months and mean age was 33.31 years. There were 17 studies that reported pregnancy rates in patients with preoperative infertility of ≥ 1 year. Overall pregnancy rate after surgery was 44.6% (95% CI 39.3 – 50.0%): 30.1% (95% CI 24.8-35.8%) were pregnant spontaneously and 21.6% (95% CI 14.2 – 31.4%) with the use of ART. Live birth rate was 41.9% (95% CI 35.2-48.9%). Mean age in this group was 32.41 years. Conclusion Surgical resection alone of DIE aids in both symptom resolution and ability to spontaneously conceive. About half of patients undergoing surgical resection achieve spontaneous pregnancy. Endometriosis is a common cause of infertility, since 44.6% of infertile patients achieved pregnancy following surgical resection of DIE, and most those pregnancies were spontaneous.