Surgery is not the only treatment for endometriosis with infertility. While surgery can improve chances of spontaneous conception for some cases of mild or moderate endometriosis, it also carries risks of damaging organs and reducing ovarian reserve. For many women with endometriosis-related infertility, medical management or assisted reproductive technologies like IVF may be better options depending on the individual's symptoms, disease extent, age, and fertility goals. The benefits of any treatment must be weighed against risks and alternatives, as each case of endometriosis is unique.

1. AGAINST the Motion-
“Surgery is the ONLY treatment of
Endometriosis with Infertility”
Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (New Delhi)
MRCOG (London)
Advanced ART Course for Clinicians (NUHS, Singapore)
Consultant: Reproductive Medicine, Genome Fertility Centre,
Kolkata
Convener: Spectrum MRCOG Course, Kolkata
Winner: Prof Geoffrey Chamberlain Award, RCOG World Congress,
London, 2019

2. AGAINST?
Endometriosis surgery should be performed
ONLY be persons
• Having adequate training
• Having expertise in dealing with such complex
procedure
• In the multidisciplinary team (MDT) setup
*ESHRE, 2014; NICE, 2017; RCOG, 2017; ETIC, 2018

3. Difference between
“what we can” and “what we should”.

4. Surgery is one of the treatments of
Endometriosis with Infertility
Peritoneal Endometriosis-
• Both ablation and excision improve the chance of spontaneous conception in
ASRM stage I/II endometriosis (CO2 laser vaporization > monopolar
electrocoagulation)
Ovarian Endometrioma-
• ≥3 cm- cystectomy preferred to drainage and coagulation/ CO2 laser vaporization
• controversial if cumulative pregnancy rate is more after surgery but time to
achieve the first pregnancy in infertile patients was significantly shorter
Deep Endometriosis-
• radical excision of endometriosis combined with bowel segmental resection and
anastomosis was associated with a higher postoperative spontaneous pregnancy
rate
*ESHRE, 2013

5. “Surgery is the ONLY treatment of
Endometriosis with Infertility”

6. Case 1
• Mrs FR, 32 years, has been trying for
pregnancy for last 2 years. AMH, AFC, HSG all
normal.
• Husband is having severe oligospermia. Donor
sperm is no acceptable. Opts for IVF-ICSI.
• 6 cm right ovarian endometrioma, minimum
dysmenorrhoea.

7. Endometrioma and IVF Outcome
1. Lower serum AMH
2. Inadequate ovarian response to gonadotrophin
3. Lower number of oocytes retrieved (mean
difference –0.23; 95% CI 0.37–0.1)
4. Higher cancellation rate (OR 2.83; 95% CI 1.32–
6.06)
*Maneschi et al., 1993; Sanchez et al., 2014; Coccia et al., 2014; Somigliana et
al., 2014; Hamdan et al., 2015; Goodman et al., 2016; Ferrero et al., 2017

8. Extrapolating…….

10. Surgery prior to IVF
• Lowers serum AMH levels further
• Progressive decline in ovarian reserve
• Higher gonadotrophin consumption
• Lower number of oocyte retrieved
*Raffi et al., 2012; Somigliana et al., 2012; Sugita et al., 2013; Hamdan et al.,
2015; Polyzos and Sunkara, 2015; Brink Laursen et al., 2017; Tao et al., 2017;
Nickkho-Amiry et al., 2018

11. IVF in Endometrioma
(ESHRE, 2013)
12

12. IVF in Endometrioma
(ESHRE, 2013)
13

13. Complications during and after OPU
• Technical difficulties during oocyte retrieval is low,
• No data to suggest that surgery will prevent adhesion reformation
and facilitate oocyte retrieval effectively.
• Risks of infection from an endometrioma (0–1.9%)
• Progression of pelvic endometriosis and ovarian endometriomas-
?
*Koch et al., 2012; RCOG, 2017

14. Risk of missing malignancy
• Extremely low in endometrioma
• The lifetime probability of Ca ovary 1-2% in the
presence of an endometrioma.
• In the context of IVF treatment, delaying surgery
for a few months or years, until the treatment
has been completed or following delivery, would
usually be a reasonable course of action unless
there are other immediate concerns.
*RCOG, 2017

15. RCOG Scientific Impact Paper (2017)
Directly ART
• Asymptomatic women,
• women of advanced
reproductive age,
• those with reduced
ovarian reserve,
• B/L endometriomas,
• a history of prior ovarian
surgery
Surgery before IVF
• highly symptomatic
women,
• with an intact ovarian
reserve,
• unilateral and large cysts,
• cysts with suspicious
radiological and clinical
features.
16

16. Endometriosis as a cause of IVF
Failure
• Undetected endometriosis- reason for RIF
• Altered endometrial receptivity- aromatase, B-3 integrin
expression
• Need to do 40 laparoscopy to achieve a pregnancy
• Down-regulation with GnRH agonist and letrozole may be
useful in RIF patients without surgically proved
endometriosis
*Lessey et al., 1996; ASRM, 2012; Khayat et al., 2018; Moustafa and Young,
2020

17. “Medical therapy is not useful in
Endometriosis-Infertility”

18. Case 2
• Mrs AB, 33, P0+0, had been trying to conceive
for one year. She is having severe
dysmenorrhoea not responding to NSAID.
There was 4 cm endometrioma in right ovary.
• HSG, AMH (2.1 ng/ml), husband’s semen- all
are normal.
• She underwent laparoscopy- ovarian
cystectomy and adhesiolysis. Tubal patency
was confirmed.

