Endometriosis and fertility
Surgery helps modestly if you are already operating. Going looking is a different decision.
Endometriosis is found in about 44% of women labelled unexplained who undergo diagnostic laparoscopy, most of it minimal or mild. So the question of whether treating it helps is not a marginal one.
The best trial randomized 341 infertile women aged 20 to 39 with minimal or mild endometriosis, all of whom were already having a diagnostic laparoscopy, either to removal of the visible lesions or to the diagnostic look alone:
| Outcome over 36 weeks | Lesions removed | Diagnostic laparoscopy only |
|---|---|---|
| Pregnancy continuing past 20 weeks | 50 of 172 | 29 of 169 |
| Cumulative probability | 30.7% | 17.7% (P = 0.006) |
| Fetal loss among recognised pregnancies | 20.6% | 21.6% |
An absolute difference of about 13 percentage points, or roughly eight women operated on for one extra ongoing pregnancy. Note that both groups had surgery, so this isolates the effect of removing the lesions rather than the effect of operating at all.
The European guideline is unusually honest about the state of the evidence: it says that
based on existing evidence, no firm recommendations could be formulated on the most appropriate treatments, and it explicitly challenges laparoscopy and histology as the diagnostic gold standard.
If you have pain as well as infertility, the calculation changes, because surgery may be worth doing for the pain on its own terms. If your only complaint is difficulty conceiving, the case for going looking is much weaker. That distinction is the one worth having explicitly with your own doctor.