The aims of this systematic review and meta-analysis were: to compare reproductive outcomes in patients who had been submitted to surgery for deep infiltrating endometriosis (DIE) before in vitro fertilization (IVF) to those who underwent IVF without a previous surgery; to analyse data according to different types of surgery (complete, incomplete) or subgroups of patients (DIE with or without bowel involvement), and to assess surgical and IVF complications and data on safety concerns. A systematic literature search from January 1980 to November 2019 with no language restriction was performed in PubMed, MEDLINE, EMBASE and WoS. The search strategy used the following MeSH terms: "in vitro", "fertilization", "IVF", "assisted reproduction", "colorectal", "endometriosis", "deep", "infiltrating", "deep infiltrative endometriosis", "intestinal", "bowel", "rectovaginal", "uterosacral", "vaginal", "bladder". We included studies that compared reproductive outcomes of infertile women with DIE who performed an IVF with or without a previous surgery of DIE lesions. Meta-analysis was performed using Review Manager version 5.3. Risk of bias of included papers was assessed using the method recommended by Cochrane Collaboration. The systematic search retrieved 150 articles, 98 studies were potentially eligible and their full texts were reviewed. Of these, 12 studies met our inclusion criteria and 5 presented data suitable for inclusion in a meta-analysis, but 2 of them provided overlapping data and only the larger study was finally included. No randomized controlled trials (RCT) were found. Pregnancy rate per patient (PRp) was 1.84 (95% CI 1.28-2.64), pregnancy rate per cycle was 1.84 (95% CI 1.26-2.70) and live birth rate per patient was 2.22 (95% CI 1.42-3.46) times more likely for operated patients compared to non-operated ones. The addition of data from the incomplete surgery groups also showed higher PRp for surgery before IVF (OR 1.63; 95% CI 1.16-2.28). Results favour previous surgery in DIE with digestive involvement (OR 2.43, 95% CI 1.13-5.22) and also in DIE without digestive involvement (OR 1.55, 95% CI 0.61-3.95). A qualitative analysis of complications of surgery and IVF showed a partial or complete lack of information on these issues and high heterogeneity in the reported data. None of these studies is RCT; therefore all have high risk of selection and allocation bias except for one study that statistically controlled this later risk by using propensity scores. Funnel plots showed no asymmetry. Results were very consistent for all the studied outcomes, showing a statistically significant benefit for surgery before IVF, although they should be confirmed with RCTs. In addition to the reproductive outcomes, safety data should also be reported in order to have a complete assessment of risks and benefits. PROSPERO ID 2020 CRD42020162480.

Introduction: Alterations in microbiota composition have been implicated in a variety of human diseases. Patients with adenomyosis present immune dysregulation leading to a persistent chronic inflammatory response. In this context, the hypothesis that alterations in the microbiota may be involved in the pathogenesis of adenomyosis, by affecting the epigenetic, immunologic, and biochemical functions of the host, has recently been postulated. The aim of the present study was to compare the microbiota composition in the vagina, endometrium, and gut of individuals with and without adenomyosis.Material and Methods: Cross‐sectional study including 38 adenomyosis patients and 46 controls, performed between September 2021 and October 2022 in a university hospital‐based research center. The diagnosis of adenomyosis was based on sonographic criteria. Fecal, vaginal, and endometrial samples were collected. Study of the microbiota using 16S rRNA gene sequencing.Results: Patients with adenomyosis exhibited a significant reduction in the gut microbial alpha diversity compared with healthy controls (Chao1 p = 0.012, Fisher p = 0.005, Observed species p = 0.005). Beta‐diversity analysis showed significant differences in the compositions of both gut and vaginal microbiota between adenomyosis patients and the control group (Adonis p‐value = 0.001; R² = 0.03 and Adonis p‐value = 0.034; R² = 0.04 respectively). Specific bacterial taxa were found to be either overrepresented (Rhodospirillales, Ruminococcus gauvreauii group, Ruminococcaceae, and Actinomyces) or underrepresented in the gut and endometrial microbiota of adenomyosis patients compared with controls. Distinct microbiota profiles were identified among patients with internal and external adenomyosis phenotypes.Conclusions: The study revealed reduced gut microbiota diversity in adenomyosis patients, accompanied by distinct compositions in gut and vaginal microbiota compared with controls. Overrepresented or underrepresented bacterial taxa were noted in the gut and endometrial microbiota of adenomyosis patients, with variations in microbiota profiles among those with internal and external adenomyosis phenotypes. These findings suggest a potential association between microbiota and adenomyosis, indicating the need for further research to comprehensively understand the implications of these differences.

Deep endometriosis (DE) occurs in 15–30% of patients with endometriosis and is associated with concomitant adenomyosis in around 25–49% of cases. There are no data about the effect of the presence of adenomyosis in terms of surgical outcomes and complications. Thus, the aim of the present study was to evaluate the impact of adenomyosis on surgical complications in women with deep endometriosis undergoing laparoscopic surgery. A retrospective cohort study including women referred to the endometriosis unit of a referral teaching hospital. Two expert sonographers preoperatively diagnosed DE and adenomyosis. DE was defined according to the criteria of the International Deep Endometriosis Analysis group. Adenomyosis was considered when 3 or more ultrasound criteria of the Morphological Uterus Sonographic Assessment group were present. Demographical variables, current medical treatment, symptoms, DE location, surgical time, hospital stay and difference in pre and post hemoglobin levels were collected. The Clavien–Dindo classification was used to assess surgical complications, and multivariate analysis was performed to compare patients with and without adenomyosis. 157 DE patients were included into the study; 77 (49.05%) had adenomyosis according to transvaginal ultrasound (TVS) and were classified in the A group, and 80 (50.95%) had no adenomyosis and were classified in the noA group. Adenomyosis was associated with a higher rate of surgical complications: 33.76% (A group) vs. 12.50% (noA group) (p < 0.001). Multivariate analysis showed a 4.56-fold increased risk of presenting complications in women with adenomyosis (CI 1.90–11.30; p = 0.001) independently of undergoing hysterectomy. There was a statistically significant association between the number of criteria of adenomyosis present in each patient and the proportion of patients presenting surgical complications (p < 0.001). Adenomyosis is an independent preoperative risk factor for surgical complications in DE surgery after adjustment for known demographic, clinical and surgical risk factors.

Objective: To assess ovarian reserve through antral follicle count (AFC) and ovarian volume (OV) determination after decapsulation (stripping technique) or CO₂ laser vaporization in the surgical treatment of patients with bilateral ovarian endometriomas. Methods: This prospective, randomized, blinded, self-controlled pilot study was set in a tertiary university hospital between January 2017 and December 2017, and included consecutive patients with bilateral ovarian endometriomas ≥3 cm. The study was registered with ClinicalTrials.gov under the title ‘Impact on ovarian reserve according to the type of ovarian endometrioma excision: laser versus conventional cystectomy’; NCT 03826355. For each patient, the endometrioma on one side was randomly selected to undergo CO₂ laser vaporization and the contralateral endometrioma to undergo laparoscopic decapsulation. Results: A total of 16 patients were included. There were no statistically significant between-group differences in OV and AFC levels at baseline. At the 6-month follow-up, OV and AFC levels were significantly higher in the laser-treated group versus the stripping technique. Conclusion: Lower OV and AFC levels following excisional surgery for endometrioma versus CO₂ laser vaporization suggest a higher impact on ovarian reserve after the stripping procedure.