Understanding Endometriosis
Endometriosis is classified by the American Society for Reproductive Medicine (ASRM) into four stages (I-IV) based on extent at laparoscopy, and by anatomical sub-type:
Superficial peritoneal endometriosis:
- Endometriotic deposits on the peritoneum of the pelvis, pelvic sidewalls, uterosacral ligaments
- Can cause significant pain despite apparently limited extent; classification stage not reliably correlated with pain severity
- Surgical excision under laparoscopy is the most effective treatment; ablation (burning) has higher recurrence
Ovarian endometrioma (chocolate cyst):
- Endometriotic cyst within the ovary - filled with old blood (chocolate-coloured)
- Causes pelvic pain, dyspareunia; impairs ovarian reserve (AMH levels reduce with increasing endometrioma size)
- Management: cystectomy (excision of the cyst wall, not drainage alone) - preserves normal ovarian tissue; reduces recurrence vs. drainage
Deep Infiltrating Endometriosis (DIE):
- Endometriosis growing >5 mm beneath the peritoneum; affects the uterosacral ligaments, rectovaginal septum, bowel, bladder, ureters
- Causes severe cyclical pain, dyschezia (painful defaecation), dysuria, deep dyspareunia
- Requires specialist multidisciplinary surgery: gynaecologist - colorectal surgeon - urologist for bowel/bladder resection
- Complete excision of DIE achieves significantly better long-term outcomes than incomplete surgery
Endometriosis and fertility:
- Mechanism: altered pelvic anatomy, adhesions distorting tubes, inflammatory cytokines impairing oocyte/embryo quality
- Stage I-II endometriosis: controversial surgical benefit on fertility; IVF often preferred without surgery
- Stage III-IV: laparoscopic treatment improves spontaneous conception rates; IVF success rates also higher post-excision than pre-operatively
Surgical Treatment of Endometriosis
Why excision is superior to ablation: Ablation (burning/coagulating/laser vaporisation of visible lesions) leaves the underlying lesion root in situ - high recurrence rates (30-50% at 5 years). Excision - cutting out the endometriotic nodule with adequate margins - removes the entire lesion base: recurrence rates 5-15% at 5 years for skilled excision surgery.
Laparoscopic endometriosis excision: Under general anaesthesia; CO- pneumoperitoneum; thorough inspection and mapping of entire pelvis; systematic excision of all visible lesions using scissors/energy device with identification of both ureters.
Endometrioma cystectomy: The cyst is opened; contents evacuated; stripping technique - cyst wall stripped from ovarian cortex preserving normal follicle-bearing tissue. Haemostasis with minimal bipolar energy to protect ovarian reserve.
Advanced DIE surgery (multidisciplinary): For rectovaginal and bowel endometriosis:
- Rectal shaving: Superficial rectal endometriosis removed tangentially from the rectal wall; no opening of bowel; used for <30% bowel wall involvement
- Discoid resection: Full-thickness disc of bowel removed; stapled transverse closure; for focal deeper involvement
- Segmental bowel resection: For extensive circumferential bowel involvement; requires colorectal surgeon; anastomosis fashioned
- Bladder resection and ureteric re-implantation (neoureterostomy) for bladder dome and ureteric DIE
- Available at partner hospitals with multidisciplinary endometriosis team (gynaecology + colorectal surgery)
Post-operative hormonal treatment: To extend disease-free interval after surgery: combined oral contraceptive pill continuously, progestagen (dienogest/Visanne), or GnRH agonist for 3-6 months reduces recurrence risk.
Recovery and Outlook After Surgery
Recovery after laparoscopic endometriosis excision:
- Hospital: 1-3 nights (simple excision 1 night; bowel surgery 3-5 nights)
- Hotel recovery: 7-10 days before flying
- Return to light work: 1-2 weeks; full activity: 3-4 weeks
- Bowel surgery recovery (segmental resection): 3-5 nights hospital; 14 days hotel; 4-6 weeks full recovery
Expected outcomes:
- Pelvic pain improvement: 70-80% of women report significant reduction in dysmenorrhoea and CPP after complete excision
- Dyspareunia improvement: 65-75% after rectovaginal endometriosis excision
- Fertility (spontaneous conception): improved in Stage III-IV excision; 2-year pregnancy rates of 40-60% in women under 35 after complete staging laparoscopy
- Recurrence: 15-20% symptomatic recurrence at 5 years after complete excision; higher rates if incomplete surgery
Fertility treatment after endometriosis surgery: If spontaneous conception has not occurred within 6-12 months post-surgery (or patient is over 35 years), IVF is the next step. BB Global Health coordinates IVF referral to partner IVF clinics.
Pre-operative investigation:
- Pelvic ultrasound with gynaecological expertise: transvaginal ultrasound for endometrioma and DIE mapping
- MRI pelvis: gold standard for mapping DIE, bowel, and ureteric involvement - critical for surgical planning
- CA-125 (non-diagnostic but elevated in advanced disease; useful for monitoring)
Cost comparison: Simple endometriosis excision Turkey: -5,000-8,000 all-inclusive; UK private: -10,000-18,000. Advanced DIE surgery Turkey: -8,000-15,000; UK private: -18,000-35,000.