MVIIIHealth The MVIII app
← Back

Research · Therapies

Endometriosis surgery

In blinded trials, laparoscopic excision or ablation eased endometriosis pain more than a sham diagnostic laparoscopy, 80% against 32% improved in one, and raised pregnancy rates in mild disease. Excision and ablation did not differ for superficial disease. Endometriosis returned in 40% to 50% by 5 years, and endometrioma surgery lowered AMH.

Checked 2026-11-13
Status
A surgical procedure, performed in the US by licensed physicians, usually gynecologic surgeons. Surgical techniques are not approved by the FDA as products, though the instruments used are regulated as medical devices.
Also called
laparoscopy for endometriosis, excision surgery, laparoscopic excision, ablation, laser ablation, keyhole surgery, cystectomy, endometrioma removal, bowel resection for endometriosis, hysterectomy for endometriosis, oophorectomy
Used for
endometriosis pain, period pain from endometriosis, pain during sex, pelvic pain, getting pregnant with endometriosis, removing endometriomas, stopping endometriosis from coming back, a cure for endometriosis

Strong several reviews agree · Moderate one review or consistent trials · Limited one or a few small studies · Untested no study in people, listed with what it rests on

Shown to help5

Reported risks4

What it is used for, and what was found

Shown to help5

ModerateStudied in womenVery common

Endometriosis pain, compared with sham surgery

Shown to ease endometriosis pain in women more than a sham diagnostic laparoscopy in two small blinded trials, with 80% against 32% improved after excision.

Compared with diagnostic laparoscopy alone, with the women unaware of their group (sham surgery) [1][2][3][4]

The numbers and sources
How common
Very common: more than 1 in 10 people.
Effect
Six months after surgery, 16 of 20 women (80%) reported improvement after full excision and 6 of 19 (32%) after a diagnostic procedure only. Quality of life improved after excision and not after the sham. About 20% did not improve after surgery [1]. In a second trial, 62.5% improved or were free of symptoms 6 months after laser ablation, against 22.6% after diagnostic laparoscopy alone, rising to 73.7% when only mild and moderate disease was counted. Results were poorest for minimal disease [2]. At 1 year, relief continued in 90% of those who first responded [3]. The Cochrane review rated pooled pain data against diagnostic laparoscopy very low in certainty (MD 0.90 at 6 months and 1.65 at 12 months on a pain relief scale, 1 trial of 16 women), and quality of life did not differ (EQ-5D MD 0.03, 95% CI -0.12 to 0.18) [4].
Population
39 women with endometriosis of all stages, crossover design [1]. 63 women with minimal to moderate endometriosis and pain [2][3]. 14 trials and 1,563 women in the review [4].
Sources
[1], [2], [3], [4]
Caveats
Both sham-controlled trials were small. The laser trial also cut the uterine nerves [2]. About 30% improved after the sham alone, a placebo response the authors found was not tied to disease severity [1]. The Cochrane review notes unclear blinding and poor reporting across trials [4].
StrongStudied in womenVery common

Pregnancy in mild endometriosis, compared with diagnostic laparoscopy

Shown to raise pregnancy rates in women with minimal or mild endometriosis against diagnostic laparoscopy alone: 30.7% against 17.7% reached 20 weeks in the largest trial.

Compared with diagnostic laparoscopy alone [4][8]; placebo, as the network analysis names its comparison [9]

The numbers and sources
How common
Very common: more than 1 in 10 people.
Effect
Surgery raised viable intrauterine pregnancy against diagnostic laparoscopy (OR 1.89, 95% CI 1.25 to 2.86, 3 trials, 528 women, moderate certainty). No trial in the review measured live birth [4]. In a Canadian trial, 50 of 172 women after resection or ablation and 29 of 169 after diagnostic laparoscopy had pregnancies lasting 20 weeks or more within 36 weeks (cumulative 30.7% against 17.7%, rate ratio 1.9, 95% CI 1.2 to 3.1). Fetal loss was 20.6% and 21.6% [8]. A network meta-analysis found higher odds of pregnancy after surgical laparoscopy than placebo (OR 1.63, 95% CI 1.13 to 2.35) [9].
Population
528 women in 3 trials [4]. 341 infertile women aged 20 to 39 with minimal or mild endometriosis [8]. 2,245 women with endometriosis-related infertility in 26 trials [9].
Sources
[4], [8], [9]
Caveats
Live birth was not measured in the pooled trials [4]. These trials covered minimal or mild disease only.
ModerateStudied in women

Endometriomas: excision compared with drainage and ablation

Shown to lower pain and cyst recurrence in women with endometriomas against drainage and ablation. Endometriomas recurred in 5% to 17% after excision against 37% after ablation.

