Treatment at the time of diagnosis

• The recommendation for laparoscopic surgery at the time of diagnosis is based on guidelines from the Royal College of Obstetricians and Gynaecologists and the European Society of Human Reproduction and Embryology [Kennedy et al, 2005; RCOG, 2006]. There is widespread consensus for treating endometriosis at the time of surgical diagnosis, depending on the experience and competency of the surgeon and the severity of disease present [Varma, Personal Communication, 2009].

Surgery for the treatment of pain associated with mild-to-moderate endometriosis

• The recommendation that laparoscopic ablation of endometrial deposits may relieve pain in some women is based on guidelines from the Royal College of Obstetricians and Gynaecologists and the European Society of Human Reproduction and Embryology [Kennedy et al, 2005; RCOG, 2006].
• Ablation of endometriotic lesions reduces the pain associated with endometriosis compared with diagnostic laparoscopy. There is limited evidence from a Cochrane systematic review (of one small randomized controlled trial [RCT]) that laser ablation, adhesiolysis, and uterine nerve ablation performed together are beneficial in the treatment of pain due to mild or moderate endometriosis compared with diagnostic laparoscopy alone. There is limited evidence from one RCT that women who have a laparoscopy with excisional surgery are likely to have less pain and an improved quality of life at 1 year compared with women who have had a diagnostic laparoscopy alone.
• The Royal College of Obstetricians and Gynaecologists guidelines state that there is no evidence that it is necessary to add laparoscopic uterine nerve ablation (LUNA, which aims to interrupt the nerve pathways that conduct pain sensation from the pelvic area to the brain) to laser ablation. Used in isolation, LUNA has no effect on endometriosis-associated dysmenorrhoea [RCOG, 2006].
• Laparoscopic helium plasma coagulation is a more recent minimally-invasive procedure used to vaporize endometriotic deposits. Current evidence on the safety and efficacy of this procedure is not adequate to recommend its use without special arrangements for consent [NICE, 2006].

Surgery for the treatment of subfertility

• There is evidence that laparoscopic surgery for the treatment of minimal and mild endometriosis may improve the chance of pregnancy, but the evidence is conflicting and limited to two RCTs.
• The role of surgery in improving pregnancy rates in women with moderate-to-severe endometriosis is uncertain. A review from the Practice Committee of the American Society for Reproductive Medicine concluded that women who have moderate or severe endometriosis, without other identifiable infertility factors, may improve their chance of conceiving with conservative surgical treatment such as laparoscopy and possibly laparotomy [Practice Committee of the American Society for Reproductive Medicine, 2006].
• There is evidence from a Cochrane systematic review [Hart et al, 2008] of six non-randomized trials of women with endometrioma that excision of the endometrioma is preferable to drainage and ablation in regard to recurrence of symptoms, recurrence of an endometrioma, and spontaneous pregnancy rates.

Treatment of severe endometriosis

• The Royal College of Obstetricians and Gynaecologists guidelines recommend radical surgery for severe and deeply-infiltrating endometriosis [RCOG, 2006]. There is high morbidity associated with these procedures, and therefore surgery for severe endometriosis should only be conducted by gynaecologists accredited in advanced laparoscopy, and should be performed in specialized tertiary endometriosis centres, where the volume of work and level of expertise ensures the best care for the woman. Multidisciplinary input in the treatment pathway for women with severe endometriosis may involve gynaecologists, radiologists, colorectal surgeons, urologists, anaesthetic pain specialists, and psychologists [Varma, Personal Communication, 2009].

Relapse rate

• A systematic review included three RCTs and found that the absolute benefit on pain relief at short-term follow up (6 months or 1 year) was 30–40% in women with mild to severe endometriosis. Data from case series also analysed in this review suggested that 50% of women still needed analgesics or hormonal treatment at 1 year. One study in the review reported long-term follow up (12–14 years) and found that the repeat surgery rate was 52% in the excision group and 48% in the observational laparoscopic group [Vercellini et al, 2009].

Use of hormonal treatment before or after surgery

• There is insufficient evidence to suggest that hormonal suppression in association with surgery for endometriosis will significantly benefit eradication of endometriosis, improvement of symptoms, pregnancy rates, and overall tolerability. The Royal College of Obstetricians and Gynaecologists does not recommend its use [RCOG, 2006].