Surgery for endometriosis: beyond

medical therapies
Sukhbir S.
Sukhbir S. Singh,
Singh, M.D.
M.D. and
and Michael
Michael W.W. H.
H. Suen,
Suen, M.D.
M.D.
Department of
Department of Obstetrics,
Obstetrics, Gynecology
Gynecology and
and Newborn
Newborn Care,
Care, University
University of
of Ottawa;
Ottawa;
Ottawa Hospital
Ottawa Hospital Research
Research Institute,
Institute, Ottawa,
Ottawa, Ontario,
Ontario, Canada
Canada

Andrew (01073190144)
Preceptor: dr. F. C. Christofani Ekapatria, Sp.OG

Kepaniteraan Klinik Ilmu Obstetrik dan Ginekologi Siloam Hospital Lippo Village – Rumah Sakit Umum
Siloam Fakultas Kedokteran Universitas Pelita Harapan
Periode Februari – April 2020
 Laparoscopy
‘Gold Standard’ diagnostic
test for endometriosis
It permits a “see & treat”
approach, although its
effectiveness may be limited
by the nature of the disease
and the surgeon’s skill

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Laparoscopy for Diagnostic purpose alone  Limitations

⋄ Unrecognized endometriosis lesions  atypical appearance, very

small (subtle)
⋄ Excision specimens  not performed  destroyed by crush/thermal
injury @removal
⋄ Surgical risk  Low complications

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 “see & treat”
Diagnostic confirmation AND simultaneous treatment
All during one anesthesia

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etriosis-associated pelvic pain (EA
Medical Treatment Surgery
 Hormonal suppression  Decline long-term
 Side effects: therapy
 Irregular menstrual  Experience significant
bleeding
side effects
 Headache
 Contraindications to
 Mood changes
medical therapy
Patient Choice
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 Counsel patients: benefits & limitations of surgical intervention
 There is a risk of pain recurrence / persistence
 Repeat surgical intervention

Berlanda et al. (2010)

“Re-surgery have the same result as primary, up to 50% recurrence of pain at 5
years  re-intervention”
Deep Endometriosis

 Most severe & morbid form

 Genitourinary tract obstruction, renal compromise, bowel
obstruction
 Extrapelvic: catamenial pneumothorax

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Manage Deep endometriosis surgically  to alleviate pain/visceral
obstruction

Conservative “radical” excision  retain the uterus & ovaries 

goal to conceive
Concomitant Malignancy

“The complex adnexal mass requires surgical management when

the DD includes malignancy”

THE KEY for “asymptomatic” ovarian endometrioma in patients

with subfertility  to improve access for ART

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Pelvic pain & Desire to conceive

 Most medical therapy prevent pregnancy  Surgery

 Benefits of surgery: Improved pain control & improved
pregnancy rates (PRs)

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Endometriosis-related Subfertility
⋄ Chronic inflammation with a proinflammatory biochemical
milleu
⋄ Pelvic adhesions  disrupt anatomy & affect oocyte / embryo
transport
⋄ Diminished ovarian reserve
Live birth
Laparoscopic of mild-to-moderate endometriosis  PRs

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  Women who have
repeat surgeries
for endometriosis
Alternative
Risk of options for
Surgical enhancing
intervention Benefit pain
fertility symptom

Reduced
PRs

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Hydrosalphinges and IVF
⋄ Endometriosis  anatomic disruption  develop
hydrosalpinges  inflammatory milieu  DIMINISHES
IVF success rate

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Surgery Indication in Endometriosis-related subfertility
without significant pain:
⋄ Mild-to-moderate
⋄ Improving access for oocyte retrieval
⋄ Treating hydrosalpinges to improve IVF outcomes
⋄ Patient declines ART due to personal, cultural, or religious reasons
⋄ Patient choice for surgery / unable to access interventions such as
ART

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Future conceive considerations in Ovarian
endometrioma:
⋄ Lower ovarian reserve
⋄ Bilateral compared to unilateral ovarian cystectomy has greater
negative effect on ovarian reserve
⋄ Recurrent endometrioma excision may reduce ovarian reserve

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Post-operative role
 To prevent the recurrence of symptoms and/or disease
 Acts as an adjuvant treatment for symptom control

Oral contraceptives (OCs) Prevent recurrence

Long-term pain control
Progestin agents

No benefit in increasing
PRs
Recurrence rate for ovarian endometriomas after surgical

50% at 5 years
Combined hormonal contraceptive is
effective at reducing recurrence & related
pain

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Patient’s symptoms Desire for pregnancy

Balanced
Approach

Patient’s expectations
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Thank You

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