How should deep infiltrating endometriosis be managed in infertile patients?

[Verified against ESHRE Guideline: Endometriosis 2022] ESHRE makes a strong recommendation that the decision to offer surgical excision of deep endometriosis lesions prior to ART should be individualised — rather than recommending for or against as a general policy. That framing is deliberate and should be reflected in counselling. The factors that shape the decision include symptom burden and whether pain is the primary problem, lesion site and extent, bowel or urinary tract involvement, prior surgery, ovarian reserve, the woman's age and how much time she has, and the surgical expertise available. The reason ESHRE does not generalise is that deep endometriosis surgery is high-risk in a way endometrioma cystectomy is not — bowel resection, ureteric injury and long-term bladder dysfunction are real possibilities, and outcomes depend heavily on surgeon and centre volume. Where pain is the dominant symptom, surgery may be justified on that basis alone regardless of the fertility question. Where fertility is the primary goal and symptoms are tolerable, proceeding to ART without prior excision is a defensible position, given that routine surgery before ART is not recommended for improving live birth rate. Referral to a centre with dedicated expertise is appropriate for anything beyond straightforward disease. This should be a multidisciplinary decision, not one made in a single fertility consultation.