Pain control and quality of life after laparoscopic en-block resection of deep infiltrating endometriosis (DIE) vs. incomplete surgical treatment with or without GnRHa administration after surgery

Surgical Treatment of Deep Endometriosis

In deep endometriosis (DE), clusters of endometrium-like cells penetrate more than 5 mm below the peritoneum: The affected organs and tissue structures can eventuate in an alteration of the anatomy with eliminated organ boundaries, which in some cases can pose a real surgical challenge, even for experienced surgeons. A comprehensive description of the different manifestations of the disease can be found in the #Enzian classification. Since the operation is usually the foundation for the successful treatment of DE, what is important are conclusive indications, appropriate preoperative preparation and, above all, appropriate experience on the part of the surgical team. This article aims to provide a review of the surgical options that are currently available.

Systematic review of patient-specific pre-operative predictors of pain improvement to endometriosis surgery

Background

Up to 28% of endometriosis patients do not get pain relief from therapeutic laparoscopy but this subgroup is not defined.

Objectives

To identify any prognostic patient-specific factors (such as but not limited to patients’ type or location of endometriosis, sociodemographics and lifestyle) associated with a clinically meaningful reduction in post-surgical pain response to operative laparoscopic surgery for endometriosis.

Search strategy

PubMed, Cochrane and Embase databases were searched from inception to 19 May 2020 without language restrictions. Backward and forward citation tracking was used.

Selection criteria, data collection and analysis:

Cohort studies reporting prognostic factors, along with scores for domains of pain associated with endometriosis before and after surgery, were included. Studies that compared surgeries, or laboratory tests, or outcomes without stratification were excluded. Results were synthesised but variation in study designs and inconsistency of outcome reporting precluded us from doing a meta-analysis.

Main results

Five studies were included. Quality assessment using the Newcastle–Ottawa scale graded three studies as high, one as moderate and one as having a low risk of bias. Four of five included studies separately reported that a relationship exists between more severe endometriosis and stronger pain relief from laparoscopic surgery.

Conclusion

Currently, there are few studies of appropriate quality to answer the research question. We recommend future studies report core outcome sets to enable meta-analysis.

Lay summary

Endometriosis is a painful condition caused by displaced cells from the lining of the womb, causing inflammation and scarring inside the body. It affects 6–10% of women and there is no permanent cure. Medical and laparoscopic surgical treatments are available, but about 28% of patients do not get the hoped-for pain relief after surgery. Currently, there is no way of predicting who gets better and who does not. We systematically searched the world literature to establish who may get better, in order to improve counselling when women choose treatment options. We identified five studies of variable quality showing: More complex disease (in specialist hands) responds better to surgery than less, but more studies needed.

The efficacy and safety of triptorelin-therapy following conservative surgery for deep infiltrating endometriosis: A multicenter, prospective, non-interventional study in China

Triptorelin is one of the most commonly used gonadotropin-releasing hormone agonists and has been used in the treatment of deep infiltrating endometriosis (DIE). This study aimed to evaluate the efficacy and safety of up to 24 weeks of triptorelin treatment after conservative surgery for DIE.This prospective, non-interventional study was performed in 18 tertiary hospitals in China. Premenopausal women aged ≥18 years treated with triptorelin 3.75 mg once every 28 days for up to 24 weeks after conservative surgery for DIE were included. Endometriosis symptoms were assessed, using a visual analogue scale (0-10 cm) or numerical range (0-10), at baseline (pre-surgery) and routine visits 3, 6, 9, 12, 18, and 24 months after surgery. Changes in symptom intensity over time were primary outcome measures.A total of 384 women (mean [standard deviation] age, 33.4 [6.2] years) were analyzed. Scores for all symptoms (pelvic pain, dysmenorrhea, ovulation pain, dyspareunia, menorrhagia, metrorrhagia, and gastrointestinal and urinary symptoms) assessed decreased from baseline over 24 months. Cumulative improvement rates in pelvic pain, dysmenorrhoa, ovulation pain, and dyspareunia were 74.4%, 83.6%, 55.1%, and 66.9%, respectively. The 24-month cumulative recurrence rate (≥1 symptom) was 22.2%. The risk of symptom recurrence was higher in patients with ≥2 versus 1 lesion (odds ratio [OR] 2.539; 95% CI: 1.458-4.423; P = .001) and patients with moderate (OR 5.733; 95% CI: 1.623-20.248; P = .007) or severe (OR 8.259; 95% CI: 2.449-27.851; P = .001) pain versus none/mild pain. Triptorelin was well tolerated without serious adverse events.Triptorelin after conservative surgery for DIE improved symptoms over 24 months of follow up. The recurrence rate of symptoms was low and triptorelin was generally well tolerated.Trial registration number: ClinicalTrials.gov, NCT01942369.

Evaluation of the SF-36 questionnaire for assessment of the quality of life of endometriosis patients undergoing treatment: A systematic review and meta-analysis

Endometriosis has a negative influence on the physical, psychological, and social aspects of a patient's life; therefore, it affects the health-related quality of life (HRQoL). The current review aimed to investigate the efficiency of a 36-item generic questionnaire survey (SF-36) for patients with endometriosis who were undergoing medical or surgical treatment. A search strategy including the key words ‘endometriosis’, ‘quality of life’ (QOL), and ‘questionnaire SF-36’ was applied using the PubMed/MEDLINE, EMBASE, and Cochrane databases in order to include articles that evaluated the QOL among women with endometriosis using the SF-36. Only articles that included interviews of patients both before and after surgical or medical endometriosis treatment or those articles that compared study groups were considered. The qualitative analysis was based on 37 articles, whereas the quantitative analysis utilized 14 articles. The research participants included 11,101 women, among whom 6,888 patients were diagnosed with endometriosis. The analysis recorded 17 studies dealing with all types of endometriosis, 9 studies dealing with deep infiltrative endometriosis (DIE), and 9 studies dealing with bowel endometriosis or DIE with bowel involvement. QOL was evaluated using only SF-36 in 12 studies that collectively included 1,912 women and using SF-36 in association with other questionnaires in 25 studies that collectively included 8,022 women. For patients with endometriosis, physical functioning [odds ratio (OR), 78.87; 95% confidence interval (CI), 68.97-88.77; I²=98.77%; P≤0.001] was the most affected life parameter. This parameter showed the highest improvement after surgical intervention (OR, 63.39; 95% CI, 48.71-78.07; I²=97.65%; P≤0.001) or hormonal treatment (OR, 38.65; 95% CI, 14.39-62.91; I²=38.65%; P≤0.001). The 36-item survey generic questionnaire seems to be an efficient tool for assessment of the QOL of life of women with endometriosis who are undergoing surgical or medical treatment. It can be applied before and after the procedure, and it can also be used for comparing study groups.

