Université Paris Descartes, Sorbone Paris Cité, Faculté de Médecine, Assistance Publique – Hôpitaux de Paris (AP- HP), Groupe Hospitalier Universitaire (GHU) Ouest, Centre Hospitalier Universitaire (CHU) Cochin, Department of Gynecology Obstetrics II and Reproductive Medicine (Professor Chapron), Paris, France.
Endometriosis, is a public health issue that bears an important social burden. Endometriosis, histologically defined as functional endometrial glands and stroma developing outside of the uterine cavity is a common gynecologic disorder. Pathogenesis of endometriosis is enigmatic and remains controversial, even if retrograde menstruation seems the most probable mechanism for the development of the disease. Approximately 5–10% of reproductive-age women are affected by endometriosis, and at least one third of these are infertile. Symptoms vary widely, including dysmenorrhea, non-cyclic chronic pelvic pain, dyspareunia, and infertility, with a considerable negative impact on quality of life. Concerning the endometriotic lesions clinical appearance, there are three phenotypes: peritoneal superficial endometriosis (SUP), ovarian endometriosis (OMA) and deep infiltrating endometriosis (DIE). Adenomyosis is frequently encountered in association with endometriosis and may contribute to both painful symptoms and altered chances of spontaneous and assisted conception.
Deep endometriosis is actually considered the most severe form of endometriosis. DIE was previously arbitrarily defined as a peritoneal invasion over 5mm. Recently it was proposed that DIE should be defined by the involvement of the muscular layer of the organs around the uterus (bladder, uterus, ureter, …). DIE is not a disease of a specific organ but represents rather a multifocal and heterogeneous disease requiring a multidisciplinary integrated approach. Pre-operative imaging work-up is essential. DIE nodules multifocality justifies a complete abdomino-pelvic work-up, because if surgery is decided, location of deep lesions governs the surgical procedure’ choice.
For DIE patients, the choice between medical treatment, surgery and ART depends of numerous parameters: age, associated endometrioma and/or adenomyosis, intensity of painful symptoms, ovarian reserve, infertility with or without associated infertility factors, previous history of surgery for endometriosis, number and location of deep nodules … Surgery is efficient, not only for managing pelvic pain and treatment of endometriosis-related infertility, but also for improving quality of life. Nevertheless, the benefits of surgery should not obscure the fact that interventions can be associated with adverse outcomes.
An important issue is that endometriosis has a high potential risk for recurrence which many reports have attributed to incomplete surgical procedures. One of the main question in the endometriosis surgical management is to know if it is a “real recurrence or persistence”.
In case of deep infiltrating endometriosis, especially in case of intestinal involvement, surgery is not harmless and benefits of pain relief and spontaneous conception following surgery should be balanced with life threating surgical risk as fistula, peritonitis, bladder and intestinal dysfunctions and risk of disease recurrence. In addition in case of associated ovarian endometrioma, fears that surgery can alter ovarian function that is already compromised sparked a rule of no surgery before ART.
The respective advantages of surgery, medical treatment, and ART intertwine complexly in women with deep infiltrating endometriosis. This intricate medley mandates a global approach to optimise every option. Indeed, only such a strategy can oppose a situation that still too often prevails, when the main reason for choice of surgery or ART stems from the primary activity of the doctor who is first consulted.