Endométriose et Infertilité. FIV ou Chirurgie en 2025 ? | Dr Senai Aksoy
Endometriosis and Infertility: IVF or Surgery in 2025?
Hello, I am Dr. Senai Aksoy. I have been working in the field of in vitro fertilization in Istanbul for over 30 years. In my clinic, I meet couples daily who face endometriosis and the desire to have a child.
The year 2025 marks a turning point in the treatment of infertility related to endometriosis. Current recommendations from ESHRE, ASRM, and national guidelines deliver a clear message: surgery is no longer the first choice. The VODE study has demonstrated the remarkable effectiveness of IVF as the first-line option.
📌 What You Will Learn in This Article:
- Why has the surgical approach changed?
- What did the VODE study show?
- When is surgery still necessary?
- The 2025 treatment algorithm
- New IVF protocols
- The role of microbiota and ferroptosis
- Non-hormonal treatments
- Frequently asked questions
Why Has the Approach Changed
Since 2022, ESHRE recommendations on endometriosis, followed by ASRM and CNGOF in 2024-2025, are clear: surgery should not be performed solely to improve IVF outcomes. Hormonal blocking treatments (GnRH analogs, continuous progestins) are not recommended for fertility purposes as they prevent conception and waste precious time.
In my practice, I observe that unnecessary surgery can affect ovarian reserve. For couples with endometriosis, time is the most precious resource.
The VODE Study: Striking Results
The randomized VODE study (2025) compared two strategies in women with ovarian or deep endometriosis:
IVF-first group:
- Live birth rate: 46%
- Pregnancies >20 weeks: 60%
Surgery-first group:
- Live birth rate: 23%
- Pregnancies >20 weeks: 27%
IVF doubles the success rate. Even in per-protocol analysis, the superiority persists (47% vs 20%).
I explain to my patients: “If your goal is pregnancy and pain is manageable, direct IVF can double your chances.”
When Surgery Remains Necessary
Surgery maintains its place in specific situations:
1. Severe pain: When medical treatment fails and pain disrupts daily life.
2. Endometrioma >3 cm: ESHRE suggests that surgery may increase spontaneous pregnancy chances for endometriomas larger than 3 cm.
3. Hydrosalpinx: An obstructed tube must be removed before embryo transfer as its fluid is toxic.
4. Mechanical obstacle: Adhesions preventing ovarian access for retrieval.
5. EFI score: The Endometriosis Fertility Index calculated after surgery predicts natural pregnancy chances. If ≤6, immediate transition to ART.
2025 Treatment Algorithm
Situation 1: Infertility + Severe Pain
- Consider surgery for pain control
- Evaluate pre-operative fertility preservation
- Calculate post-operative EFI
- If EFI ≤6: immediate ART
Situation 2: Infertility + Absent/Controlled Pain
- Direct IVF (strategy validated by VODE)
- Avoid time and reserve loss
Optimized IVF Protocols
PPOS: The New Standard
The PPOS protocol (Progestin Primed Ovarian Stimulation) uses progestins to control the cycle. All embryos are frozen then transferred later.
2025 advantages:
- Shorter stimulation, fewer medications
- Equivalent or better birth rates
- Possibly reduced miscarriage rate (8% vs 17%)
- Optimal frozen embryo transfer
In my clinic, PPOS has become our reference protocol for endometriosis patients.
Down-Regulation: No Longer Routine
ESHRE 2025 confirms: long pre-IVF suppression does not systematically increase live births. Reserved for selected cases.
Oocyte Quality: A Myth Shattered
The Old Dogma Questioned
A 2025 review challenges our certainties about oocyte quality in endometriosis:
New evidence:
- Normal fertilization rates
- Euploid embryos (normal chromosomes) in normal proportion
- Normal implantation rates with egg donation
The real problem: The toxic pelvic environment (inflammation, oxidative stress, toxins), not the oocyte itself.
Why IVF works: It bypasses this deleterious environment by removing the oocyte, fertilizing it in the laboratory, then transferring it to a prepared uterus.
PGT-A: Not Recommended
ASRM 2024 recommendations are clear: routine PGT-A is contraindicated in endometriosis.
Reasons:
- Fewer embryos available (especially post-surgery)
- Risk of losing viable mosaic embryos
- Embryos already chromosomally normal
Artificial Intelligence
AI for endometrial analysis emerges in 2025. Projects like Matrix use AI-assisted ultrasound to predict endometrial receptivity and optimize transfer timing.
Microbiota and Ferroptosis
Systemic Vision of Endometriosis
Endometriosis is now viewed as a systemic inflammatory disease linked to the microbiota.
Mechanisms:
- Intestinal dysbiosis: Increased intestinal permeability, passage of bacterial LPS, chronic inflammation
- Estrobolome: Bacteria regulating estrogens, excessive hormonal recycling
2025 clinical evidence: Vaginal microbiota before transfer predicts success:
- Lactobacillus dominant: 48% pregnancy
- Bacterial vaginosis: 21% pregnancy
Our clinic now integrates microbiota screening and probiotic treatments.
Ferroptosis: Iron Toxicity
Ferroptosis is cell death by iron overload.
