Comments on the ESHRE recommendations for the treatment of minimal endometriosis in infertile women

According to ESHRE recommendations for women with stage I/II endometriosis, if a decision is made to proceed to laparoscopy then operative laparoscopy (excision or ablation of the endometriotic lesions) should be performed rather than only diagnostic laparoscopy, to increase ongoing pregnancy rates. Also, for infertile women with stage I/II endometriosis doctors may consider complete surgical removal of endometriosis to improve live birth rate prior to assisted reproductive treatment. This last recommendation is not well established. Does laparoscopic treatment of minimal endometriosis increase the fertility of women with minimal endometriosis? Should we perform surgery in all cases of minimal endometriosis to improve reproductive outcomes prior to assisted reproductive treatment? The aim of this article is to present evidence on these two questions and comment on the ESHRE recommendations. Evidence is quite robust that laparoscopic destruction of minimal to mild endometriosis and associated adhesions enhances fecundity. On the other hand, to date no clear benefit has been demonstrated of performing laparoscopy for minimal endometriosis in women undergoing IVF/intracytoplasmic sperm injection, therefore it is not recommended in these cases. Further studies are needed to assess the mechanisms of endometriosis-associated infertility and how it may be overcome in cases of minimal and mild endometriosis.