Laparoscopic treatment of deep endometriosis with a diode laser: our experience

Purpose

To evaluate whether laparoscopic treatment with a diode laser is feasible, safe, and effective in symptomatic patients affected by deep endometriosis (DE).

Methods

This retrospective study was performed using medical record data. The surgical reports, chronic pain scores, and quality of life (QoL) data were evaluated for 50 patients who had undergone laparoscopic surgery between November 2017 and March 2019 at two university hospitals (Monserrato (CA) and Foggia, Italy). Indications for surgery were chronic pelvic pain and/or infertility in patients who wished to conceive spontaneously. Endometriosis lesions/nodules were excised using a diode laser (Leonardo®, Biolitec® DUAL 45) that can combine 980 and 1470 nm wavelengths transmitted through a 1000 µm conical optical fibre.

Results

The median patient age was 32 years (range 21–44), with a body mass index (BMI) mean of 21.7  ±  2.9 kg/m². The mean operation time was 147 min (range 106–190). No intraoperative or early complications (< 30 days) were reported. All patients left the hospital, on average, within 3 days (range 2–9 days) after surgery. A significant improvement in pain was observed at the 3-, 6-, and 12-month follow-up (p < 0.01) in all patients. Moreover, patients reported a significant QoL improvement at the 12-month follow-up.

Conclusion

The diode laser confirmed its feasibility and safety for treating endometriosis. During the shaving surgical procedure, the diode laser system ensures a safe and effective laparoscopic dissection of deep endometriotic lesions. Further comprehensive randomized trials are necessary to confirm these preliminary data in terms of efficacy, recurrence rates, and pregnancy outcomes.

Recommended standardized anatomic terminology of the posterior female pelvis and vulva based on a structured medical literature review

BACKGROUND

Anatomic terminology in both written and verbal forms has been shown to be inaccurate and imprecise.

OBJECTIVE

Here, we aimed to (1) review published anatomic terminology as it relates to the posterior female pelvis, posterior vagina, and vulva; (2) compare these terms to "Terminologia Anatomica," the internationally standardized terminology; and (3) compile standardized anatomic terms for improved communication and understanding.

STUDY DESIGN

From inception of the study to April 6, 2018, MEDLINE database was used to search for 40 terms relevant to the posterior female pelvis and vulvar anatomy. Furthermore, 11 investigators reviewed identified abstracts and selected those reporting on posterior female pelvic and vulvar anatomy for full-text review. In addition, 11 textbook chapters were included in the study. Definitions of all pertinent anatomic terms were extracted for review.

RESULTS

Overall, 486 anatomic terms were identified describing the vulva and posterior female pelvic anatomy, including the posterior vagina. "Terminologia Anatomica" has previously accepted 186 of these terms. Based on this literature review, we proposed the adoption of 11 new standardized anatomic terms, including 6 regional terms (anal sphincter complex, anorectum, genital-crural fold, interlabial sulcus, posterior vaginal compartment, and sacrospinous-coccygeus complex), 4 structural terms (greater vestibular duct, anal cushions, nerve to the levator ani, and labial fat pad), and 1 anatomic space (deep postanal space). In addition, the currently accepted term rectovaginal fascia or septum was identified as controversial and requires further research and definition before continued acceptance or rejection in medical communication.

CONCLUSION

This study highlighted the variability in the anatomic nomenclature used in describing the posterior female pelvis and vulva. Therefore, we recommended the use of standardized terminology to improve communication and education across medical and anatomic disciplines.

Symptom control after different duration of triptorelin treatment following conservative surgery for deep infiltrating endometriosis: Post-hoc analysis of a multicentre, prospective, real-world study

Triptorelin has been used after surgery in deep infiltrating endometriosis. This post-hoc analysis aimed to evaluate symptom control between patients receiving 1-3 triptorelin injections and those receiving 4-6 injections within 24 months of conservative surgery for deep infiltrating endometriosis, in the real-world.Included patients were divided into two groups (received up to 3 months injections in group A, 4-6 injections in group B) based on the numbers of triptorelin (Diphereline, 3.75 mg intramuscular injection once every 28 days for up to 24 weeks) administration. Evolution in score of pain intensity at 3, 6, 9, 12, 18, and 24 months after primary triptorelin administration and symptom improvement/recurrence rates between two groups were compared. Symptoms of pain intensity were assessed using a visual analogue scale (VAS) with a range from 0 to 10 cm. An improvement in symptoms was defined as a reduction of at least 3 cm or 3 units from pre-surgery levels.156 patients in group A and 228 in group B. Pain symptom score (mean ± standard deviation) diminished to a nadir at 3-months for group A and 6-months for group B; at 6-months nadir scores were significantly lower in group B (0.9 ± 1.7 vs 0.4 ± 1.2 respectively, P = .002). No significant difference for pain symptom scores between both groups at 24-months (P = .269). The 6-month and 24-month cumulative improvement rates of pain (80.6% vs 89.8%, P = .014 and 82.6% vs 90.7%, P = .025) and gastro-intestinal symptoms (61.0% vs 80.8%, P = .022 and 61.0% vs 83.3%, P = .008) were significantly higher in group B, whereas there was no significant difference in rates of menstrual disorders and urinary symptoms. There is no significant difference for 12-months and 24-months cumulative recurrence rates of total symptoms between both groups (11.3% vs 13.8%, P = .568 and 16.1% vs 26.0%, P = .094).In women with deep infiltrating endometriosis, longer treatment with triptorelin following conservative surgery was associated with a decrease in symptom intensity and greater improvement of pain symptoms in the short-term and greater improvement of gastro-intestinal symptoms in the long-term.Trial registration number: ClinicalTrials.gov, NCT01942369.

Oxycodone versus morphine for analgesia after laparoscopic endometriosis resection

Background

The objective of this study was to compare the analgesic potency of oxycodone versus morphine after laparoscopic deep infiltrating endometriosis resection.

Methods

Fifty patients undergoing laparoscopic deep infiltrating endometriosis resection were randomized to receive oxycodone or morphine intravenous-PCA after surgery. The primary outcome was opioid consumption during the 24 h after surgery. Secondary outcomes included time to first request for analgesia, the number of bolus, pain, sedation, nausea, vomiting, respiratory depression, and bradycardia. The prominent pain that caused patients to press the analgesic device was also recorded.

