Pregnancy and delivery outcomes in women with rectovaginal endometriosis treated either conservatively or operatively

Women with rectovaginal endometriosis treated either conservatively or operatively have good reproductive prognosis in long-term follow-up but the rate of complications is high during pregnancy and delivery.

VOLUME 115, ISSUE 2, P406-415


Anni Tuominen, M.D., Liisu Saavalainen, M.D., Ph.D., Aila Tiitinen, M.D., Ph.D.,
Oskari Heikinheimo, M.D., Ph.D., Paivi Harkki, M.D., Ph.D.



To study reproductive outcomes, and pregnancy and delivery complications after conservative or operative treatment of rectovaginal endometriosis during long-term follow-up.


Retrospective cohort study.


University hospital.


Women with rectovaginal endometriosis referred to hospital due to any indication from 2004 to 2013 (N = 543) who were treated initially either conservatively (group CONS, n = 183), or operatively (OPER, n = 360) either with resection of rectovaginal nodule (RVR, n = 192) or with concomitant bowel resection (BR, n = 132).


Conservative or operative management.

Main Outcome Measure(s)

Clinical pregnancy rate, live-birth rate, and assessment of the complications during pregnancy and delivery.


Between women in the CONS group or OPER group, no differences were found in either clinical pregnancy rate (56%, n = 102 vs. 50%, n = 181) or live-birth rate (48%, n = 87 vs. 42%, n = 153). Of the pregnancies, 64% (n = 65) and 49% (n = 89), respectively, started after medically assisted reproduction. No differences emerge in the subanalysis of women <40 years-old who wished to conceive. The most common pregnancy complication was preterm birth: 15% (n = 13) in the CONS group and 20% (n = 30) in the OPER group. The cesarean delivery rate also was high (46%, n = 40 vs. 49%, n = 76). Complications emerged in 21% (n = 10) versus 29% (n = 23) of vaginal deliveries and 45% (n = 18) versus 53% (n = 40) of cesarean deliveries. The most common delivery complication was excessive bleeding. The follow-up period was 4.9 years in the CONS group and 5.6 years in the OPER group.


Women with rectovaginal endometriosis have comparable and good reproductive prognosis regardless of the treatment method.

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Dear Dr William Gibbons

We highly appreciate your kind editorial on our article concerning reproductive outcome in women with RVE treated either conservatively or operatively. We do believe that we can choose the treatment of RVE based on the symptoms; women suffering from severe pain should be operated but women having tolerable pain together with a wish for pregnancy could be first offered medically assisted reproduction without surgery. Every woman is entitled to the best possible treatment and that is why centers of excellence are recommended by WES, ESHRE and ESGE for both infertility treatment as well as for endometriosis surgery. In addition, continuous collaboration with infertility and operative colleagues helps to optimize the treatment for each woman. Operative treatment should be carried out according to the international guidelines with multidisciplinary teams to avoid repeat and incomplete surgeries (1-2). Surgical experience seems to be important for the good outcome (3).

Women living with RVE have good reproductive prognosis but high number of pregnancy and delivery complications. Most of the deliveries end up in Cesarean section. Women should be informed of these risks and thorough follow-up of these pregnancies is recommended.

Päivi Härkki MD PhD

Corresponding author

Department of Obstetrics and Gynecology

Helsinki University Hospital, Helsinki, Finland

  1. Dunselman GAJ, Vermeulen N, Becker C et al. ESHRE guidelines: management of women with endometriosis. Hum Reprod 2014;29(3):400-12.
  2. Working group of ESGE, ESHRE and WES. Keckstein J, Becker CM, Canis M et al. Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis. Hum Reprod Open. 2020 Feb 12;2020(1):hoaa002.
  3. Byrne D, Curnow T, Smith P et al. Laparoscopic excision of deep rectovaginal endometriosis in BSGE endometriosis centres: a multicentre prospective cohort study. BMJ Open2018 Apr 9;8(4):e018924.