The case for surgery for endometriosis
Benefits and complications of therapy
With regard to fertility, excisional surgery improves rates of spontaneous pregnancy in the 9 to 12 months after surgery as compared to ablative surgery.19 Moreover, laparoscopic surgery has been demonstrated to improve rates of live birth and pregnancy compared with diagnostic laparoscopy alone. In contrast, there is no evidence that medical treatment improves clinical pregnancy rates.19 Although management of endometriomas is controversial, medical therapy may lead to temporary reduction in size but not resolution of cysts. Therefore, surgery is the recommended primary approach for symptomatic and/or large cysts and there are no indications for prescribing medical treatment before cystectomy.20
Gonadotropin-releasing hormone analogs (GnRH-a) and minimally invasive surgery are associated with increased pregnancy rates in women with endometriosis, but GnRH-a, danazol, and depot progestogens are associated with a higher incidence of adverse events.21 Lastly, data have been published on damage to ovarian tissue by excision of endometriomas. However, surgery remains the gold standard, provided that it is performed with proper techniques by highly trained surgeons.22 In fact, previous medical treatment of endometriosis or large cyst size may be a significant factor associated with higher rates of disease recurrence.23
Patients with endometriomas may have decreased ovarian reserve compared with age-matched subjects with other benign ovarian cysts, suggesting that an endometrioma may be harmful to ovarian reserve if left unchecked. With early surgical intervention, that could potentially be avoided, preventing occurrence of endometriomata in the first place.24
Laparoscopic resection can relieve endometriosis-associated symptoms and enhance psychological well-being.25 Complete excision, including vaginal resection, can offer significant improvement in sexual function, quality of life, and pain in symptomatic patients,26 and a well-trained interdisciplinary team can perform laparoscopic treatment of deeply fibrotic endometriosis with a low incidence of major complications.27
In contrast, medical therapy is neither diagnostic nor a long-term treatment option. Counseling patients to undergo a lengthy protocol of suppression serves only to further delay the diagnosis and definitive treatment. GnRH-a administration may be followed by a temporary improvement of pain in patients with incomplete surgical treatment, but it has no role in postsurgical pain when a surgeon is able to completely excise disease.28 Hence, surgery is the diagnostic and gold standard treatment, although indeed results are often operator-dependent.