Endometriosis and Reproductive Sparing Surgery: A Narrative Review and AGREE II-S-Based Evaluation of International Guidelines

Endometriosis is a complex disease that may affect a woman's fertility and quality of life. Owing to substantial variations in symptom severity, lesion distribution, and reproductive impact, its management presents considerable clinical challenges. The most recent internationally recognized guidelines include those issued by the European Society of Human Reproduction and Embryology (ESHRE, 2022), the German Society of Gynecology and Obstetrics (DGGG/SGGG/OEGGG S2k, 2025), the World Endometriosis Society (WES), the National Institute for Health and Care Excellence (NICE, 2024), and the American College of Obstetricians and Gynecologists (ACOG, reaffirmed 2022). To provide a comprehensive overview of these recommendations, we critically compared these guidelines, with particular emphasis on the recently updated German S2k guideline. Searches were conducted through PubMed and institutional repositories using selected key terms, and the AGREE II tool (Appraisal of Guidelines for Research and Evaluation) was employed to assess methodological quality. Key clinical domains examined included indications for conservative and radical surgery, management of endometriomas and deep infiltrating endometriosis (DIE), the role of surgery before Assisted Reproductive Technology (ART), the impact of second-look procedures, and integration of psychosocial dimensions via Patient-Reported Outcome Measures (PROMs). The results show a general trend toward interdisciplinary treatment models, cautious use of radical resection techniques, and customized, symptom-based surgical interventions. Despite ongoing disagreements, there is general agreement on collaborative decision-making, preserving fertility, and adjusting surgery time and technique between the guidelines to meet the requirements of individual patients.