Fig. 28.1
(a) Case of right infundibulopelvic ligament with surface endometriosis. (b) Brownish multiple areas of superficial peritoneal endometriosis in the pelvis
“Excision or ablation of endometriotic lesions plus adhesiolysis to improve fertility in minimal-mild endometriosis is effective compared to diagnostic laparoscopy alone to improve ongoing pregnancy rates” [2] (evidence level 1a). CO2 laser vaporization of endometriosis can be considered instead of monopolar electrocoagulation, since laser vaporization is associated with higher cumulative spontaneous pregnancy rates (grade C recommendation). Excision of the cyst wall rather than drainage and coagulation increases spontaneous pregnancy rates (ESHRE 2014 guidelines, grade A recommendation) [2]
The Cochrane Collaboration meta-analysis suggests an improved pregnancy rate (6R 1.66, 95 %; CI 1.01–2.51) and a pregnancy continuing beyond 20 weeks (OR 1.64, 95 %; CI 1.05–2.57), with laparoscopy in these patients [3]. Hence, 3–100 laparoscopies would be required to achieve one extra pregnancy. The risk of low complications of laparoscopy has to be weighed against this advantage while making an informed decision with the patient.
28.3 Surgical Treatment in Moderate or Severe Endometriosis and Endometriomas: AFS Stage III, IV, and Above
In patients with moderate or severe endometriosis, the chances of spontaneous conception are low at a monthly fecundity rate of < 3 %. In those with pain additionally as a symptom, surgical clearance of endometriotic disease has resulted in significant pain relief.
As per the ESHRE 2014 guidelines, “no RCTs or meta-analyses are available to answer the question whether surgical excision of moderate to severe endometriosis enhances pregnancy rate.” Two prospective cohort studies showed crude spontaneous pregnancy rates of 57–69 % (moderate endometriosis) and 52–68 % (severe endometriosis) after laparoscopic surgery, which are much higher than the crude pregnancy rates of 33 % (moderate) and 0 % (severe) after expectant management. So, operative laparoscopy can be considered instead of expectant management to increase spontaneous pregnancy rates (grade B recommendation) [2].
A good practice point made is that laparoscopic ovarian cystectomy is recommended:
If an ovarian endometrioma ≥3 cm in diameter is present to confirm the diagnosis histopathologically
To reduce the risk of infection
To improve access to follicles
To improve ovarian response
The woman should be counseled regarding the risks of reduced ovarian function after surgery and the loss of the ovary/ovaries. The decision may be reconsidered if she has had previous ovarian surgery.
28.4 Effect of Ovarian Cystectomy on Ovarian Reserve
It has been shown that previous cystectomy did not predispose to the risk of removing normal ovarian tissue and compromising ovarian function [4, 5] suggesting that “multiple cystectomies might not be a risk factor for the removal of normal ovarian tissue provided the procedures are performed by experienced surgeons” (Figs. 28.2a–c and 28.3a–c) [5].
Fig. 28.2
(a) Endometriomas with adhesions in pouch of Douglas. (b) Small multiple endometria dissected; use sharp dissection during cyst excision where possible and in the adherent areas. (c) Peeling of large endometriotic cyst wall in progress; cauterize vessels on the side of the cyst wall rather than on the ovarian surface
Fig. 28.3
(a) Adherent appendix to endometrioma. (b, c) Retroperitoneal dissection of ureter enables safer excision of endometriotic disease in the area
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