First-line surgery vs first-line ART to manage infertility in women with deep endometriosis without bowel involvement: A multi-centric propensity-score matching comparison

Published:November 24, 2022DOI:



      To compare first-line surgery with first-line assisted reproductive techniques (ART) in infertile women with deep infiltrating endometriosis (DIE) without colorectal involvement.

      Study design

      A retrospective comparative cohort study with a propensity-score matching analysis, in four tertiary-care referral centers. The population was infertile women with DIE without colorectal involvement. The patients were managed either by first-line surgery followed by spontaneous conception attempts and/or ART, or by first-line ART. 284 patients were extracted from the databases. After matching, 92 patients were compared in each group. Clinical pregnancy rates (PR) and live-birth rates (LBR) were the primary outcomes, and cumulative pregnancy rate (CPR) and cumulative live birth rate (CLBR) were the secondary outcomes.


      The mean number of IVF-ICSI cycles per patient was 1.4, with a significant difference between the groups: 1.6 in the first-line ART group and 1.2 in the first-line surgery group (p = 0.006). The PR was significantly higher in the first-line surgery group (72 % vs 35 %; p < 0.001). In the first-line surgery group, non-ART pregnancies occurred in 18 % (17/92) while no non-ART pregnancies was noted in the first-line ART group. The LBR was significantly higher in the first-line surgery group (61 % vs 24 %; p < 0.001). After ART, the CPR were 72 % (47/67) in the first-line surgery group, and 35 % (32/92) in the first-line ART group (p < 0.001).


      After matching, our results support that first-line surgery offer higher pregnancy and live-birth rates than first-line ART in patients with DIE without colorectal involvement.


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        • Giudice L.C.
        • Kao L.C.
        Lancet. 2004; 364: 1789-1799
        • Meuleman C.
        • Vandenabeele B.
        • Fieuws S.
        • Spiessens C.
        • Timmerman D.
        • D’Hooghe T.
        High prevalence of endometriosis in infertile women with normal ovulation and normospermic partners.
        Fertil Steril juill. 2009; 92: 68-74
        • de Ziegler D.
        • Borghese B.
        • Chapron C.
        Endometriosis and infertility: pathophysiology and management.
        Lancet. 2010; 376: 730-738
        • Penzias A.S.
        Subfertility, fecundability, and the impact of laparoscopy on conception rates.
        Fertil Steril déc. 2005; 84: 1579-1580
      1. Impact of Complete Surgery of Colorectal Deep Infiltrating Endometriosis on Fertility (ENDOFERT). NCT02948972. Consultable sur

        • Dunselman G.A.J.
        • Vermeulen N.
        • Becker C.
        • Calhaz-Jorge C.
        • D’Hooghe T.
        • De Bie B.
        • et al.
        ESHRE guideline: management of women with endometriosis.
        Hum Reprod Mars. 2014; 29: 400-412
      2. Endometriosis and infertility: a committee opinion [Internet]. Fertility and sterility. 2012 [cité 15 oct 2020]. Disponible sur:

      3. L K, K D, M D, C O. Diagnosis and management of endometriosis: summary of NICE guidance [Internet]. BMJ (Clinical research ed.). 2017 [cité 15 oct 2020]. Disponible sur:

        • Bourdel N.
        • Chauvet P.
        • Canis M.
        Diagnostic strategies for endometriosis: CNGOF-HAS Endometriosis Guidelines.
        Gynecol Obstet Fertil Senol mars. 2018; 46: 209-213
        • Nisenblat V.
        • Bossuyt P.M.M.
        • Farquhar C.
        • Johnson N.
        • Hull M.L.
        Imaging modalities for the non-invasive diagnosis of endometriosis.
        Cochrane Database Syst Rev. 2016; 2: CD009591
        • Bazot M.
        • Daraï E.
        Diagnosis of deep endometriosis: clinical examination, ultrasonography, magnetic resonance imaging, and other techniques.
        Fertil Steril déc. 2017; 108: 886-894
      4. Bendifallah S, Roman H, Mathieu d’Argent E, Touleimat S, Cohen J, Darai E, et al. Colorectal endometriosis-associated infertility: should surgery precede ART? [Internet]. Fertility and sterility. 2017 [cité 15 oct 2020]. Disponible sur:

