a. Basic tenets
(1) The definitive diagnosis of endometriosis is by direct visualization and biopsy via laparoscopy.
(2) Lesions can have a variety of appearances, including the following:
(a) Clear: most likely early lesions
(b) Red: histologically active
(c) White: scarring
(d) Brown-black: inactive endometrial glands and stroma
(3) All patients found to have endometriosis should be surgically staged via the American Fertility Society Classification.
b. Indications for surgery
(1) Pain is present in 50% of patients with endometriosis.
(2) Adnexal masses are unexplained ovarian enlargements that necessitate ultrasound and surgery.
(3) Infertility: Endometriosis can lead to adhesions, ovarian dysfunction, tubal abnormalities, LPDs, and decreased fertilization.
c. Surgical procedures
(1) Conservative surgery by laparoscopy, the goal of which is to ablate and resect lesions and lyse adhesions with minimal disruption to normal surrounding tissue.
(i) This procedure is most commonly used.
(ii) Electrosurgery may be unipolar or bipolar.
(iii) A variety of instruments are available to operate with. A point coagulator is especially useful for small, individual lesions.
(b) Thermocoagulaton causes tissue desiccation by increasing the temperature to 100° to 120° F and not by electric current
(i) This procedure offers precise tissue destruction.
(ii) CO2 laser is best for vaporization.
(iii) Nd:YAG is best for coagulation.
(2) Conservative surgery by laparotomy: The goal of this surgery is also to ablate and resect lesions and to lyse adhesions with minimal disruption to normal surrounding tissue,
(a) Microsurgical technique: Tissues must be handled carefully to avoid trauma.
(b) Ablation and resection of lesions: Uses the previously mentioned modalities to achieve the best results.
(c) Preoperative suppression: Successful surgery can be more easily accomplished in certain cases with preoperation suppression with GnRH agonist. Some argue that this makes the lesions more difficult to resect, but in most cases this is not the case.
(d) Laparoscopy versus laparotomy.
(i) Laparoscopy is probably most dependent on the surgeon’s skills.
(ii) Current data supports the less costly, probably more effective laparoscopic approach.
(3) Definitive surgical therapy.
(a) Hysterectomy with bilateral salpingoophorectomy is the definitive surgical therapy.
(b) Estrogen replacement should be instituted after surgery is completed with little risk of disease recurrence.
a. Stenosis: The surgical therapy for cervical stenosis is dilation.
b. Myomas: Removal is via hysteroscope resectoscope.
c. Polyps: Removal is via hysteroscope resectoscope. Uterine factor.
a. Leiomyomata: They should be removed only if they impinge on the cavity or are thought to be causing repeated losses.
(1) Hysteroscopic resection
(2) Abdominal myomectomy
(a) Abdominal myomectomy causes adhesions.
(b) A second-look laparoscopy 7 days after the myomectomy should be considered to lyse early adhesions.
b. Polyps should be removed hysteroscopically.
c. Intrauterine adhesions.
(1) Hysteroscopic resection with scissors
(a) An intraoperative HSG should be performed to confirm complete lysis of the adhesions.
(b) An 8-French, 3-cc pediatric Foley catheter should be placed in the endometrial cavity at the end of the procedure to prevent reformation of adhesions. The Foley should be left in place for 5 to 7 days, during which time the patient is on antibiotics, and estrogen (Premarin 2.5 mg bid or Estrace 4 mg bid). The estrogen is continued for 25 days with 10 mg of Provera administered on days 16 to 25. Menses should occur 48 to 72 hours after the estrogen and Provera are discontinued.
d. Congenital uterine anomalies.
(1) Unicornuate: No, surgery is necessary unless a rudimentary horn is present and requires removal.
(2) Bicornuate versus septate uterus: This diagnosis can be made only by laparoscopy. A septum can be resected hysteroscopically. A bicornuate uterus requires a metroplasty if it is associated with repeated losses.
(3) Uterine didetphys: Surgery is not generally required.
4. Male factor.
5. Hormonal dysfunction: This is usually corrected via controlled ovarian hyperstimulation, with or without insemination or assisted reproductive technology. (See 6.b.)
6. Pelvic adhesions.
a. Surgical lysis of adhesions
b. Assisted reproduction
(1) In vitro fertilization (IVF)
(i) Poor prognosis tubal factor
(iii) Male factor
(iv) Immunologic infertility
(v) DES exposure
(vi) Unexplained infertility
(i) Ovarian hyperstimulation
(ii) Oocyte retrieval
(iii) Oocyte insemination fertilization
(iv) Transcervical embryo transfer
(i) Approximately 20% ongoing pregnancy rate
(ii) Multiple pregnancy rate of 30%
(iii) May need embryo manipulation, such as assisted hatching, to facilitate implantation
(2) Gamete intrafallopian transfer (GIFT)
(i) Cervical factor
(ii) Mild to moderate male factor infertility
(iii) Pelvic adhesions: need one healthy tube
(iv) Unexplained primary or secondary infertility
(v) Ovarian failure: using donor oocytes
(i) Ovarian hyperstimulation
(ii) Oocyte retrieval: usually transvaginal
(iii) Laparoscopy with tubal transfer of sperm and oocytes (usually four)
(i) Approximately 30% ongoing pregnancy rate
(ii) Approximately 4% ectopic pregnancy rate
c. Zygote intrafallopian transfer (ZIFT) and tubal embryo transfer (TET)
(a) Severe male factor: allows fertilization to occur before laparoscopy
(b) Immunologic infertility
(d) Oocyte donation
(e) Unexplained infertility
(a) Ovarian hyperstimulation
(b) Oocyte retrieval
(c) Oocyte insemination fertilization
(d) Laparoscopic zygote embryo transfer (24 to 56 hours after retrieval)
(3) Outcome: a 30% to 35% ongoing pregnancy rate
d. Oocyte donation
(a) Ovarian failure
(b) Genetic abnormalities
(c) Gonadal dysgenesis
(d) Poor oocyte quality
(a) Ovarian hyperstimulation of the donor
(b) Uterine preparation of the recipient
(c) Fertilization of the oocytes
(d) Transcervical embryo transfer (GIFT, ZIFT)
(3) Outcome: pregnancy rates approach 50%
7. Ovarian failure: surgical therapy with oocyte donation. (See previous section.)
8. Unexplained infertility: surgical therapy, a. Assisted reproductive technologies