All stages of endometriosis are associated with infertility. The
nature of the association between minimal (stage I) or mild (stage
II) endometriosis and infertility is not clear. A common assumption
is that the endometriosis causes the infertility. Some have suggested
that it may in fact be that the infertility causes these early
stages of endometriosis. There is little scientific data to add
strength to either of these positions. One fact that has been
consistently found is that treatment of these early stage lesions
of endometriosis with either surgery or medications has no significant
demonstrable benefit in terms of fertility. The usual rationale
for treating early stage endometriosis if it is not associated
with pain (where treatment is shown to be beneficial) is that
the severity of the disease usually progresses over time and is
likely to develop into higher stage endometriosis if not removed.
The surgical treatment of stage III (moderate) or IV (severe)
endometriosis associated with infertility has been shown to be
beneficial in terms of fertility. Anatomic distortions, dense
pelvic adhesions or obstructive lesions caused by the chronic
inflammation of endometriosis are frequently able to be treated
effectively with modern surgical techniques.
There are several surgical tools that are designed to remove (ablate)
tissue, each with their own set of operating characteristics.
Additionally, the surgical approach may be via
* (1) laparotomy
- opening the abdomen and performing the surgery directly through
the large incision
- requires a stay in the hospital
- several week recovery period or
* (2) laparoscopy
- minimally invasive same day surgical approach
- a telescope is entered through an incision about 1 cm long
near the umbilicus and one to three smaller incisions are also
usually made in the lower abdomen for entry of additional instruments
- few day recovery period.
The surgical tools that remove, destroy or incise tissue include
* (1) scalpels and scissors,
a variety of blade sizes and shapes as well as scissor sizes and
shapes are available.
The knife is ideal for cutting the skin, with research documenting
greater tensile strength and faster healing in skin cut with a
knife as compared to the carbon dioxide laser, harmonic scalpel
or electrosurgical devices.
Scissors are ideal instruments for dissection of tissue and can
also be used effectively to cut tissues ranging from tough to
filmy. These instruments can be used to remove tissue on which
endometriosis has grown. Excised tissue will include some normal
tissue and any bleeding created needs to be controlled. This has
limited the use of these instruments in the routine treatment
* (2) electrosurgical devices
these can be adjusted to provide different amounts of power (20
to 80 watts is usually used) with different blends of cutting
and coagulation. A wide range of effects is possible. Pure cutting
current has little char (which acts to coagulate). Fulgaration
produces a superficial layer of char by holding the electrode
a small distance from the tissue and allowing the current to spark.
Lateral thermal damage with these instruments due to heating of
surrounding tissue limits their use in the ablation of endometriosis,
especially when close to other vital structures.
* (3) thermocoagulation devices
these differ from electrocoagulation devices in that they do not
deliver high frequency electrical current to generate heat in
the tissues. Rather they deliver heat directly via a hot metal
tip that is applied to the tissue. These devices are adjusted
to deliver heat at up to 160 degrees centigrade, and tissue generally
turns white when desiccation causes coagulation. Of course it
is necessary to avoid inadvertently touching tissues other than
those desired while using this tool and during its cool down period.
This is an ideal coagulating device but extensive lateral thermal
damage has limited its use in the treatment of endometriotic lesions
that are close to other vital structures.
* (4) lasers
these can deliver fine beams of intense energy to tissue with
the power density (watts per square centimeter) at the tissue
site determining the effect (vaporization, excision, coagulation).
There are different laser systems. These include fiber delivery
via KTP-532 or Nd:YAG lasers where the energy released from the
tip of the fiber diverges to dissipate the energy (highest closest
to the tip of the laser fiber). The carbon dioxide (CO2) laser
focuses the laser energy with a series of mirrors into differing
size spots that help to determine the power density at the tissue.
Also, the CO2 lasers can deliver the power in different wave forms
that determine the power density achieved and lateral thermal
damage. The most common laser in use for laparoscopy is the CO2
laser and the optimal wave form is the ultrapulse wave.
