A randomized study demonstrated an increased ovarian follicular response to gonadotrophin stimulation for women who underwent excisional surgery when compared to ablative surgery (weighted mean difference (WMD) 0.6; 95% CI, 0.04–1.16) (305). There is insufficient evidence to favor excisional surgery over ablative surgery with respect to the chance of pregnancy after controlled ovarian stimulation and intrauterine insemination (OR 1.40; 95% CI, 0.47–4.15) or treatment with assisted reproductive technology (299). It is controversial whether there is a potential negative effect of ovarian cystectomy on reproductive function. In a small prospective randomized clinical trial, 10 patients assigned to undergo laparoscopic cystectomy had a lower antral follicle count and a more pronounced reduction in serum anti-m¨ullerian hormone (AMH) levels (from 3.9 to 2.9 ng/mL) 6 months after surgery when compared to the 10 patients treated with a “three-stage procedure” as described above (reduction in AMH levels from 4.5 to 3.99 ng/mL) (306,307). More randomized trials are needed to assess the effect of ovarian cystectomy on ovarian reserve and on reproductive function, especially with respect to conception after treatment with medically assisted reproduction.
It is possible that the surgical techniques used to treat ovarian endometriotic cysts may inﬂuence postoperative adhesion formation and/or ovarian function. In a randomized study comparing surgical methods to achieve ovarian hemostasis after laparoscopic endometriotic ovarian cystectomy, closure of the ovary with an intraovarian suture resulted in a lower rate and extension of postsurgical ovarian adhesions at 60 to 90 days follow-up when compared to only bipolar coagulation on the internal ovarian surface (308).
Deeply infiltrating endometriosis is usually multifocal and complete surgical excision must be performed in a one-step surgical procedure in order to avoid more than one surgery, provided the patient is fully informed (1,179,287). Because management of deeply infiltrating endometriosis is complex, referral to a center with sufficient expertise to offer all available treatments in a multidisciplinary approach is strongly recommended (1). Surgical management is only for symptomatic deeply infiltrating endometriosis. Asymptomatic patients must not undergo surgery. Progression of the disease and appearance of specific symptoms rarely occurred in patients with asymptomatic rectovaginal endometriosis (288). When surgical treatment is decided, the treatment must be radical with excision of all infiltrating lesions (1). It is difficult to perform randomized studies to detect the best surgical technique to treat deeply infiltrative endometriosis because these severe cases are all managed individually and not all surgeons are familiar with all treatment options (1). Complete excision while preserving the uterus and ovarian tissue might include the resection of the uterosacral ligaments, the resection of the upper part of the posterior vaginal wall, and urological and bowel operations.
Surgical Treatment of Pain