Endometriosis: Surgical Therapy

Women of childbearing potential who have asymptomatic endometriosis do not require surgical repair. After ruling out a tubal (“fallopian tube-related”) infertility factor or a male cause of infertility, hormonal stimulation therapy followed by insemination (sperm transfer) can be performed.

Surgical therapy of endometriosis is indicated only in cases of acute or chronic recurrent (“recurring”) endometriosis-induced symptoms or in cases of unfulfilled desire to have children. It involves resection (surgical removal) of endometriosis lesions, loosening of adhesions (adhesions) and, if possible, restoration of dysfunction of affected organs and, if necessary, restoration of fertility (fertility).

The surgical procedure for infertility and endometriosis depends largely on the stage of endometriosis:

Indications

  • Minimal to mild endometriosis (ASRM I-II).
    • Laparoscopy with resection of the foci results in an increase in live births and pregnancy rate (SSR).
    • Excision or ablation of endometriosis foci resulted in an increase in SSR compared with diagnostic laparoscopy.
    • Repeated surgery led to a reduction in SSR.
  • Moderate to severe endometriosis (ASRM III-IV).
    • The ESHRE (European Society of Human Reproduction and Embryology) guideline gives the supervising physician the choice of performing surgical laparoscopy to increase spontaneous SSR. In doing so, the surgical risk should be critically weighed beforehand in comparison to the symptoms and the desire for a spontaneous pregnancy. Furthermore, the age of the patient should be considered: e.g., note that naturally reduced fertility is present after the age of 35, even without endometriosis.
  • Deep infiltrating endometriosis (DIE).
    • Indication for surgery: improvement of pain symptoms or functional limitations of the bowel. In this context, the preservation of the ovaries and the uterus should be the primary goal in women who wish to have children.

Reasons for surgery before performing reproductive medicine procedures (“assisted reproduction technologies” ART) are:

  • Minimal to mild endometriosis (ASRM I-II).
  • Improvement of puncture access to the ovary
  • Treatment of a saccosalpinx (sac-shaped deformed fallopian tube (uterine tuba), which is closed at the ampulla end and cystically expanded) to improve IVF outcome.

The procedure

Laparoscopy (laparoscopy)/pelviscopy is considered the method of choice not only for therapy but also for histological diagnosis and is also helpful for staging. Complex operations involving e.g. bladder, bowel or ureters should be performed in an appropriate center.

Further notes

  • Postoperative hormone therapy may result in prolongation of the recurrence-free interval.