Surgery Before IVF: Evidence-Based Recommendations
Surgery before IVF does not improve outcomes for most infertile women and may actually harm ovarian reserve, with the notable exception of submucosal fibroids where hysteroscopic myomectomy significantly improves pregnancy rates. 1
Endometriosis and Endometriomas: Surgery Not Recommended
For women with endometriomas planning IVF, surgery should be avoided as it does not improve pregnancy outcomes and significantly reduces ovarian reserve. 2
Key Evidence Against Surgery for Endometriomas
Women with endometriomas have similar live birth rates (OR 0.98; 95% CI [0.71,1.36]) and clinical pregnancy rates (OR 1.17; 95% CI [0.87,1.58]) compared to women without endometriomas undergoing IVF. 2
Surgical removal of endometriomas before IVF yields similar live birth rates (OR 0.90; 95% CI [0.63,1.28]), similar clinical pregnancy rates (OR 0.97; 95% CI [0.78,1.20]), and similar oocyte retrieval numbers compared to no surgery. 2
Surgery for endometriomas is deleterious to ovarian reserve and function, with convincing evidence showing no additional fertility benefits. 3
Post-surgical complications include higher risk of premature ovarian failure, earlier menopause, higher IVF cycle cancellation rates, and reduced ovarian response to gonadotropins. 3, 4
Limited Exceptions When Surgery May Be Justified
Surgery for endometriomas should only be considered in these specific circumstances:
- Severe dysmenorrhea significantly impacting quality of life 5
- Suspected malignancy requiring tissue diagnosis 5
- Very large endometriomas (>6 cm) that physically impede follicle access during oocyte retrieval 5
- Very large endometriomas preventing adequate ovarian response to controlled ovarian stimulation 5
Deep Endometriosis: Insufficient Evidence
One meta-analysis showed higher pregnancy rates per patient and live birth rates in women who underwent surgery for deep endometriosis before IVF compared to those without surgery. 6
However, available data are insufficient to recommend surgical excision of deep endometriosis as first-line treatment for asymptomatic patients to enhance IVF outcomes. 6
Prolonged pituitary downregulation (GnRH agonist protocol) in women with surgically diagnosed endometriosis may increase clinical pregnancy rates in subsequent IVF cycles. 5
Uterine Fibroids: Surgery Depends on Location
Submucosal Fibroids: Surgery Strongly Recommended
Hysteroscopic myomectomy is the treatment of choice for submucosal fibroids before IVF, as these fibroids have the most detrimental effect on fertility with pregnancy rates of only 10% and implantation rates of 4.3%. 1
After hysteroscopic myomectomy, pregnancy rates improve to 85% with live birth rates of 65%. 1
The procedure offers shorter hospitalization and faster recovery compared to other surgical approaches. 1
Intramural Fibroids: Consider Surgery
Intramural fibroids significantly reduce pregnancy rates (16.4%) and implantation rates (6.4%) compared to women without fibroids, even without cavity distortion. 1
Surgical treatment should be considered before ART treatment, though evidence is less clear than for submucosal fibroids. 1
Laparoscopic or open myomectomy are options with similar pregnancy and live birth rates. 1
Subserosal Fibroids: Surgery Not Indicated
- Subserosal fibroids do not significantly impact fertility, with pregnancy rates (34.1%) and implantation rates (15.1%) similar to women without fibroids (30.1% and 15.7% respectively). 1
Large Fibroids (20-Week Size)
Open myomectomy is preferred over laparoscopic approaches for very large uteri or multiple fibroids, offering better access and outcomes. 1
Combined miscarriage rate after myomectomy (14%) is comparable to the general population. 1
Uterine artery embolization is not recommended for women desiring fertility due to increased risks of miscarriage (35%), cesarean sections (66%), and postpartum hemorrhage (13.9%). 1
Other Surgical Considerations
Ovarian Transposition (Oophoropexy)
- For women requiring pelvic radiation, oophoropexy has uncertain fertility outcomes with approximately 50% pregnancy success rate due to scatter radiation, altered ovarian blood supply, and fallopian tube damage. 7
Fertility-Sparing Gynecologic Surgery
Trachelectomy (cervical removal while preserving uterus) is appropriate for early-stage cervical cancer with no evidence of higher cancer relapse rates in appropriate candidates. 7
Conservative gynecologic surgery should minimize normal tissue resection when oncologically safe. 7
Common Pitfalls to Avoid
Do not delay IVF for endometrioma surgery unless one of the specific exceptions listed above applies—surgery extends time to pregnancy without improving outcomes. 3
Do not perform bilateral endometrioma surgery or repeat surgical procedures, as these dramatically worsen ovarian reserve. 6
Do not use GnRH agonists for ovarian protection during chemotherapy as they do not reliably preserve fertility despite some improvement in menstrual recovery. 8
Always perform transvaginal ultrasound to accurately classify fibroids as subserosal, intramural, or submucosal before making surgical decisions. 1