Page 14 - World Journal of Laparoscopic Surgery

Ganeshselvi Premkumar

TREATMENT OF ENDOMETRIOSIS without enough explanation. In view of cost effectiveness
between laparoscopy and ART, it was criticized that it needs to
Endometriosis can be treated medically and surgically by be considered as an individualized management plan which
laparoscopy and laparotomy. Medical hormone treatment has can’t be generalized.
no role in the treatment of endometriosis associated infertility
in the absence of pain. This is because any hormonal treatment A large randomized controlled trial revealed that
used to suppress endometriosis is contraceptive and does not laparoscopic ablation of endometriotic implants in minimal to
improve pregnancy rates. mild endometriosis increased the cumulative pregnancy rate
The treatment of choice will depend on the patient’s age, with a 95% confidence interval 1.28 to 3.24 and also the on-
symptoms and previous surgery and fertility requirements. After going pregnancy more than 20 weeks with 95% confidence
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defining the severity and extent of disease, the choice of interval 1.18 to 3.22. The investigators compared laparoscopic
treatment should be made in conjunction with the patient. This treatment with no surgical treatment. In contrast an Italian
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should take into account the potential risks and complexity of study involving 101 women in 1999 reported no benefit from
surgery. In the infertile patient particular thought should also endometriotic ablation in improving pregnancy rate in minimal/
be given to alternative treatment such as IVF which may offer mild endometriosis with a 95% confidential interval of 0.31 to
them a much better chance of conceiving than surgery. 1.88 for pregnancy rate and for live birth was 0.32 to 2.28. But
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Surgical treatment includes laser/diathermy ablation to the Cochrane Systematic review in 2002 included these two
endometriotic implant, adhesiolysis, excision of endometriotic studies and concluded that use of laparoscopic surgery to
cyst, cyst drainage and/or cyst wall ablation and uterosacral manage minimal/mild endometriosis associated infertility may
nerve ablation. improve reproductive outcome with 95% confidence interval of
The advantages of laparoscopic surgery are quicker recovery 1.05 to 2.57 for ongoing pregnancy and live birth rates.
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time, shorter hospital stay, reduced physical and psychological A large prospective study by Adamson et al 1993 showed
stress, effective treatment of ovarian endometriomata and relief that laparoscopic surgery significantly increases the cumulative
of pain. At the same time, it may enable a woman to achieve pregnancy rate. This was later confirmed by a metaanalysis by
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more than one pregnancy, without increasing the risk of multiple Adamson and Pasta in 1994. Adamson in 1997, proposed
pregnancy associated with assisted conception treatment. The that surgery for endometriosis-associated infertility is more
limitation of laparoscopy is the surgical intraoperative risk of effective for severe than mild endometriosis and ideally should
injury to adjacent structures, infection and adhesion formation. be carried out at the time of diagnostic laparoscopy. It has been
Appropriate surgical skill is required and the availability of proposed that pregnancy rate depends upon the presence of
appropriate equipment. There is a 6.3% conversion rate to tubal adhesions and is unrelated to the stage of endometriosis. 26
laparotomy associated with gynecological laparoscopy. 14 Laparoscopic treatment therefore is ideal, because it preserves
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Therefore patients should be informed preoperatively about tissue integrity and reduces denovo adhesion formation. In
the chance of conversion to laparotomy depending upon 1980’s, various small studies supported the successful role of
intraoperative findings. Otherwise laparotomy is indicated only laparoscopic ablation and or resection of endometriotic lesions
in cases of severe endometriosis with extensive dense adhesions in treating both moderate/severe and extensive endometriosis.
along with deeply infiltrating endometriosis. 15 In a five year follow-up of women after laparoscopic surgery,
Laparoscopic laser treatment or microsurgery during Porpora et al 2002 reported a 65% pregnancy rate, with 23% of
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laparotomy increases this rate to 50%. Few studies reported women conceiving in the first twelve months. After 12 months,
that laparoscopic excision of endometrioma before in vitro the likelihood of conceiving was significantly decreased.
fertilization (IVF) reduces the risk of worsening endometriosis Two randomized controlled trials reported that laparoscopic
during ovarian stimulation, reduces the risk of infection during ovarian cystectomy for endometriomata results in a better
oocyte retrieval and allows histological diagnosis avoiding pregnancy rate than drainage alone. 29,30 When cystectomy for
occult malignancy. It has therefore been advocated that the endometrioma is technically difficult, laparoscopic aspiration
best management of endometriosis-associated infertility should of cyst and destruction of cyst wall with laser or diathermy is an
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be surgical. If spontaneous pregnancy does not occur after acceptable alternative. The advantage of excision over ablation
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surgery, IVF should be considered. A study of laparoscopic is that the cyst can be examined histologically and a diagnosis
treatment of endometriosis following multiple failed IVF has of ovarian cancer excluded. There is no advantage of repeating
shown benefit in improving pregnancy rates in subsequent IVF surgery within a short interval as this may reduce ovarian
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cycles and spontaneously. But this study has some limitations reserve. A randomized crossover study involving 39 women
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such as retrospective study, inadequate power, poor selection followed up for 12 months reported reduction of chronic pelvic
criteria for control and subject group and some women in the pain and dyspareunia after laparoscopic debulking for
study had laparoscopic surgery after one cycle of IVF and rectovaginal endometriosis thereby improving quality of life. 33

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