Results

Oxycodone consumption (14.42 ± 2.83) was less than morphine consumption (20.14 ± 3.83). Compared with the morphine group, the total number of bolus (78 vs 123) was less and the average time to first request for analgesia (97.27 ± 59.79 vs 142.17 ± 51) was longer in the oxycodone group. The incidence of nausea was higher in the morphine group than in the oxycodone group at 0–2 h (45.45% vs 17.19%), 2–4 h (50% vs 17.19%),12–24 h (40.91% vs 13.04%) and 0–24 h (39.17% vs 19.13%). The overall incidence of vomiting was higher in the morphine group (27.27% vs 13.92%). There was no difference in visual analogue scale score, the incidence of respiratory depression, and bradycardia between groups. Of the three types of pain that prompted patients to request analgesia, the incidence of visceral pain was highest (59.9%, P < 0.01).

Conclusion

Oxycodone was more potent than morphine for analgesia after laparoscopic endometriosis resection, and oxycodone has fewer side effects than morphine.

Name of the registry: Chinese Clinical Trial Registry

Trial registration number: ChiCTR1900021870

URL of trial registry record:http://www.chictr.org.cn/edit.aspx?pid=35799&htm=4

Date of registration: 2019/3/13 0:00:00

Effects of postoperative medical treatment and expectant treatment on dysmenorrhea after conservative laparoscopic surgery for deep-infiltrating endometriosis accompanied by dysmenorrhea

Objective

To compare the efficacy of postoperative adjuvant treatment (gonadotropin-releasing hormone agonists [GnRHas] and oral contraceptives [OCs]) and expectant treatment in preventing recurrent dysmenorrhea following conservative laparoscopic surgery for deep infiltrating endometriosis (DIE) with dysmenorrhea.

Methods

A prospective cohort study was conducted in Shanghai, China. In total, 147 patients with dysmenorrhea who underwent conservative laparoscopic surgery for DIE were enrolled. Following surgery, patients received either postoperative adjuvant therapy (GnRHa or OCs) for 6 months or expectant treatment according to a shared medical decision-making approach. The primary outcome was the postoperative recurrence of dysmenorrhea. The secondary outcomes included reproductive outcomes and drug-induced side effects.

Results

The generalized estimating equation analysis illustrated that the visual analog scale for dysmenorrhea was significantly higher in the adjuvant treatment group than in the expectant treatment group. Kaplan–Meier analysis and the log-rank test demonstrated that the cumulative recurrence rate was higher in the expectant treatment group than in the adjuvant treatment group, but no difference was noted between the two hormonal treatments. Similar cumulative 24-month clinical pregnancy rates were observed among the three groups.

Conclusions

Compared with expectant management, postoperative medical treatment more effectively relieved symptoms and prevented the recurrence of dysmenorrhea.

Management Challenges of Deep Infiltrating Endometriosis

Deep infiltrating endometriosis (DIE) is the most aggressive of the three phenotypes that constitute endometriosis. It can affect the whole pelvis, subverting the anatomy and functionality of vital organs, with an important negative impact on the patient's quality of life. The diagnosis of DIE is based on clinical and physical examination, instrumental examination, and, if surgery is needed, the identification and biopsy of lesions. The choice of the best therapeutic approach for women with DIE is often challenging. Therapeutic options include medical and surgical treatment, and the decision should be dictated by the patient's medical history, disease stage, symptom severity, and personal choice. Medical therapy can control the symptoms and stop the development of pathology, keeping in mind the side effects derived from a long-term treatment and the risk of recurrence once suspended. Surgical treatment should be proposed only when it is strictly necessary (failed hormone therapy, contraindications to hormone treatment, severity of symptoms, infertility), preferring, whenever possible, a conservative approach performed by a multidisciplinary team. All therapeutic possibilities have to be explained by the physicians in order to help the patients to make the right choice and minimize the impact of the disease on their lives.

Pre- and postsurgical medical therapy for endometriosis surgery

BACKGROUND

Endometriosis is a common gynaecological condition affecting 10% to 15% of reproductive-age women and may cause dyspareunia, dysmenorrhoea, and infertility. One treatment strategy is combining surgery and medical therapy to reduce the recurrence of endometriosis. Though the combination of surgery and medical therapy appears to be beneficial, there is a lack of clarity about the appropriate timing of when medical therapy should be used in relation with surgery, that is, before, after, or both before and after surgery, to maximize treatment response.

OBJECTIVES

To determine the effectiveness of medical therapies for hormonal suppression before, after, or both before and after surgery for endometriosis for improving painful symptoms, reducing disease recurrence, and increasing pregnancy rates.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, and two trials registers in November 2019 together with reference checking and contact with study authors and experts in the field to identify additional studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) which compared medical therapies for hormonal suppression before, after, or before and after, therapeutic surgery for endometriosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. Where possible, we combined data using risk ratio (RR), standardized mean difference or mean difference (MD) and 95% confidence intervals (CI). Primary outcomes were: painful symptoms of endometriosis as measured by a visual analogue scale (VAS) of pain, other validated scales or dichotomous outcomes; and recurrence of disease as evidenced by EEC (Endoscopic Endometriosis Classification), rAFS (revised American Fertility Society), or rASRM (revised American Society for Reproductive Medicine) scores at second-look laparoscopy.

