Endometriosis is a chronic disease. It affects about 6-10% of women in their reproductive life. Infertility occurs in about 60% of women with endometriosis.

Due to its high recurrence rates, we are often faced with a dilemma between performing ART (assisted reproductive technology) or using a surgical approach initially.
 

There is continued debate as to the merits of surgery in endometriosis. The question remains whether surgical excision may cause damage to the residual ovarian function.

Endometriosis presents in three different ways:
 

1. Peritoneal endometriosis.
2. Ovarian endometriosis.
3. Deep infiltrating endometriosis.

Peritoneal Endometriosis.

Surgery to remove adhesions (scar tissue) and remove the endometriosis implants is more effective than just a diagnostic laparoscopy. However, expectant treatment without surgery has also been shown to be effective in early stages of the disease.
 

The decision to either use Art or continue with expectant management is dependent upon the patient’s age, duration of infertility, type and results of previous treatments and the presence of male factor infertility.

Relief of pain following surgery, one year after the surgical procedure is between 50-95%.

Ovarian Endometriomas.

Studies have shown that 17-44% of patients with endometriosis related infertility present with ovarian endometriosis, (chocolate cysts).
 

Patients presenting with endometriomas generally undergo surgery followed by ART. However, the size of the endometriomas is an important issue. Some researchers have used 4 centimeters (cms) as the cutoff. Less than 4 cms, the patient may proceed directly to ART, whereas the larger cysts are initially removed with surgery.
 

The surgical decision is made based upon the following factors: Patient’s age, ovarian reserve, previous pelvic surgery, presence of pain and the mean diameter of the cyst.
 

The possibility of removal of normal ovarian tissue and vascular damage to the ovary is always a consideration.

Since there is a high rate of recurrence, repeat surgical excision is discouraged.

Deep Infiltrating Endometriosis.

Deep endometriosis occurs in the area between the rectum and the vagina (rectovaginal septum). It affects about 20% of  endometriosis patients.
 

It affects the uterosacral ligaments, the rectosigmoid colon, the vagina and the bladder in decreasing order. The degree of pelvis pain has a poor co-relation with the extent of the disease. Clinical and imaging exams are needed to make the diagnosis. Magnetic resonance imaging (MRI) is the best technique to diagnose deep endometriosis.

Surgical treatment is the best option for this disease.
 

Fertility outcomes range from 44-70% after surgical resection. Spontaneous pregnancy rates are about 30% after the surgery.

Finally, there is the option of doing an ART cycle and freezing eggs before major endometriosis surgery is undertaken.

To summarize:

Peritoneal endometriosis can be treated laparoscopically or by ART. Ovarian endometriomas tend to be handled surgically, but the age of the patient and the size of the lesion are factors that influence the best therapeutic option. ART may be required after surgery. Deep infiltrating endometriosis is treated by surgical excision as the first choice.