19. Case 2 (Contd.)
• Mrs AB, now 37 presented 4 years after the
initial laparoscopy. Tried many cycles of OI and
IUI. She wants to try IVF.
• Now there is 6 cm endometrioma in right
ovary.
• Dysmenrrhoea is well controlled with NSAID.
• AMH 0.8 ng/ml

20. IVF can NOT be the only treatment
Medical Overuse
• a combination of overtesting/overdiagnosis with
overtreatment that results in an unfavorable
balance between
1. incremental benefits
2. risk of harms
3. cost of healthcare interventions
*Moynihan et al., 2012; Colla, 2014; Morgan et al., 2016

21. 1. 3-10% chances of damaging
the surrounding organs-
bladder, bowel, ureter, nerves
2. Risk of oophorectomy.
3. Complete excision of
endometriotic tissue not
possible.
4. May not reverse the
inflammatory and
biomolecular changes shown
to influence fertilisation and
implantation.
*Vercellini et al., 2009; Lebovic, 2016

22. Case 3
• Mrs PC, 32, trying for pregnancy for 1 year.
• All investigations (Semen, AMH, HSG) normal.
• 2 cm endometrioma in left ovary.
• No pain.

23. Conservative management for spontaneous
conception
Encourage to try natural conception before seeking fertility treatment-
1. Young women,
2. regular menstrual cycles and
3. an incidental finding of an ovarian endometrioma
4. without suspicion of malignancy
•43% spontaneous pregnancy rate during the 6-month follow up period
•Similar ovulation rates in the affected ovary to the healthy ovary
*Benaglia et al., 2009; Leone Roberti Maggiore et al., 2015; RCOG, 2017
25

24. Unexplained infertility and
Endometriosis
• 20-40% cases of unexplained infertility may be
because of undiagnosed endometriosis
*Hurt, 2003; Fadhlaoui et al., 2014

26. Disclaimer

27. Recent Studies on Endometriosis and
Unexplained Infertility
• RCTs- Parazzini, 1999; Gad and Badroui, 2012

28. Recent Studies on Endometriosis and
Unexplained Infertility
• RCTs- Parazzini, 1999; Gad and Badroui, 2012
• Meta-Analysis
Jacobson et al., 2010 Duffy et al., 2014
OR for ongoing pregnancy (95% CI) 1.64 (1.05– 2.57) 1.94 (1.20–3.16)
The number of infertile women that should
undergo destruction of superficial peritoneal
endometriosis
12 8
The prevalence of grade I/ II endometriosis among
women with unexplained infertility
≤50%
NNT 24 16

29. Recent Studies on Endometriosis and
Unexplained Infertility
• RCTs- Parazzini, 1999; Gad and Badroui, 2012
• Meta-Analysis
• Success rate of IVF - ∼25% (NNT- 4)
*European IVF-Monitoring Consortium (EIM) for ESHRE, 2016
Jacobson et al., 2010 Duffy et al., 2014
OR for ongoing pregnancy (95% CI) 1.64 (1.05– 2.57) 1.94 (1.20–3.16)
The number of infertile women that should
undergo destruction of superficial peritoneal
endometriosis
12 8
The prevalence of grade I/ II endometriosis among
women with unexplained infertility
≤50%
NNT 24 16

30. Staging of Endometriosis
• Does not correlate well with the symptoms of
pain or fertility.
• Offer endometriosis treatment according to
the woman's symptoms, preferences and
priorities, rather than the stage of the
endometriosis.
*NICE, 2017

31. • Routine laparoscopy should NOT be done in
women with infertility without pelvic pain
(Quality of evidence- High)
• Consider surgery for superficial endometriosis
ONLY in women
1. Having moderate-severe pain
2. Seeking natural conception, declining ART

32. Deep endometriosis - asymptomatic
• Uncommon to be asymptomatic
• Uncomplicated- If no symptoms of ureter/
bowel stenosis- No need of surgery
• 9 out of 10 will not progress
• Improper resection will worsen bowel/
bladder symptoms
*Dunselman et al., 2014; Berlanda et al., 2016; ETIC, 2018

33. Deep endometriosis- when to operate
Only when-
1. Occlusive disease (ureter/ bowel)
2. Wishing natural conception, declining IVF
*Dunselman et al., 2014; Berlanda et al., 2016; ETIC, 2018

34. Patient's age
Pain symptoms
Extent of disease
Patient's
reproductive
plans
Treatment risks
Side effects
Cost
considerations
Every
endometriosis
is different

35. Conclusion
• ‘Endometriosis should not be treated just
because it’s there’ (Thomas, 1993).
• Surgery is one of the treatment modalities in
improving pain.
• Surgery can improve the chance of natural
conception in some cases.
• The potential benefits must be balanced
against the risks and alternatives.
• Surgery is NOT the ONLY treatment

38. “Only”, “Never, “Always” !!!