MAIN RESULTS

We included 26 trials with 3457 women with endometriosis. We used the term "surgery alone" to refer to placebo or no medical therapy. Presurgical medical therapy compared with placebo or no medical therapy Compared to surgery alone, we are uncertain if presurgical medical hormonal suppression reduces pain recurrence at 12 months or less (dichotomous) (RR 1.10, 95% CI 0.72 to 1.66; 1 RCT, n = 262; very low-quality evidence) or whether it reduces disease recurrence at 12 months - total (AFS score) (MD -9.6, 95% CI -11.42 to -7.78; 1 RCT, n = 80; very low-quality evidence). We are uncertain if presurgical medical hormonal suppression decreases disease recurrence at 12 months or less (EEC stage) compared to surgery alone (RR 0.88, 95% CI 0.78 to 1.00; 1 RCT, n = 262; very low-quality evidence). We are uncertain if presurgical medical hormonal suppression improves pregnancy rates compared to surgery alone (RR 1.16, 95% CI 0.99 to 1.36; 1 RCT, n = 262; very low-quality evidence). No trials reported pelvic pain at 12 months or less (continuous) or disease recurrence at 12 months or less. Postsurgical medical therapy compared with placebo or no medical therapy We are uncertain about the improvement observed in pelvic pain at 12 months or less (continuous) between postsurgical medical hormonal suppression and surgery alone (MD -0.48, 95% CI -0.64 to -0.31; 4 RCTs, n = 419; I² = 94%; very low-quality evidence). We are uncertain if there is a difference in pain recurrence at 12 months or less (dichotomous) between postsurgical medical hormonal suppression and surgery alone (RR 0.85, 95% CI 0.65 to 1.12; 5 RCTs, n = 634; I² = 20%; low-quality evidence). We are uncertain if postsurgical medical hormonal suppression improves disease recurrence at 12 months - total (AFS score) compared to surgery alone (MD -2.29, 95% CI -4.01 to -0.57; 1 RCT, n = 51; very low-quality evidence). Disease recurrence at 12 months or less may be reduced with postsurgical medical hormonal suppression compared to surgery alone (RR 0.30, 95% CI 0.17 to 0.54; 4 RCTs, n = 433; I² = 58%; low-quality evidence). We are uncertain about the reduction observed in disease recurrence at 12 months or less (EEC stage) between postsurgical medical hormonal suppression and surgery alone (RR 0.80, 95% CI 0.70 to 0.91; 1 RCT, n = 285; very low-quality evidence). Pregnancy rate is probably increased with postsurgical medical hormonal suppression compared to surgery alone (RR 1.22, 95% CI 1.06 to 1.39; 11 RCTs, n = 932; I² = 24%; moderate-quality evidence). Pre- and postsurgical medical therapy compared with surgery alone or surgery and placebo There were no trials identified in the search for this comparison. Presurgical medical therapy compared with postsurgical medical therapy We are uncertain about the difference in pain recurrence at 12 months or less (dichotomous) between postsurgical and presurgical medical hormonal suppression therapy (RR 1.40, 95% CI 0.95 to 2.07; 2 RCTs, n = 326; I² = 2%; low-quality evidence). We are uncertain about the difference in disease recurrence at 12 months or less (EEC stage) between postsurgical and presurgical medical hormonal suppression therapy (RR 1.10, 95% CI 0.95 to 1.28; 1 RCT, n = 273; very low-quality evidence). We are uncertain about the difference in pregnancy rate between postsurgical and presurgical medical hormonal suppression therapy (RR 1.05, 95% CI 0.91 to 1.21; 1 RCT, n = 273; very low-quality evidence). No trials reported pelvic pain at 12 months or less (continuous), disease recurrence at 12 months - total (AFS score) or disease recurrence at 12 months or less (dichotomous). Postsurgical medical therapy compared with pre- and postsurgical medical therapy There were no trials identified in the search for this comparison. Serious adverse effects for medical therapies reviewed There was insufficient evidence to reach a conclusion regarding serious adverse effects, as no studies reported data suitable for analysis.

AUTHORS' CONCLUSIONS

Our results indicate that the data about the efficacy of medical therapy for endometriosis are inconclusive, related to the timing of hormonal suppression therapy relative to surgery for endometriosis. In our various comparisons of the timing of hormonal suppression therapy, women who receive postsurgical medical therapy compared with no medical therapy or placebo may experience benefit in terms of disease recurrence and pregnancy. There is insufficient evidence regarding hormonal suppression therapy at other time points in relation to surgery for women with endometriosis.

Endometriosis recurrence following post-operative hormonal suppression: a systematic review and meta-analysis

BACKGROUND

Although surgery for endometriosis can improve pain and fertility, the risk of disease recurrence is high. There is little consensus regarding the benefit of medical therapy in preventing recurrence of endometriosis following surgery.

OBJECTIVE AND RATIONALE

We performed a review of prospective observational studies and randomised controlled trials (RCTs) to evaluate the risk of endometriosis recurrence in patients undergoing post-operative hormonal suppression, compared to placebo/expectant management.

SEARCH METHODS

The following databases were searched from inception to March 2020 for RCTs and prospective observational cohort studies: MEDLINE, Embase, Cochrane CENTRAL and Web of Science. We included English language full-text articles of pre-menopausal women undergoing conservative surgery (conserving at least one ovary) and initiating hormonal suppression within 6 weeks post-operatively with either combined hormonal contraceptives (CHC), progestins, androgens, levonorgesterel-releasing intra-uterine system (LNG-IUS) or GnRH agonist or antagonist. We excluded from the final analysis studies with <12 months of follow-up, interventions of diagnostic laparoscopy, experimental/non-hormonal treatments or combined hormonal therapy. Risk of bias was assessed using the Cochrane Risk of Bias Tool for RCTs and the Newcastle-Ottawa Scale (NOS) for observational studies.

OUTCOMES

We included 17 studies (13 RCTs and 4 cohort studies), with 2137 patients (1189 receiving post-operative suppression and 948 controls), which evaluated various agents: CHC (6 studies, n = 869), progestin (3 studies, n = 183), LNG-IUS (2 studies, n = 94) and GnRH agonist (9 studies, n = 1237). The primary outcome was post-operative endometriosis recurrence, determined by imaging or recurrence of symptoms, at least 12 months post-operatively. The secondary outcome was change in endometriosis-related pain. Mean follow up of included studies ranged from 12 to 36 months, and outcomes were assessed at a median of 18 months. There was a significantly decreased risk of endometriosis recurrence in patients receiving post-operative hormonal suppression compared to expectant management/placebo (relative risk (RR) 0.41, 95% CI: 0.26 to 0.65), 14 studies, 1766 patients, I² = 68%, random effects model). Subgroup analysis on patients treated with CHC and LNG-IUS as well as sensitivity analyses limited to RCTs and high-quality studies showed a consistent decreased risk of endometriosis recurrence. Additionally, the patients receiving post-operative hormonal suppression had significantly lower pain scores compared to controls (SMD −0.49, 95% CI: −0.91 to −0.07, 7 studies, 652 patients, I² = 68%).

WIDER IMPLICATIONS

Hormonal suppression should be considered for patients not seeking pregnancy immediately after endometriosis surgery in order to reduce disease recurrence and pain. Various hormonal agents have been shown to be effective, and the exact treatment choice should be individualised according to each woman’s needs.