In endometriosis:
- Retrograde menstruation → massive iron release
- Endometriotic cells: iron resistance
- Oocytes/granulosa: ferroptosis vulnerability
Iron in endometrioma “rusts” adjacent ovarian tissue, decreasing reserve.
Perspectives: Iron chelators or ferroptosis modulators to protect fertility.
Non-Hormonal Treatments in Development
2025 revolution: Non-hormonal drugs targeting inflammation without blocking ovulation.
Promising candidates:
1. Linzagolix: Selective anti-inflammatory, Phase 3 (clinical trials)
2. JNK inhibitors: Target the immune pathway, lesion regression (Phase 1 human)
3. DCA (Dichloroacetate): Modifies endometriotic cell metabolism (Phase 2)
4. Immunotherapy: Checkpoint inhibitors repositioned
These treatments will allow pain management while preserving natural fertility.
Multidisciplinary Approach
Modern endometriosis treatment requires a team:
- Reproduction specialist (IVF, reserve)
- Minimally invasive surgeon (selected cases)
- Nutritionist (anti-inflammatory diet)
- Gastroenterologist (intestinal health)
- Pain specialist (chronic management)
Each patient has unique priorities requiring a personalized plan.
Frequently Asked Questions
1. Why is IVF now preferred over surgery in endometriosis?
The 2025 VODE study provided definitive scientific proof: the IVF-first strategy doubles the live birth rate (46% vs 23%). In my clinical practice, I observe that surgery, when performed solely to improve fertility, can damage ovarian reserve and waste 6-12 precious months. The ESHRE and ASRM recommendations confirm: surgery should be reserved for severe pain, not infertility alone.
2. Should endometriomas always be operated on before IVF?
No, this is the major change of 2025. I only operate on endometriomas in specific situations: uncontrolled severe pain, size >5-6 cm with ovarian compression, suspicion of malignancy, or impossible access for oocyte retrieval. For asymptomatic endometriomas <4 cm, direct IVF with PPOS protocol gives better results than surgery. Each operation removes healthy ovarian tissue and irreversibly decreases the reserve.
3. How many IVF cycles are needed with endometriosis?
According to the VODE study and my experience in our Istanbul clinic, the majority of patients achieve pregnancy within the first 1-2 cycles with the optimized PPOS protocol. The cumulative live birth rate reaches 46% as first-line treatment. Determining factors are your age, ovarian reserve (AMH, follicle count), and embryo quality, more than the stage of endometriosis. The toxic pelvic environment is bypassed by IVF, which explains its remarkable effectiveness.
4. Does vaginal microbiota really influence IVF results in endometriosis?
Absolutely, and this is a major 2025 discovery. Microbiota research shows that healthy vaginal microbiota (Lactobacillus-dominant) before transfer yields 48% pregnancy, versus only 21% in case of dysbiosis or vaginosis. In our clinic, we systematically perform screening 1-2 months before transfer. If necessary, we prescribe specific vaginal probiotics and sometimes targeted antibiotic treatment. This simple optimization can transform your success chances.
5. What new non-hormonal treatments are available for endometriosis?
This is the hope of 2025: treatments targeting inflammation without blocking ovulation. Linzagolix (selective anti-inflammatory) is in phase 3 clinical trials, so close to approval. JNK inhibitors show lesion regression in animals and are in human phase 1. DCA (dichloroacetate) targets the abnormal metabolism of endometriotic cells and is in phase 2. These revolutionary molecules will soon allow pain management while preserving natural fertility, unlike current hormonal treatments which are contraceptive by nature.
Conclusion: The New Era of Treatment
2025 marks a major turning point:
✅ IVF as first-line treatment (VODE: 46% vs 23%)
✅ Selective surgery (pain, mechanical obstacles)
✅ Optimized PPOS protocol
✅ Oocyte myth shattered (problem = environment, not oocyte)
✅ Systemic vision (microbiota, ferroptosis, inflammation)
✅ Promising non-hormonal treatments
What Can I Do For You?
In our IVF clinic in Istanbul, we apply these 2025 recommendations to create personalized plans.
Is pain your priority or do you want rapid pregnancy? What is your reserve? Do you have surgical history? Let’s evaluate together the best strategy for you.
The right information and right timing can double your success chances.
Schedule an appointment for a personalized consultation
📚 Scientific Summary
✔ ESHRE 2022-2025: No surgery to improve IVF only
✔ ASRM 2024-2025: PGT-A contraindicated, priority to non-hormonal treatments
✔ VODE 2025: IVF-first 46% vs surgery-first 23% live births
✔ HAS-CNGOF 2025: Non-invasive diagnosis, surgery in expert centers
✔ Microbiota 2025: Lactobacillus 48% vs dysbiosis 21% pregnancy
✔ Ferroptosis 2025: Iron toxicity affects oocyte quality and reserve
⚖️ Legal Disclaimer
Date of publication: November 3, 2025
This article by Dr. Senai Aksoy is informational. Each patient is unique. IVF results vary according to many factors. Always consult a specialist for your personal situation.
© 2025 Dr. Senai Aksoy - All rights reserved
Le contenu a été créé par Dr. Senai Aksoy et approuvé médicalement.