The effect of second-line surgery on reproductive performance of women with recurrent endometriosis: a systematic review.

Estimates of endometriosis recurrence after primary surgery are around 10% per annum during the first postoperative quinquennium. The aim of this study was to define the effect of reoperation in women seeking conception. A MEDLINE and PubMed search was conducted to identify English language studies published in the last 30 years evaluating reproductive performance after second-line surgery. Repeat surgery for recurrent endometriosis and identification of women seeking pregnancy were selected. Two authors abstracted data on standardized forms. The initial literature screening yielded 41 citations, but 19 were excluded because no data on reoperation were described, seven as no original figures were included, three because analyses were performed on the same cohort, and one because extremely skewed data were reported. A total of 313 patients who sought pregnancy after repetitive surgery for recurrent endometriosis were found, 139 in six non-comparative studies, and 174 in five retrospective comparative studies. Overall, pregnancy was achieved in 81 women (26%; 95% confidence interval (CI), 21-31%), without significant difference between the laparotomy (27%) and laparoscopy (25%) approach. Three studies compared pregnancy rate after second-line (28/124; 23%) and primary surgery (236/577; 41%; common odds ratio (OR), 0.44; 95% CI, 0.28-0.68%), and two compared the probability of conception after in-vitro fertilization (IVF) (14/27; 30%) and repetitive surgery (10/50; 20%; common OR, 1.51; 95% CI, 0.58-3.91%). Conclusions. The probability of conception after repeat surgery for recurrent endometriosis appeared limited and reduced compared with that after primary surgery. The results of IVF were not inferior to those of reoperation.