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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

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

P Vercellini, E Somigliana, P Vigano, S De Matteis, G Barbara, and L Fedele.

Review published: 2009.

Link to full article: [Journal publisher]

CRD summary

This review evaluated the effect of repetitive surgery for endometriosis on conception. It found that repetitive surgery was associated with lower pregnancy rates compared with primary surgery, and that the results of in-vitro fertilisation were not inferior to those of re-operation. Given potential limitations in the quality of the data and review process, the reliability of these conclusions is uncertain.

Authors' objectives

The primary objective was to define the effects of repetitive surgery for recurrent endometriosis on postoperative pregnancy rate. The secondary objectives were to verify if the probability of conception after re-operation was reduced compared with that after first-line surgery, and to compare reproductive outcome after in-vitro fertilisation with repeat surgery.


MEDLINE was searched from inception to May 2009 for English language articles. Search terms were reported. Bibliographies of retrieved articles were also searched, together with a range of relevant review articles, books and monographs.

Study selection

Studies were included if patients were diagnosed with recurrent endometriosis and were treated with laparotomy or laparoscopy. Eligible studies also had to report the number of women seeking and achieving pregnancy after reoperation. Studies were excluded if: they reported data available from another paper; disease relapse after initial surgery was described but management of recurrences was not; they did not report surgical modality; they were abstracts from scientific meetings.

For most included studies there was no comparison group; in other studies, comparisons included primary surgery and in-vitro fertilisation (IVF) embryo transfer. All included women were pre-menopausal. Most of the older studies used laparotomy; most of the newer studies used laparoscopy. Where reported, the Acosta classification system was used for older studies, and the revised American Fertility Society classification was used for newer studies. According to this latter system, most diseases were graded either stage III or stage IV.

Two reviewers selected articles for inclusion.

Assessment of study quality

No formal quality assessment was reported.

Data extraction

For comparative studies, pregnancy outcome data required to calculate odds ratios (ORs) with 95% confidence intervals (CIs) were extracted. For non-comparative studies, mean post-operative conception rates with 95% confidence intervals were extracted separately for laparotomy and laparoscopy.

Two reviewers independently extracted the data. Disagreements were resolved through consensus and arbitration with a third reviewer.

Methods of synthesis

For non-comparative studies, weighted mean differences in post-operative conception rates at the end of follow-up, with 95% confidence intervals, were pooled to compare the effects of laparoscopy with laparotomy. Pooled odds ratios, with 95% confidence intervals, were calculated to compare pregnancy rates following repetitive or primary surgery, and to compare pregnancy rates following second-line surgery with rates following IVF embryo transfer

For comparative studies, odds ratios with 95% confidence intervals were pooled, using the Mantel-Haenszel method, were calculated to compare the odds of conception following laparoscopy with the odds of conception following laparotomy.

Statistical heterogeneity was assessed using the χ2 test.

Results of the review

Eleven studies (n=313 women in repetitive surgery arm, range 9 to 89) were included in the review. Six studies were classed as non-comparative (n=139 women), and five studies as comparative (n=174 women). Where reported, length of follow-up ranged from nine to 60 months.

Comparison between repeat and primary surgery: Within three studies (n=701 women), the pooled pregnancy rates at end of follow-up were 41% (95% CI 37 to 45) for the primary surgery group and 23% (95% CI 16 to 31) for the repetitive surgery group. The pooled odds ratio of pregnancy rates comparing repetitive and primary surgery groups was 0.44 (95% CI 0.28 to 0.68) in favour of primary surgery groups (n=236 out of 577 women in the primary surgery group; n=28 out of 124 women in the repetitive surgery group).

Comparison between second-line surgery and IVF embryo transfer: The pooled results of two studies (n=97 women) reported no statistically significant difference between the two treatments.

Comparison between laparotomy and laparoscopy: The mean weighted conception rate at end of follow-up was 27% (95% CI 20 to 35) with laparotomy, and 25% (95% CI 18 to 33) with laparoscopy, indicating no significant differences between the two treatment approaches.

Heterogeneity was assessed as insignificant within both comparative and non-comparative studies.

Authors' conclusions

The authors concluded that the probability of conception after repeat surgery for recurrent endometriosis appeared limited and reduced compared with after primary surgery; and that the results of IVF were not inferior to those of re-operation.

CRD commentary

The review addressed a clear research question supported by relevant inclusion criteria for all aspects except for study design. The search appeared to be limited, and language bias was a possibility. The processes of study selection and data extraction were carried out with sufficient attempts to reduce error and bias.

No formal validity assessment was reported, which made it difficult to determine the reliability of the different study designs included in the review. The level of primary study detail provided seemed adequate, except that few details were provided for comparison groups.

Given the limitations mentioned, the reliability of the authors' conclusions is uncertain.

Implications of the review for practice and research

Practice: The authors stated that, after first line surgery, women should be informed on the high risk of endometriosis recurrence and, as time is a major risk factor, they should be invited to seek conception as soon as possible.

Research: The authors stated that randomised control trials on IVF compared with repeat surgery for infertility associated with recurrent endometriosis are urgently needed to define the best therapeutic option in terms of pregnancy rate, and patient compliance and adherence.


Centre for Research in Obstetrics and Gynecology, Milan, Italy; University of Milan School of Medicine, grant number 12-01-5068118-00067.

Bibliographic details

Vercellini P, Somigliana E, Vigano P, De Matteis S, Barbara G, Fedele L. The effect of second-line surgery on reproductive performance of women with recurrent endometriosis: a systematic review. Acta Obstetricia et Gynecologica Scandinavica 2009; 88(10): 1074-1082. [PubMed: 19707899]

Indexing Status

Subject indexing assigned by NLM


Adult; Endometriosis /surgery; Female; Fertilization in Vitro; Humans; Pregnancy; Pregnancy Outcome; Pregnancy Rate; Recurrence; Reoperation; Reproductive Techniques, Assisted



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 19707899

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