Introduction: Surgical intervention in women with endometriosis particularly those with endometrioma is technically challenged and associated with multiple complications. Annalogically, surgery in endometriosis is a “two edged sword” treatment, alleviates the symptoms but also causing detrimental effect on the fertility.
Case: A 35-year-old female, nulliparous, been trying to conceive for 12 years, was referred to our centre for recurrent endometrioma with background of multiple surgeries for endometriosis. She was first diagnosed in June 2007 as an incidental finding during a laparoscopy and dye test as part of her investigation for primary infertility. Left tubal blockage was found with endometrioma confirmed by histopathological examination (HPE). She had recurrent cyst within 5 months and laparotomy cystectomy was done. GnRH analogue was given for 3 months and remained asymptomatic for 5 years. Fertility treatment was not done due to financial constraints. In 2013, she presented with recurrent ovarian cyst and underwent laparoscopic left cystectomy and right cyst aspiration. HPE reported as benign cyst. Another laparoscopic drainage of endometrioma was done in April 2014 as patient presented with abdominal mass and worsening dysmenorrhea. In April 2017, patient noticed of abdominal distention and examination revealed abdominal mass clinically of 20 weeks size. AMH level was 3.96 pmol/L preoperatively. CT scan showed huge bilateral ovarian cyst. Midline laparotomy bilateral ovarian cystectomy, removal of mesenteric cyst, appendicectomy were performed on April 9th, 2017. Intraoperatively, noted severe bowel adhesion to the uterus and ovarian cyst which required surgical team assistance. Large serosal tear – 8 cm at small bowel and at sigmoid colon – 15 cm length were repaired. Left cyst was embedded in the small bowel mesentery together with mesenteric cyst. Right ovarian endometrioma of 8 cm size was ruptured during manipulation. Total blood loss was 1.5 litre. Post-operative complication with ileus was treated conservatively. She was discharged on day 6 post operation. Dienogest 2 mg daily started. HPE showed endometriosis on the right cyst wall, benign serous cyst of the left cyst and benign mesenteric cyst.
Discussion: Endometriosis can affect fertility in many ways. The disease process alone can give a negative impact on the ovarian reserve and surgery on endometriosis will further lower it hence surgical management on endometriosis is not straight forward. Judicious use of diathermy and manipulation may spare some pre-antral follicles. Surgical removal in women planned for IVF is not indicated as it shown not to improve the outcomes. The management of endometriosis must be individualised to account for patient symptoms, stages of diseases and patient’s expectations.