        • Martens E.P.
        • de Boer A.
        • Pestman W.R.
        • Belitser S.V.
        • Stricker B.H.C.
        • Klungel O.H.
        Comparing treatment effects after adjustment with multivariable Cox proportional hazards regression and propensity score methods.
        Pharmacoepidemiol Drug Saf janv. 2008; 17: 1-8
        • Bazot M.
        • Cortez A.
        • Darai E.
        • Rouger J.
        • Chopier J.
        • Antoine J.M.
        • et al.
        Ultrasonography compared with magnetic resonance imaging for the diagnosis of adenomyosis: correlation with histopathology.
        Hum Reprod. 2001; 16: 2427-2433
        • Poupon C.
        • Owen C.
        • Arfi A.
        • Cohen J.
        • Bendifallah S.
        • Daraï E.
        Nomogram predicting the likelihood of complications after surgery for deep endometriosis without bowel involvement.
        Eur J Obstet Gynecol. Reproduct. Biol. X. 2019; (Disponible sur:)
        • Roman H.
        • Auber M.
        • Mokdad C.
        • Martin C.
        • Diguet A.
        • Marpeau L.
        • et al.
        Ovarian endometrioma ablation using plasma energy versus cystectomy: a step toward better preservation of the ovarian parenchyma in women wishing to conceive.
        Fertil Steril déc. 2011; 96: 1396-1400
        • Mathieu d’Argent E.
        • Cohen J.
        • Chauffour C.
        • Pouly J.L.
        • Boujenah J.
        • Poncelet C.
        • et al.
        Deeply infiltrating endometriosis and infertility: CNGOF-HAS Endometriosis Guidelines.
        Gynecol Obstet Fertil Senol mars. 2018; 46: 357-367
        • Rosenbaum P.R.
        • Rubin D.B.
        The central role of the propensity score in observational studies for causal effects.
        Biometrika. 1983; 70: 41-55
        • Ballester M.
        • d’Argent E.M.
        • Morcel K.
        • Belaisch-Allart J.
        • Nisolle M.
        • Daraï E.
        Cumulative pregnancy rate after ICSI-IVF in patients with colorectal endometriosis: results of a multicentre study.
        Hum Reprod avr. 2012; 27: 1043-1049
        • Hodgson R.M.
        • Lee H.L.
        • Wang R.
        • Mol B.W.
        • Johnson N.
        Interventions for endometriosis-related infertility: a systematic review and network meta-analysis.
        Fertil Steril févr. 2020; 113: 374-382.e2
        • Cohen J.
        • Ballester M.
        • Selleret L.
        • Mathieu D’Argent E.
        • Antoine J.M.
        • Chabbert-Buffet N.
        • et al.
        Finding the balance between surgery and Medically Assisted Reproduction in women with deep endometriosis.
        Minerva Ginecol. 2016;
        • Meuleman C.
        • Tomassetti C.
        • Wolthuis A.
        • Van Cleynenbreugel B.
        • Laenen A.
        • Penninckx F.
        • et al.
        Clinical outcome after radical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis: a prospective cohort study.
        Ann Surg mars. 2014; 259: 522-531
      5. Donnez J, Squifflet J. Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules [Internet]. Human reproduction (Oxford, England). 2010 [cité 23 oct 2020]. Disponible sur:

        • Adamson G.D.
        • Pasta D.J.
        Endometriosis fertility index: the new, validated endometriosis staging system.
        Fertil Steril. 2010; 94: 1609-1615
        • Maheux-Lacroix S.
        • Nesbitt-Hawes E.
        • Deans R.
        • Won H.
        • Budden A.
        • Adamson D.
        • et al.
        Endometriosis fertility index predicts live births following surgical resection of moderate and severe endometriosis.
        Hum Reprod. 2017; 32: 2243-2249
      6. Wang W, Li R, Fang T, Huang L, Ouyang N, Wang L, et al. Endometriosis fertility index score maybe more accurate for predicting the outcomes of in vitro fertilisation than r-AFS classification in women with endometriosis. Reprod Biol Endocrinol. 11 déc 2013;11:112.

        • Garavaglia E.
        • Pagliardini L.
        • Tandoi I.
        • Sigismondi C.
        • Viganò P.
        • Ferrari S.
        • et al.
        External validation of the endometriosis fertility index (EFI) for predicting spontaneous pregnancy after surgery: further considerations on its validity.
        Gynecol Obstet Invest. 2015; 79: 113-118
      7. Ferrier C, Boujenah J, Poncelet C, Chabbert-Buffet N, Mathieu D’Argent E, Carbillon L, et al. Use of the EFI score in endometriosis-associated infertility: A cost-effectiveness study [Internet]. European journal of obstetrics, gynecology, and reproductive biology. 2020 [cité 28 oct 2020]. Disponible sur:

        • Black N.
        Why we need observational studies to evaluate the effectiveness of health care.
        BMJ. 1996; 312: 1215-1218
        • Austin P.C.
        Double propensity-score adjustment: A solution to design bias or bias due to incomplete matching.
        Stat Methods Med Res févr. 2017; 26: 201-222
        • Feng P.
        • Zhou X.H.
        • Zou Q.M.
        • Fan M.Y.
        • Li X.S.
        Generalized propensity score for estimating the average treatment effect of multiple treatments.
        Stat Med. 2012; 31: 681-697