* (5) the harmonic scalpel
this is a device that incorporates a tip that vibrates at an ultrasonic
frequency to rapidly denature proteins and separate tissue with
little generated heat. Conceptually, this is a great tool for
ablation of endometriosis and lysis of adhesions. Experience with
the harmonic scalpel has not yet led to widespread acceptance
of this tool. Additionally, the results seen on second look laparoscopy
several weeks following its use have had mixed findings.
* (6) the cavitron ultrasonic surgical aspirator (CUSA)
this is widely used for tumor debulking by gynecologic oncologists.
It has a vibrating tip that reacts to an alternating electromagnetic
field (alternates 23,000 times per second) and produces significant
heat such that cooling is provided by saline liquid solution sprayed
over the tip at a rate of 3-10 ml per minute. This is not commonly
used for treatment of endometriosis.
Surgical success in the treatment of endometriosis is related
to the severity of disease at the time of surgery. Reported pregnancy
rates following surgery are in the 35% range for severe endometriosis
and up to 60% if moderate endometriosis. Although an occasional
infertility specialist may routinely use medication to further
treat endometriosis postoperatively, this is generally avoided
so as to focus the attempt at achieving pregnancy since the best
success in fertility is within a year of surgery.
The decision on whether to proceed with endometriosis surgery
includes the following considerations:
- * reportedly there is a good cumulative long term pregnancy
rate with untreated stage I and stage II endometriosis, up to
90% in 5 years (compared to a normal fertility rate of 90% in
- * in patients with endometriosis, COH (controlled ovarian
hyperstimulation) and IUIs (intrauterine inseminations) appear
to improve the fecundity (rate of pregnancy per cycle) but does
not clearly improve the overall cumulative pregnancy rates (which
are high if viewed over 5 years).
- * endometriosis that causes mechanical interference
preventing or limiting the egg and sperm from meeting can be effectively
treated surgically. Medical management of endometriosis does not
effectively treat anatomic distortions and adhesions;
- * when endometriosis must be removed from the ovary,
even when deeply invading or causing nonfunctional cysts (called
endometriomas), a goal should be to preserve as much ovary as
possible since as little as 10% of one ovary may allow fertility
- * hormonal (medical) management of endometriosis has
no proven value in terms of fertility yet can effectively treat
some patients with pain due to endometriosis
- * endometriosis tends to recur (return) since the cause
(such as retrograde menstruation, vascular or lymphatic dissemination
or metaplasia of the coelomic epithelium) of the endometriosis
can not be treated. The recurrence rate of endometriosis is unpredictable,
but is generally reported in the range of 5-20% per year with
a cumulative rate over 5 years of about 40%.
- * progressive severe dysmenorrhea (pain during the
menses) is typically associated with deep lesions of endometriosis
that are often not adequately treated with medication alone
- * many patients with infertility and endometriosis
have absolutely no dysmenorrhea (possibly due to a reduction in
nerve endings that register painful stimuli in the peritoneum
of the pelvis), incorrectly feel that the lack of pelvic discomfort
means that they do not have significant endometriosis, and continue
with their fertility efforts without treatment
- * a couple that has not achieved a pregnancy after
2 years of appropriate management following surgical treatment
for endometriosis has a poor prognosis in term of fertility
- * the most effective long term treatment of endometriosis
is removal of the uterus and the ovaries, an undesirable (or unacceptable)
option for women interested in reproduction.
- * if a patient has decided to undergo radical endometriosis
surgery (removal of the uterus and some ovarian tissue) and is
younger than 40-45 years of age, leaving an "uninvolved ovary"
in place appears to increase the risk for recurrence of endometriosis
only slightly. The remaining ovary would then be able to supply
the patient with hormones that are beneficial to her until menopause.
- * atypical endometriosis has a varied appearance that
takes experience to recognize, may be quite active in response
to the sex steroid hormones, and should be removed if the decision
to treat stage I or II endometriosis surgically has been made.
In fact, there is a high rate of endometriosis identified on pathology
report in biopsies of normal appearing peritoneum both in women
with endometriosis documented elsewhere (up to 40%) and in infertile
women without any visible endometriosis (up to 15%).
- * when endometriosis is incidentally found in a young woman
who is not immediately interested in fertility, placement on birth
control pills may be considered if early stage disease (to reduce
the progression of the disease) or ovulation suppressing medications
if more advanced disease (to reduce the bulk of disease).