Abstract
Endometriosis is the presence of endometrial glands or stroma outside of the uterine cavity. While it is difficult to estimate overall incidence, it is thought that up to 10% of reproductive-age women have endometriosis, which can often result in infertility and pelvic pain. The variation and spectrum of symptoms produced by endometriosis can make patient management challenging, as some patients will present with debilitating pelvic pain and some will have few, if any, symptoms. Definitive diagnosis is made surgically, often with histological correlation. Symptomatic women can be managed either medically or surgically. Further complicating the treatment is the infertile patient with known or suspected endometriosis. While surgical treatments may benefit many patients with endometriosis-associated infertility, there is a subset of patients who may benefit more from proceeding to assisted reproductive technology. This paper will discuss surgical management of endometriosis in women with the primary complaint of infertility and women with the primary complaint of pain. Additionally, we will cover the surgical management of endometriomas, as well as their impact on fertility. Finally, we will discuss recurrence following surgical treatment. In all women with endometriosis, recurrence is common and measures must be taken to reduce the recurrence risk after any treatment.
Disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
Key issues
• Endometriosis causes debilitating pelvic pain and can contribute to infertility.
• Laparoscopy is a means for both diagnosis as well as treatment of symptoms and improvement in fertility rates.
• Even the best surgeon has a significant risk of morbidity when dealing with deeply infiltrating endometriosis, so conservative surgery is recommended if fertility is the main goal of treatment.
• Surgical excision of ovarian endometriomas appears to have better outcome than drainage with coagulation/vaporization of the cyst wall and less recurrence.
• If a patient needs a second surgery for recurrence of endometriosis or endometrioma in the presence of infertility, they may be better served by using assisted reproductive technology.
• Medical treatment can suppress the recurrence of endometriosis, but the effect is less clear with pelvic pain symptoms only, as multiple etiologies for pain are often present.