Compared with drainage and ablation of the cyst [10]

The numbers and sources
Effect
Up to two years after surgery, excision lowered the return of period pain (OR 0.25, 95% CI 0.12 to 0.52, 49% after ablation against 10% to 34% after excision) and of pain during sex (OR 0.09, 95% CI 0.03 to 0.22, 58% against 4% to 23%). At one year, endometriomas returned less often (OR 0.17, 95% CI 0.09 to 0.34) and fewer women needed more surgery (32% after ablation against 3% to 16%). Spontaneous pregnancy in the first year did not differ (OR 1.27, 95% CI 0.33 to 4.87) [10].
Population
578 women of reproductive age with endometriomas of at least 3 cm in 9 trials [10].
Sources
[10]
Caveats
Low certainty, with no blinding and small numbers. No trial reported surgical complications other than conversion to open surgery [10].
LimitedStudied in women

Hysterectomy compared with excision alone

Linked to fewer repeat operations and more pain relief than excision alone in women, in observational studies. By 7 years, 77% to 92% avoided reoperation, against 45%.

Compared with laparoscopic excision with the uterus and ovaries kept [11][12]; hysterectomy with and without removal of the ovaries, against each other [11][12]

The numbers and sources
Effect
At 2, 5 and 7 years, 79.4%, 53.3% and 44.6% of women had avoided further surgery after excision alone, against 95.7%, 86.6% and 77.0% after hysterectomy keeping the ovaries and 96.0%, 91.7% and 91.7% after hysterectomy with the ovaries removed. In women aged 30 to 39, removing the ovaries did not significantly lengthen surgery-free time [11]. At 24 months, against excision alone, hysterectomy keeping the ovaries improved pain outside periods by 1.41 more points out of 10, pain during sex by 1.12, back pain by 1.29 and quality of life by 8.77 out of 100. With the ovaries removed, the gains were 2.22, 1.05, 1.18 and 12.41 [12].
Population
240 women at one US clinic, 120 per group [11]. Women having surgery for rectovaginal endometriosis at 86 specialist endometriosis centers, 2009 to 2021 [12].
Sources
[11], [12]
Caveats
Neither study was randomized, so women chosen for hysterectomy may differ from others. The second study's oophorectomy result was sensitive to loss to follow-up [12]. Hysterectomy ends the ability to carry a pregnancy, and removing both ovaries brings on menopause.
ModerateStudied in women

Hormonal suppression after surgery, compared with none

Shown to lower endometriosis recurrence in women after conservative surgery when hormonal suppression followed, by about 59% against no treatment or placebo.

Compared with expectant management or placebo after surgery [13]

The numbers and sources
Effect
Recurrence, by imaging or return of symptoms at a median 18 months, was lower with hormonal suppression after surgery (RR 0.41, 95% CI 0.26 to 0.65, 14 studies, 1,766 patients, I² 68%). Pain scores were also lower (SMD -0.49, 95% CI -0.91 to -0.07). Results held for combined hormonal contraceptives and the levonorgestrel IUD, and in analyses limited to randomized trials [13].
Population
2,137 premenopausal women who kept at least one ovary, in 13 randomized trials and 4 cohort studies [13].
Sources
[13]
Caveats
Heterogeneity was substantial. Suppression prevents pregnancy while it is used [13].

Not shown to help1

StrongStudied in women

Excision compared with ablation

Not shown to differ: excision and ablation eased pain from superficial endometriosis in women by similar amounts at 12 months, in two reviews.

Compared with ablation of the lesions [4][5][6][7]

The numbers and sources
Effect
Pooled across 3 trials, reductions in period pain (MD -0.03, 95% CI -1.27 to 1.22), pain with bowel movements (MD 0.46, 95% CI -1.09 to 2.02) and pain during sex (MD 0.10, 95% CI -2.36 to 2.56) did not differ at 12 months, nor did scores beyond 12 months [5]. Overall pain at 12 months did not differ in the Cochrane review (MD 0.00, 95% CI -1.22 to 1.22, 1 trial, 103 women) [4]. A blinded trial found no difference in overall pain at 12 months [6]. In a robot-assisted trial, the only difference was in pain during sex at 6 months, which favored ablation [7].
Population
346 women with minimal to mild endometriosis in 4 trials [5]. 103 women [4]. Women with pelvic pain and visible endometriosis [6]. 73 women with minimal to mild endometriosis [7].
Sources
[5], [4], [6], [7]
Caveats
These trials covered superficial, minimal to mild disease, not deep endometriosis. The reviewers call for larger trials with longer follow-up [5].