One-stage, radical laparoscopic endometriosis excision involving three different organ systems: A case report from tertiary referral center

Introduction:

We present a case of an extensive endometriosis involving left paracolpium and left parametrium, rectovaginal septum, urinary bladder, left interiliac region between artery and vein, left ureter and rectum, presenting as dysmenorrhoea, alternating bouts of diarrhea and constipation and hydronephrosis.

Methods:

Laparoscopic surgery made by a multidisciplinary team consist of gynecologic, abdominal surgeon and urologist.

Results:

Successfully managed deep infiltrated endometriosis.

Conclusion:

The aim of this report is to demonstrate benefit of one-stage, minimally invasive radical surgical procedure performed in a tertiary referral center. To the best of our knowledge, this report presents an extremely complex case because we successfully managed deep infiltrating endometriosis in three different organ systems at the same time, using minimally invasive nerve-sparing technique. A case with the same constellation has not been published yet since reported cases of extrapelvic endometriosis chiefly address one organ system involvement.

Post-operative management and follow-up of surgical treatment in the case of rectovaginal and retrocervical endometriosis

Introduction

Deep infiltrating endometriosis (DIE) affects between 3.8% and 37% of all endometriosis patients, mostly affecting rectovaginal septum or retrocervical space and characterized by the severe endometriosis-related complaints. Nowadays, generally managed with surgery. However, this is associated with a risk of postoperative complications. To better evaluate intra- and postoperative complications and outcomes for rectovaginal (RVE) and retrocervical endometriosis (RCE), the preoperative management should be accurately described and compared.

Methodology

This is a cohort retrospective study performed at the Endometriosis Centre of Charité-University Clinic, Berlin. 34 patients were investigated in their reproductive age, n = 19 with RVE and n = 15 RCE, operated between 2011 and 2015. The surgical approach was divergent in both groups. Single laparoscopy was performed in RCE patients (RCEP) and vaginal assisted laparoscopy in RVE patients (RVEP). Long-term postoperative outcome included complications, fertility rate and recurrence rate.

Results

The median follow-up time was three years (y). Symptom-free status was revealed in n = 12 RVEP and n = 9 RCEP. Postoperatively, endometriosis-related complaints were presented in n = 7 RVEP and n = 6 RCEP, but with significant pain relief. From n = 8 RVE patients seeking fertility, pregnancy occurred in n = 7 and from n = 9 RCEP pregnancy appeared in n = 5 patients in the meantime of 6 months. Postoperative complications were reported in n = 1 RVEP with early postoperative bleeding, after ureter leakage and n = 1 RCEP with postoperative anastomotic insufficiency. The postoperative recurrence rate was equivalent to zero.

Conclusion

The appropriate surgical approach for each group, preserving anatomy and functionality of the organs, seems to be very essential and efficient.

Reproductive capacity and recurrence of disease after surgery for moderate and severe endometriosis - a retrospective single center analysis

BACKGROUND

Endometriosis can be associated with considerable pain and sterility. After surgical excision of moderate or severe endometriosis lesions, the rate of recurrence reaches up to 67%. The objective of this retrospective study was to establish the recurrence and pregnancy rates following surgical resection of stage III/IV endometriosis lesions. Indications for operation were endometriosis symptoms, sonographic findings and/or infertility.

METHODS

A total of 456 patients who underwent stage III/IV endometriosis surgery between 2004 and 2014 were sent a questionnaire relating to their postoperative medical treatment, pregnancies, relief of symptoms and recurrence. Responses of 206 patients (45.2%) and their clinical data were analysed for this study.

RESULTS

A total of 66.5% (N = 137) of patients had stage III disease, and 33.5% (N = 69) had stage IV disease. The average age was 37 years (17-59). A total of 63.1% (N = 130) of surgeries were performed by laparoscopy, 21.8% (N = 45) were performed by laparotomy and 15% (N = 31) were performed by conversion. Complete resection of endometriosis lesions was achieved in 90.8% of patients (N = 187). After surgery, 48.5% (N = 100) of the women did not receive hormonal treatment; the main reason was the desire for children in 53%. Complete or partial relief in complaints was achieved in 93.2% (N = 192). The rate of recurrence was 21.8% (N = 45). The statistically significant factors that was associated with a higher risk to develop recurrence was an age < 35 (p < 0.005). After surgery, 65.8% (79/120) of patients who wished to have children became pregnant. There was a statistically significant association among a higher postoperative pregnancy rate and age < 35 (p < 0.003) in multivariate logistic regression analysis and laparoscopic surgical access in univariate logistic regression analysis (p < 0.01).

CONCLUSION

We assessed the high percentage of complete or partial relief of symptoms of 93.2%, the high postoperative pregnancy rate of 65.8% and the low rate of recurrence of 21.8% compared to international literature to be very encouraging for women suffering from moderate and severe endometriosis. Though laparoscopy is considered the 'gold standard'of endometriosis surgery, laparotomy still may be indicated in patients with extensive endometriosis especially to preserve reproductive function.

Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis

Chronic pelvic pain (CPP) in women is defined variably, but for clinical use it is cyclical or non-cyclical pain of at least 3-6 months' duration. It has major impacts on individuals and society. There are both structural and idiopathic causes. Whereas CPP is not curable in many cases, it is treatable. The most promising approach is multidisciplinary patient-centered care including cause-directed therapy, lifestyle changes, talking therapies, meditation, acupuncture, and physiotherapy (this is not a complete list). One of the most common structural causes for CPP is endometriosis. This review investigates current scientific concepts and recent innovations in this field as well as for CPP in general.

Role of Hormones in Common Benign Uterine Lesions: Endometrial Polyps, Leiomyomas, and Adenomyosis

Leiomyoma, adenomyosis, and endometrial polyps are benign uterine disorders which seem to develop in the context of hormonal imbalances, due to steroid hormones, estrogen and progesterone, in association with various factors ranging from genetic factors to modifiable lifestyle factors. A growing body of evidence suggests that those hormones and their receptors are key modulators in the genesis and the growth of those pathologic entities. Further studies are required to understand their involvement in the pathogenesis of those lesions and their link to other factors such as extracellular matrix components, growth factors, chemokines, cytokines, and tissue repair mechanisms.

