A recent consensus statement on endometriosis and infertility indicates that some women may benefit from a combination of assisted reproduction and surgery. Unfortunately the data are limited and somewhat conflicting. This is not uncommon when surgery is involved as there is inevitably a degree of operator (or surgeon) dependence. It is self-evident with diseases such as endometriosis that the surgeon can be a major differentiator in terms of successful operations. The situation is vastly different from the removal of an appendix or a gallbladder where it is easier to define success and also easier to track and define complication data. Endometriosis can take many forms and stages and it may at times be difficult to perceive the extent of disease. By way of example I am quite sure that many patients have been labelled as having pelvic inflammatory disease (PID) when in fact they have severe endometriosis with cul de sac obliteration which has not been recognized as such. Experience may not necessarily be advantageous. Many surgeons may have had a long “experience” dealing with endometriosis but if their understanding of the disease and surgical techniques are limited outcomes will be suboptimal. At this time, certainly in Australia, most generalist obstetricians and gynaecologists would consider that they have the surgical skills to cope with all but the most severe cases. Whilst this may have been the case in the past I believe the situation is evolving rapidly particularly in the management of those infertile patients with severe endometriosis. It is worth considering that in virtually every other surgical discipline the trend has been to move towards sub specialization. By way of example I have just had my shoulder operated on and made very sure my orthopaedic surgeon only operated on shoulders.
Ovarian endometriosis or endometriomas (chocolate cysts) are fortunately rare but represent the more severe stage of disease. They are rarely isolated, often associated with more significant disease and it is not uncommon for the bowel to be involved. In some respects they serve as a marker for severe disease and certainly bowel involvement should be suspected. In this group in particular it makes sense to actively look for the most common form of bowel involvement. Recently new techniques in ultrasound have allowed the identification of bowel involvement although this can be difficult particularly in the presence of large endometriomas. The technique offers the tantalizing possibility of decreasing the number of diagnostic laparoscopies that are performed.
The published literature in relation to the treatment of ovarian endometriomas particularly with regard to fertility is limited. It is controversial as to whether removing endometriomas improves pregnancy rates although there are data to support this and the Cochrane review lists ovarian cystectomy as a preferred surgical option to simple drainage and ablation. The data have revealed an increase in the pregnancy rates when the endometriosis is removed and ovarian cystectomy performed.
Recent data from our own unit and others around the world have unfortunately changed the dynamics. Previously the surgical plan was to deal with all of the endometriosis including the ovarian cyst and possibly bowel resection and then attempt spontaneous conception. Should this not have occurred within a timely fashion IVF was then employed. This new data creates particular difficulties with this strategy. It appears there is an up to 50% decrease in the AMH level of patient’s with endometriosis and this clearly has significant effects in terms of ovulatory reserve and the subsequent chance of conception. This is a particularly difficult scenario if people already have a depressed AMH or for those patients over the age of 35 where age is also depressing the levels. It then becomes exceedingly difficult to decide the most appropriate path of management. This group in particular would benefit from consulting with a practitioner who practices both surgery for endometriosis and assisted conception. We have been contemplating simple drainage of the endometrioma with, if at all possible, removal of further endometriosis encountered within the pelvis (including bowel resection) and then either spontaneous conception or IVF. Particularly in those with limited ovarian reserve we have been utilising strategies to as far as possible decrease any ovarian damage thus further decreasing ovarian reserve. At times this strategy may require resort to repeat surgery, hopefully following conception, to deal with the ovarian endometriosis. In those patients who are younger or not in a relationship further difficulties are encountered and this may be a group where oocyte vitrification (egg freezing) may be a reasonable strategy to consider also.
At this stage the situation is far from clear as to what the preferred approach is although increasingly I am beginning to treat ovarian endometriosis more conservatively especially when fertility is a concern.