Protocols studied

The sham-controlled trials compared full excision [1], or laser ablation with uterine nerve ablation [2], against a diagnostic laparoscopy in which disease was seen and left in place, with women and outcome assessors unaware of the group. In one, everyone had a second laparoscopy at 6 months with removal of any disease [1]. The fertility trial resected or ablated visible lesions during the diagnostic laparoscopy and followed women for 36 weeks [8]. The excision and ablation trials were done by laparoscopy [5][6], one with robotic assistance [7], one with supervised trainee gynecologists as surgeons [6]. Endometrioma trials compared cystectomy with drainage and ablation for cysts of 3 cm or more [10]. Hormonal suppression after surgery was started within 6 weeks and used combined hormonal contraceptives, progestins, the levonorgestrel IUD or GnRH agonists, with follow-up of 12 to 36 months [13].

Risks

Reported risks4

LimitedStudied in womenVery common

Endometriosis coming back, and repeat surgery

Limited evidence: endometriosis returned in an estimated 21.5% of women by 2 years after surgery and 40% to 50% by 5 years.

The numbers and sources
How common
Very common: more than 1 in 10 people.
Effect
A review of published series estimated recurrence at 21.5% at 2 years and 40% to 50% at 5 years, with few consistent risk factors [14]. In one US clinic, 20.6% of women needed more surgery within 2 years of excision alone, 46.7% within 5 years and 55.4% within 7 years [11]. One year after endometrioma surgery, 32% needed more surgery after drainage and ablation and 3% to 16% after excision [10].
Population
Published surgical series [14]. 120 women after excision [11]. Women in endometrioma trials [10].
Sources
[14], [11], [10]
Caveats
The recurrence estimate comes from a narrative review, not a meta-analysis, and studies defined recurrence differently [14].
LimitedCommon

Complications of bowel surgery for deep endometriosis

Case series: after removal of a bowel segment for deep endometriosis, rectovaginal fistula averaged 2.3% to 3.6%, anastomotic leak 1.7% and urinary retention about 5%.

The numbers and sources
How common
Common: between 1 in 100 and 1 in 10 people.
Effect
Rectovaginal fistula averaged 3.6% (range 0 to 16.6%) with conventional resection and 2.3% (0 to 10.5%) with nerve-sparing resection. Anastomotic leak averaged 1.7% with both. Urinary retention occurred in 4.5% and 4.9%, and long-term bladder catheterization in 4.9% and 5.6% [17].
Population
7,549 women in 63 studies of segmental bowel resection for colorectal endometriosis [17].
Sources
[17]
Caveats
Uncontrolled series with inconsistent reporting. This applies to deep bowel disease, not to excision or ablation of superficial lesions [17].
LimitedStudied in womenCommon

Complications in trials of excision or ablation for milder disease

Limited evidence: trials of excision or ablation for mild disease reported few complications, 3 minor ones among 172 women in the largest.

The numbers and sources
How common
Common: between 1 in 100 and 1 in 10 people.
Effect
Four minor complications were reported in the fertility trial, an intestinal bruise, a slight tear of a tube's outer layer, a difficult abdominal inflation and a vascular injury, three in the surgery group and one in the diagnostic group [8]. The laser trial reported no operative complications [2]. The Cochrane review found adverse events poorly reported, with no conversions to open surgery in one trial of 341 women [4].
Population
341 women [8]. 63 women [2]. 14 trials [4].
Sources
[8], [2], [4]
Caveats
Trials were small and most did not look for adverse events, so rare serious complications cannot be ruled out [4].
StrongStudied in womenHow often is not known

Lower anti-Mullerian hormone after endometrioma surgery

Shown to lower anti-Mullerian hormone, a marker of egg supply, after endometrioma surgery in women, by about 35% to 54% in pooled studies.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
AMH fell by 1.77 ng/mL at 1 to 6 weeks, 1.17 ng/mL at 2 to 6 months and 2.13 ng/mL at 9 to 18 months after cystectomy, mean falls of 44.4%, 35.1% and 54.2%. Antral follicle counts did not change significantly [15]. A second review found falls of 1.39, 1.13 and 2.12 ng/mL over the same periods, with no difference between removing a cyst from one ovary or both [16].
Population
650 women in 14 prospective studies [15]. Women in 30 studies [16].
Sources
[15], [16]
Caveats
These are before-and-after measures in the same women, and heterogeneity was high (I² 92% to 94%) [15]. A lower AMH is not the same as lower fertility, which these reviews did not measure.

Claims tested and not found

  1. That excision relieves pain more than ablation for superficial endometriosis. Pain scores did not differ at 12 months in pooled trials [5] or in the Cochrane review [4].
  2. That the pain relief after surgery is all placebo. In a blinded trial, 80% improved after excision against 32% after a sham diagnostic laparoscopy [1].
  3. That untreated endometriosis always gets worse. At second-look surgery in women left untreated, disease had progressed in 45%, stayed the same in 33% and improved in 22% in one trial [1], and progressed in 29%, regressed in 29% and stayed the same in 42% in another [3].

