After first-line surgery for endometriosis, women should be invited to seek conception as soon as possible. Alternatively, OC use until pregnancy is desired should be considered because several lines of evidence suggest that ovulation inhibition reduces the risk of endometriosis recurrence (477). A recurrent endometrioma developed in 26 of 250 regular users (10%; 95% CI, 7%–15%) compared with 46 of 115 never users (40%; 95% CI, 31%–50%), with a common odds ratio of 0.16 (95% CI, 0.04–0.65) (477).
Medical Treatment of Recurrence
In a randomized prospective clinical study, continuous treatment for 6 months with desogestrel (75 μg per day) (n = 20) versus a combined oral contraceptive (ethinyl estradiol 20 μg plus desogestrel 150 μg) resulted in a significant and comparable improvement of both pelvic pain and dysmenorrhea with breakthrough bleeding in 20% of the desogestrel-treated patients, and a significant body weight increase in 15% of the OC-treated women (478).
Surgical Treatment of Recurrence
The optimal surgical solution in women with recurrent symptoms after previous conservative procedures for endometriosis should be based on the desire for conception and on psychological characteristics (479). Studies on surgical management of recurrent rectovaginal endometriosis are warranted because of the peculiar technical difficulties and the high risk of complications associated with this challenging disease (479).
Conservative Surgery According to review papers, the long-term probability of pain recurrence after repeat conservative surgery for recurrent endometriosis varies from 20% to 40%, and a further surgical procedure will occur in 15% to 20% of the cases (470,479). These figures are probably an underestimate related to drawbacks in study design, exclusions of dropouts, and publication bias and should be considered with caution (479). No studies evaluated the association of presacral neurectomy to the surgical treatment of recurrent endometriosis among patients with recurrent disease (470). The spontaneous conception rate among women undergoing repetitive surgery for recurrent endometriosis associated with infertility is 20% (12-and 24-month cumulative pregnancy rates of 14% and 26%), whereas the overall crude pregnancy rate after a primary surgical procedure is 40% (12-and 24-month cumulative pregnancy rates of 32% and 38%) (470,479). Among infertile patients treated with repetitive surgery for recurrent endometriosis the spontaneous pregnancy rate was 19% (12-and 24-month cumulative pregnancy rates), whereas it was 34% for those untreated (12-and 24-month cumulative pregnancy rates of 25% and 30%). The probability of conception after IVF is not significantly lower after repetitive surgery (20%) when compared to primary surgery (30%) (hazard ratio [HR] 1.51; 95% CI, 0.58–3.91%) (479).
Hysterectomy The outcome of hysterectomy for endometriosis-associated pain at medium-term follow-up seems satisfactory. About 15% of patients had persistent symptoms and 3% to 5% experienced worsening of pain (479).
Coping with Disease