Italian researchers studied 130 women with infertility. Live birth was more than twice as frequent among women who started with IVF in the randomized comparison.
The findings inform the treatment sequence for ovarian and deep endometriosis, while highlighting the need to consider possible ovarian reserve loss after surgery.
Should a woman with endometriosis-related infertility have surgery first, or begin IVF? Endometriosis can interfere with conception, but removing lesions does not necessarily offer the better route to a live birth. In this study, women starting with IVF had a higher live birth rate than women undergoing surgery followed by attempts at natural conception.
Researchers from the University of Milan and two other Italian medical centers compared treatment outcomes in 130 women with ovarian endometriomas or deep endometriosis. Their findings were published online in the American Journal of Obstetrics and Gynecology on October 24, 2026.
Live birth: 26% after surgery versus 57% with IVF in the randomized groups
Of the participants, 55 were randomly assigned to treatment. Twenty-seven underwent endometriosis surgery and then attempted natural conception; 28 began IVF instead of surgery.
Seven of 27 women in the surgery group had a live birth (26%), compared with 16 of 28 in the IVF group (57%). The live birth rate was approximately 2.2 times as high in the IVF group.
The separate group of 75 women who chose their treatment showed a similar pattern. Seven of 25 women choosing surgery had a live birth (28%), compared with 32 of 50 choosing IVF (64%).
These percentages describe the proportion of women starting a treatment strategy who subsequently had a live birth. They do not mean that 57% had a baby after one IVF cycle.
Does endometriosis always require surgery?
Endometriosis involves tissue resembling the uterine lining growing outside the uterus, including on the ovaries or peritoneum. Inflammation and adhesions can interfere with ovarian and tubal function and may affect the environment for eggs and fertilization.
Ovarian endometriomas are particularly relevant to infertility. Persistent inflammation around the ovary can damage healthy tissue and adversely affect the environment in which eggs develop.
Does removing the lesion necessarily improve the chance of pregnancy? Not always.
Healthy ovarian tissue may be damaged during endometrioma removal. Ovarian reserve can decline after surgery, and fewer eggs may be available during subsequent IVF.
Potential additional loss of ovarian function deserves particular consideration in women with low ovarian reserve, endometriomas in both ovaries or previous ovarian surgery.
IVF fertilizes eggs outside the body and transfers an embryo into the uterus. It can therefore bypass some barriers to natural conception associated with endometriosis.
Some patients still need surgery
The findings do not mean that every patient with endometriosis should start with IVF.
Participants met specific eligibility conditions, including being younger than 40 and having ovarian endometriomas smaller than 4 cm. Women with certain problems, including severe organ involvement or hydrosalpinx, were excluded.
Surgery may be needed when severe pelvic pain persists, or when endometriosis affects bowel or ureter function. Large endometriomas that interfere with egg retrieval and lesions suspicious for malignancy also require separate assessment.
The study was small. Recruitment ended before the intended enrollment target was reached, and only 55 women were randomized. Further research is needed before generalizing the findings to all women with endometriosis-related infertility.
When pregnancy is the goal, treatment order matters
Treating endometriosis and improving the chance of pregnancy are related but distinct goals.
Surgery can remove lesions and relieve pain without necessarily increasing live birth rates. IVF is directed at achieving pregnancy, but does not eliminate endometriosis itself.
Women seeking pregnancy therefore need an assessment that considers age, ovarian reserve, duration of infertility, pain and tubal status, as well as lesion size and location.
Unnecessary surgery may delay fertility treatment and place additional strain on ovarian function when time matters. Conversely, severe pain or concern about damage to nearby organs can make surgery the priority.
This study adds evidence that surgery need not always be the first option for endometriosis-related infertility. The key is to determine which sequence best protects an individual's health while supporting the chance of a live birth.
Before deciding on surgery, women with endometriosis and infertility should discuss ovarian function, lesion characteristics and the feasibility of IVF with a reproductive medicine specialist.
Source: “IVF versus surgery for infertility in women with deep and ovarian endometriosis: a partially randomized patient preference trial,” by researchers at the University of Milan and two other Italian medical centers. American Journal of Obstetrics and Gynecology, online October 24, 2026. DOI: 10.1016/j.ajog.2026.10.024. PMID: 42925945.
Related reading: Why endometriosis pain may persist after surgery: findings from a mouse study.
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