Anti-inflammatory cytokines in endometriosis

Although the pathogenesis of endometriosis is not fully understood, it is often considered to be an inflammatory disease. An increasing number of studies suggest that differential expression of anti-inflammatory cytokines (e.g., interleukin-4 and -10, and transforming growth factor-β1) occurs in women with endometriosis, including in serum, peritoneal fluid and ectopic lesions. These anti-inflammatory cytokines also have indispensable roles in the progression of endometriosis, including by promoting survival, growth, invasion, differentiation, angiogenesis, and immune escape of the endometriotic lesions. In this review, we provide an overview of the expression, origin, function and regulation of anti-inflammatory cytokines in endometriosis, with brief discussion and perspectives on their future clinical implications in the diagnosis and therapy of the disease.

Systematic review of quality of life measures in patients with endometriosis

OBJECTIVES

Endometriosis and quality of life has been the subject of much research, however, there is little consensus on how best to evaluate quality of life in endometriosis, resulting in many and diverse scales being used. In our study, we aim to identify quality of life scales used in endometriosis, to review their strengths and weaknesses and to establish what would define an ideal scale in the evaluation of endometriosis-related quality of life.

MATERIALS AND METHODS

A search of the MEDLINE and EMBASE databases was carried out for publications in English and French for the period from 1980 to February 2017, using the words 'endometriosis' and 'quality of life'. Publications were selected if they reported on quality of life in patients with endometriosis and specified use of a quality of life scale. A quantitative and a qualitative analysis of each scale was performed in order to establish the strengths and weaknesses for each scale (systematic registration number: PROSPERO 2014: CRD42014014210).

RESULTS

A total of 1538 articles publications were initially identified. After exclusion of duplicates and application of inclusion criteria, 201 studies were selected for analysis. The SF-36, a generic HRQoL measure, was found to be the most frequently used scale, followed by the EHP-30, a measure specific to endometriosis. Both perform well, when compared with other scales, with scale weaknesses offset by strengths. EHP-5 and EQ-5D also showed to be of good quality. All four were the only scales to report on MCID studied in endometriosis patients.

CONCLUSION

For clinical practice, routine evaluation of HRQOL in women with endometriosis is essential both for health-care providers and patients. Both SF-36 and EHP-30 perform better overall with regard to their strengths and weaknesses when compared to other scales.

Surgery for Endometriosis Improves Major Domains of Quality of Life: A Systematic Review and Meta-Analysis

Because surgery for endometriosis can involve severe complications, it is important to determine if the patient's quality of life (QOL) is indeed improved after surgery. A systematic review and meta-analysis, when appropriate, was conducted and included 38 studies that assessed the QOL using validated questionnaires administered before and after surgery. Results were grouped according to the type of endometriosis reported: all types endometriosis, deep infiltrative endometriosis (DIE), and bowel endometriosis. Quantitative analysis was performed on 17 homogeneous studies. Pooled response mean differences between the 36-Item and 12-Item Short Form Survey (SF-36 and SF-12) showed significant improvement in Mental Component Score (MCS) after surgery for all types of endometriosis (.21; 95% confidence interval [CI], .04-.38); significant improvement after surgical treatment for DIE in Vitality (.67; 95% CI, .41-.94), Social Functioning (.59; 95% CI, .18-.99), Role Emotional .49; 95% CI, .02-.97), Mental Health (.39; 95% CI, .03-.74), Physical Functioning (.93; 95% CI, .49-1.38), Bodily Pain (1.23; 95% CI, .47-1.99), General Health (.57; 95% CI, .02-1.12), MCS (.55; 95% CI, .10-1.00), and Physical Component Score (PCS; .73; 95% CI, .27-1.18); and significant improvement after surgery for bowel endometriosis for all 8 domains (Vitality [1.00; 95% CI, .56-1.43], Social Functioning [.97; 95% CI, .57-1.37], Role Emotional [1.17; 95% CI, .7-1.63], Mental Health [.94; 95% CI, .5-1.38], Physical Functioning [.74; 95% CI, .3-1.18], Role Physical [1.25; 95% CI, .75-1.76], Bodily Pain [1.39; 95% CI, .79-1.98], General Health [.84; 95% CI, 1.46-1.22]), MCS (.93; 95% CI, .47-1.40), PCS (.82; 95% CI, .40-1.23), and total score (1.15; 95% CI, .48-1.83). Only 1 study assessed patients with minimal disease and showed significant improvement in PCS (p = .002) and MCS (p <.001). This systematic review reveals that surgery for endometriosis resulted in overall improvement in most health domains of health-related QOL, with the greatest improvement found in the Bodily Pain domain.

New Developments in Surgery for Endometriosis and Pelvic Pain

Endometriosis is a common disease affecting reproductive age women. Pain is one of the most common symptoms associated with endometriosis. When medical therapy has failed or in known deeply infiltrating endometriosis, surgical management is warranted. Laparoscopy is the gold standard for diagnosis and treatment of endometriosis. Recent developments in surgery have shown the feasibility of robotic surgery for endometriosis, although these methods have not been shown to be superior to conventional laparoscopy. Enhanced imaging techniques including fluorescence imaging and narrow band imaging have also been studied. However, long-term clinical benefits have yet to be demonstrated.

Techniques in minimally invasive surgery for advanced endometriosis

PURPOSE OF REVIEW

Surgery can be an important treatment option for women with symptomatic endometriosis. This review summarizes the recommended preoperative work up and techniques in minimally invasive surgery for treatment of deeply infiltrating endometriosis (DIE) involving the obliterated posterior cul-de-sac, bowel, urinary tract, and extrapelvic locations.

RECENT FINDINGS

Surgical management of DIE can pose a challenge to the gynecologic surgeon given that an extensive dissection is usually necessary. Given the high risk of recurrence, it is vital that an adequate excision is performed. With improved imaging modalities, preoperative counseling and surgical planning can be optimized. It is essential to execute meticulous surgical technique and include a multidisciplinary surgical team when indicated for optimal results.

SUMMARY

Advanced laparoscopic skills are often necessary to completely excise DIE. A thorough preoperative work up is essential to provide correct patient counseling and incorporation of the preferred surgical team to decrease complications and optimize surgical outcomes. Surgical management of endometriosis is aimed at ameliorating symptoms and preventing recurrence.

Conservative treatment of deep infiltrating endometriosis: review of existing options

Endometriosis with its estimated incidence rate of ∼7-10% of women of reproductive age is a disease with the wide spectrum of symptoms depending on form and localization of endometrial foci. One clinical form of endometriosis is deep infiltrating endometriosis (DIE), most difficult to manage and generating a lot of direct and indirect treatment costs. We search the literature from PubMed database to establish the role of conservative treatment of DIE. Randomised controlled trials are lacking but in experts opinion hormonal treatment should be the first-line treatment in DIE. After evaluation of pain or other symptoms, second-line therapy with GnRH analogs or danazol should be offered or minimally invasive surgery. Consensus is not made whether surgery is the best therapeutic treatment for affected patients. Strong depending on surgeon's experience conservative surgery should be offered if the total excision of DIE foci is possible, which is essential for a successful outcome. If available treatment options do not release pain associated with DIE, experimental treatment in clinical trials should be discussed with patients.