Related

Progestins for endometriosis and heavy bleedingGnRH drugs for fibroidsHormonal birth controlNSAIDs

Sources

  1. Abbott J, Hawe J, Hunter D, et al. Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Fertility and Sterility. 2004. https://doi.org/10.1016/j.fertnstert.2004.03.046
  2. Sutton CJ, Ewen SP, Whitelaw N, Haines P. Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertility and Sterility. 1994. https://doi.org/10.1016/s0015-0282(16)56990-8
  3. Sutton CJ, Pooley AS, Ewen SP, Haines P. Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis. Fertility and Sterility. 1997. https://doi.org/10.1016/s0015-0282(97)00403-2
  4. Bafort C, Beebeejaun Y, Tomassetti C, Bosteels J, Duffy JM. Laparoscopic surgery for endometriosis. Cochrane Database of Systematic Reviews. 2020. https://doi.org/10.1002/14651858.cd011031.pub3
  5. Burks C, Lee M, DeSarno M, Findley J, Flyckt R. Excision versus Ablation for Management of Minimal to Mild Endometriosis: A Systematic Review and Meta-analysis. Journal of Minimally Invasive Gynecology. 2021. https://doi.org/10.1016/j.jmig.2020.11.028
  6. Healey M, Ang WC, Cheng C. Surgical treatment of endometriosis: a prospective randomized double-blinded trial comparing excision and ablation. Fertility and Sterility. 2010. https://doi.org/10.1016/j.fertnstert.2010.02.044
  7. Riley KA, Benton AS, Deimling TA, Kunselman AR, Harkins GJ. Surgical Excision Versus Ablation for Superficial Endometriosis-Associated Pain: A Randomized Controlled Trial. Journal of Minimally Invasive Gynecology. 2019. https://doi.org/10.1016/j.jmig.2018.03.023
  8. Marcoux S, Maheux R, Bérubé S. Laparoscopic surgery in infertile women with minimal or mild endometriosis. New England Journal of Medicine. 1997. https://doi.org/10.1056/nejm199707243370401
  9. Hodgson RM, Lee HL, Wang R, Mol BW, Johnson N. Interventions for endometriosis-related infertility: a systematic review and network meta-analysis. Fertility and Sterility. 2020. https://doi.org/10.1016/j.fertnstert.2019.09.031
  10. Kalra R, McDonnell R, Stewart F, et al. Excisional surgery versus ablative surgery for ovarian endometrioma. Cochrane Database of Systematic Reviews. 2024. https://doi.org/10.1002/14651858.cd004992.pub4
  11. Shakiba K, Bena JF, McGill KM, Minger J, Falcone T. Surgical treatment of endometriosis: a 7-year follow-up on the requirement for further surgery. Obstetrics & Gynecology. 2008. https://doi.org/10.1097/aog.0b013e3181758ec6
  12. Lewin J, Vashisht A, Hirsch M, Al-Wattar BH, Saridogan E. Comparing the treatment of endometriosis-related pain by excision of endometriosis or hysterectomy: A multicentre prospective cohort study. BJOG. 2024. https://doi.org/10.1111/1471-0528.17910
  13. Zakhari A, Delpero E, McKeown S, et al. Endometriosis recurrence following post-operative hormonal suppression: a systematic review and meta-analysis. Human Reproduction Update. 2021. https://doi.org/10.1093/humupd/dmaa033
  14. Guo SW. Recurrence of endometriosis and its control. Human Reproduction Update. 2009. https://doi.org/10.1093/humupd/dmp007
  15. Younis JS, Shapso N, Ben-Sira Y, Nelson SM, Izhaki I. Endometrioma surgery-a systematic review and meta-analysis of the effect on antral follicle count and anti-Müllerian hormone. American Journal of Obstetrics and Gynecology. 2022. https://doi.org/10.1016/j.ajog.2021.06.102
  16. Murdock C, Murdock C, Sanchez-Ramos L, et al. The Impact of Laparoscopic Cystectomy for Ovarian Endometrioma on Anti-Müllerian Hormone Levels: A Systematic Review and Meta-Analysis. Gynecologic and Obstetric Investigation. 2025. https://doi.org/10.1159/000545230
  17. Darici E, Salama M, Bokor A, et al. Different segmental resection techniques and postoperative complications in patients with colorectal endometriosis: A systematic review. Acta Obstetricia et Gynecologica Scandinavica. 2022. https://doi.org/10.1111/aogs.14379

Everything in the library