To date, management of infertile women with bowel endometriosis remains a clinical challenge. The two primary therapeutic approaches include first-line medically assisted reproduction (MAR) or primary surgery, including bowel resection, with or without subsequent fertility treatments.

In patients with little or no pain, primary MAR is often proposed to specifically shorten the delay in conception, to prevent postoperative ovarian reserve impairment, and to avoid the negative impact of potential surgical complications on patient fertility [1, 2, 3]. On the other hand, women with severe symptoms generally undergo primary surgery. Although the beneficial role of laparoscopic resection of bowel endometriosis in the long-term improvement of pelvic complaints, bowel symptoms, and quality of life is well established [4, 5, 6], the impact of such a procedure on fertility rates remains uncertain.

Recent studies have proposed surgical resection of bowel endometriosis as a fertility-enhancing procedure, both increasing their likelihood of spontaneous conception and fertility rates when undergoing MAR [7, 8, 9, 10]. Nonetheless, management is based mainly on cohort studies, with no available randomized controlled trials addressing this issue. Moreover, current guidelines do not make precise recommendations about the optimal conduct for infertile women with bowel endometriosis [11, 12, 13, 14].

The aim of this study was to conduct a systematic review and meta-analysis to establish the cumulative pregnancy rate for the different therapeutic options usually offered to patients with bowel endometriosis-associated infertility (i.e., expectancy, first-intention MAR or primary bowel surgery, with or without further fertility treatments).