Research development of a new GnRH antagonist (Elagolix) for the treatment of endometriosis: a review of the literature

PURPOSE

Limitated studies have reported the efficacy of GnRH antagonist on endometriosis symptoms. The aim of our study was to review all available trials to investigate the medical treatment of endometriosis with only GnRH antagonists, with special attention to pharmacodynamic activity, safety, and efficacy.

METHODS

Pub Med and Sciencedirect database were searched using terms of "endometriosis treatment", "GnRH antagonist", and "Elagolix". The search was limited to clinical studies published in English. Title and abstract were screened to identify relevant articles.

RESULTS

Five studies covering use of GnRH antagonist were found. A phase 1 study evaluated the safety, pharmacokinetics, and inhibitory effects on gonadotropins and estradiol of single dose and 7 day elagolix administration to healthy premenopausal women; two phase II studies evaluated efficacy in patient with endometriosis. Moreover, there are two Phase III clinical trials just completed.

CONCLUSION

GnRH antagonists may have the advantage of oral administration and lower incidence of adverse events. Currently, only Phase II studies have been published demonstrating promising results in terms of efficacy, safety, and tolerability. From the results of the phase III studies, elagolix may become a valuable addition to the armamentarium of pharmacological agents to treat endometriosis-related pain.

Adenomyosis: a systematic review of medical treatment

Adenomyosis is a heterogeneous gynaecologic condition with a range of clinical presentations, the most common being heavy menstrual bleeding and dysmenorrhoea; however, patients can also be asymptomatic. Several studies support the theory that adenomyosis results from invasion of the endometrium into the myometrium, causing alterations in the junctional zone. These changes are commonly seen on imaging studies, such as transvaginal ultrasound and magnetic resonance imaging. The aim of this review is to discuss the medical approach to the management of adenomyosis symptoms, including pain and abnormal uterine bleeding. The standard treatment of adenomyosis is hysterectomy, but there is no medical therapy to treat the symptoms of adenomyosis while still allowing patients to conceive. Medical therapies using suppressive hormonal treatments, such as continuous use of oral contraceptive pills, high-dose progestins, selective oestrogen receptor modulators, selective progesterone receptor modulators, the levonorgestrel-releasing intrauterine device, aromatase inhibitors, danazol, and gonadotrophin receptor hormone agonists can temporarily induce regression of adenomyosis and improve the symptoms.

Surgical treatment of deep infiltrating rectal endometriosis: in favor of less aggressive surgery

Deep infiltrating endometriosis of the rectum is a severe disease concerning young women of reproductive age. Because it is a benign condition, aggressive surgical treatment and subsequent complications are not always accepted by young patients. Two surgical approaches exist: the radical approach, employing colorectal resection; and the conservative approach, based on rectal shaving or full-thickness disc excision. At present, the majority of patients with rectal endometriosis worldwide are managed by the radical approach. Conversely, as high as 66% of patients with colorectal endometriosis can be managed by either rectal shaving or full-thickness disc excision. Most arguments that used to support the large use of the radical approach may now be disputed. The presumed higher risk of recurrence related to conservative surgery can be balanced by a supposed higher risk of postoperative bowel dysfunction related to the radical approach. Bowel occult microscopic endometriosis renders debatable the hypothesis that more aggressive surgery can definitively cure endometriosis. Although most surgeons consider that radical surgery is unavoidable in patients with rectal nodules responsible for digestive stenosis, conservative surgery can be successfully performed in a majority of cases. In multifocal bowel endometriosis, multiple conservative procedures may be proposed, provided that the nodules are separated by segments of healthy bowel of longer than 5 cm. Attempting conservation of a maximum length of rectum may reduce the risk of postoperative anterior rectal resection syndrome and subsequent debilitating bowel dysfunction and impaired quality of life. Promotion of less aggressive surgery with an aim to better spare organ function has become a general tendency in both oncologic and benign pathologies; thus the management of deep colorectal endometriosis should logically be concerned, too.

Postoperative hormonal therapy after surgical excision of deep endometriosis

The clinical management of women with deep peritoneal endometriosis remains controversial. The debate focuses mainly on the precise role of hormonal medical treatment and surgery and on the most suitable surgical technique to be used. In particular, considering the risks of second-line surgery, prevention of recurrences after first-line surgery is a priority in this context. Post-surgical medical therapy has been advocated to improve the effectiveness of surgery and prevent recurrences. However, adjuvant therapy, i.e. a short course of 3-6 months of hormonal therapy after surgery, has been proven to be of limited or no benefit for endometriosis in general and for deep peritoneal endometriosis in particular. On the other hand, two cohort studies suggest a beneficial effect of prolonged hormonal therapy after surgery for deep endometriosis. Even if this evidence is too weak to confidently advocate systematic administration of prolonged medical therapy after surgery, we argue in favour of this approach because of the strong association of deep endometriosis with other disease forms. In fact, women operated on for deep endometriosis may also face recurrences of endometriomas, superficial peritoneal lesions and pelvic pain in general. The demonstrated high effectiveness of prolonged postoperative therapy for the prevention of endometriomas' formation and dysmenorrhea recurrence should thus receive utmost consideration in the decision-making process.

Safe endobag morcellation in a single-port laparoscopy subtotal hysterectomy

Recently, the American Food and Drug Administration (FDA) published an alert about the risks of uterine tissue morcellation during laparoscopic procedures. In particular, the possible risk of spreading an undiagnosed malignant tumor was emphasized. From then on, a fervent debate in the media has led major scientific societies to express their position on the matter. We present a safe endobag abdominal morcellation in a single port-access laparoscopy subtotal hysterectomy. The endobag abdominal morcellation is feasible and safe; consequently, the development of devices dedicated to intracavitary morcellation in a closed system has been encouraged.

Single-port versus conventional multiport access prophylactic laparoscopic bilateral salpingo-oophorectomy in high-risk patients for ovarian cancer: a comparison of surgical outcomes

Bilateral salpingo-oophorectomy (BSO) in carriers of BRCA1 and BRCA2 mutations is widely recommended as part of a risk-reduction strategy for ovarian or breast cancer due to an underlying genetic predisposition. BSO is also performed as a therapeutic intervention for patients with hormone-positive premenopausal breast cancer. BSO may be performed via a minimally invasive approach with the use of three to four 5 mm and/or 12 mm ports inserted through a skin incision. To further reduce the morbidity associated with the placement of multiple port sites and to improve cosmetic outcomes, single-port laparoscopy has been developed with a single access point from the umbilicus. The purpose of this study was to evaluate the surgical outcomes associated with reducing the risks of salpingo-oophorectomy performed in a single port, while comparing multiport laparoscopy in women with a high risk for ovarian cancer. Single-port laparoscopy-BSO is feasible and safe, with favorable surgical and cosmetic outcomes when compared to conventional laparoscopy.

Surgical technique of endometrioma excision impacts on the ovarian reserve. Single-port access laparoscopy versus multiport access laparoscopy: a case control study

Several recent studies report the detrimental effect of endometrioma excision on the ovarian reserve. Surgical technique and the excessive use of bipolar coagulation could be the key factors. Single-port access laparoscopy (SPAL) ovarian cystectomy has been reported as a comparable procedure to conventional laparoscopy in terms of operative outcomes. The aim of this study was to evaluate whether the single-port surgery affects the ovarian reserve whilst performing laparoscopic ovarian cystectomy for unilateral endometrioma. This was a prospective, case-control study of 99 women with unilateral endometrioma. Forty-nine women underwent single-port cystectomy and 50 women underwent multiport laparoscopic (MPL) conventional cystectomy. The primary outcome was the assessment of the ovarian reserve. We evaluated the serum anti-Mullerian hormone (AMH) levels before, 4-6 weeks and 3 months after surgery. At T2 we performed an ultrasound assessment of the antral follicular count (AFC). We have drawn attention to a statistically significant decrease of the mean AMH value and AFC in the SPAL group at the 4-6-week and 3-month follow-up compared to the conventional laparoscopy group. In conclusion, our results suggest that SPAL cystectomy should not be recommended to patients undergoing surgery for endometrioma excision who want to preserve their fertility.

The role of ovarian fossa evaluation in patients with ovarian endometriosis

PURPOSE

The aim of this study is to evaluate prospectively the presence of endometriosis in the peritoneum of the ovarian fossa of patients affected by endometriomas and its correlation with the adhesion between this peritoneum and endometrioma.

METHODS

Patients presenting ovarian endometriomas and candidate to laparoscopy were considered for inclusion in the study. Patients underwent laparoscopic excision of endometriomas. The presence of adherence of the ovarian fossa to endometrioma was investigated. In all patients, the removal of a peritoneum fragment from the ovarian fossa of the affected ovary was carried out.

RESULTS

68 patients were enrolled in the study. 48 patients presented adhesions to the ovarian fossa. Histopathologic examination of the peritoneum of the ovarian fossa revealed the presence of endometriosis in 87 % of patients presenting adhesions of the endometriomas with ovarian fossa; surprisingly it was present only in 15 % of patients not presenting this condition (p < 0.0001). Pain symptoms were more frequent in patients with endometriomas adhesion to the ovarian fossa. CA125 levels were not statistically significantly different between groups. At 12-month follow-up, four patients presented endometrioma recurrence. All of them presented adhesion of the ovarian fossa to the endometrioma in the first operation.

CONCLUSIONS

There is a strong association between adhesion of the endometriomas to the ovarian fossa and the presence of endometriosis on the peritoneal surface of the fossa. This condition significantly correlates with pain symptoms and may predict endometrioma recurrence. The removal of this peritoneum in case of adherent endometrioma may potentially reduce the incidence of recurrence.

Single-port Access Subtotal Laparoscopic Hysterectomy: A Prospective Case-Control Study

STUDY OBJECTIVE

The objective was to evaluate the perioperative outcomes, safety, and patient acceptance of single-port access laparoscopic subtotal hysterectomy (SPAL-SH) in comparison with conventional multiport access laparoscopic subtotal hysterectomy (MPAL-SH).

DESIGN

Case-control study. Canadian Task Force Classification II-2.

SETTING

The study was conducted at university hospitals in Cagliari, Italy, and Rouen, France.

PATIENTS

Sixty-one women with metrorrhagia, abnormal uterine bleeding with uterine myomas, or symptomatic adenomyosis were included in the study.

INTERVENTIONS

Thirty-one patients underwent SPAL-SH, and 30 patients underwent conventional MPAL-SH.

MEASUREMENTS AND MAIN RESULTS

We analyzed the data to compare the outcomes of SPAL-SH versus MPAL-SH. Patients in the SPAL-SH group had longer operative times than those in the MPAL-SH group (p < .001) but shorter hospital stays (p < .001). Postoperative pain immediately after surgery, after 6 hours, and after 24 hours were lower in the SPAL-SH group (p < .001). The SPAL-SH group reported significantly higher cosmetic satisfaction at 1, 4, and 24 weeks after surgery (p < .01).

CONCLUSION

We conclude that SPAL-SH is a feasible and safe alternative to standard MPAL-SH in selected patients. Ongoing refinement of the surgical technique and instrumentation is likely to expand its role in gynecologic surgery in the future. In addition, SPAL-SH has a definite benefit in relation to body image and cosmesis.

Focusing on surgery results in infertile patients with deep endometriosis

Infertility is a common problem in patients with endometriosis and the involved mechanisms are still not completely known. The management of infertility in endometriosis patients includes surgery as well as assisted reproductive technology. Laparoscopic surgery has shown better results in infertility patients with endometriosis in comparison to laparotomy procedures. Laparoscopic surgery has proposed benefits in both minimal to moderate diseases. However, while there may be some benefits with severe diseases, there is still not enough evidence to recommend laparoscopic surgery as the recommended surgery when the main goal is to obtain fertility. We performed a MEDLINE search for articles on fertility in women with deep infiltrating endometriosis (DIE) published between 1990 and April 2015 using the following keywords: "endometriosis", "deep infiltrative endometriosis", "infertility", "fertility after surgery", "laparoscopy surgery", "laparotomy", "pregnancy", "fertility outcome", "bladder endometriosis", and "ureteral endometriosis". The aim of this review was to analyze the results of available clinical studies (randomized controlled or not controlled studies; retrospective cohort studies; or case-control and prospective studies) and guidelines on surgical treatment of infertile endometriosis patients, and pregnancy outcomes after surgery.