Treatment of Minimal Endometriosis

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"The question has been raised as to the impact and relevance of minimal endometriosis, how it's managed, and what its implications are for the infertile female. It is indeed a very controversial issue. The significance of it is much in doubt, particularly when it does not seem to relate to the mechanics of tubo-ovarian pick-up. However, there's been some information suggesting that there certainly is a correlation with decreased fertility rates and minimal endometriosis.

There are some older studies, which suggests that there's the same impact in minimal disease as there is in moderate disease, the perspective of fertility rates before and after therapy. And for that reason, we treat minimal endometriosis and moderate disease in much the same way, in so much as that we initially surgically de-bulk it. With minimal disease we attempt to excise it, first to make a histological diagnosis of the suspected lesions themselves. In addition we attempt to get some histology from areas of the peritoneum, proximate to the suspected lesions, from the perspective of how to then subsequently manage the patient. Management, I think, can be divided into four categories post-operatively.

One would be expectant management - where you essentially do nothing. The second would be some form of medical therapy, ranging from GnRH agonists therapy to ovulation suppression with a progestational based combinational contraceptive. The third management is a controlled ovarian stimulation rationale, particularly perhaps for older women who have an increased infertility rate. And the fourth management, I think, would be one of the assisted reproductive procedures, specifically since you've just done a laparoscopy, perhaps some vitro-fertilization.

I think the management largely needs to be individualized depending upon a number of different issues. The aggressiveness of which, I think, would be determined in part by the patient's age, in so much as we will manage a 40-year-old patient with minimal endometriosis much more aggressively than we'll manage a 30-year-old with minimal disease. I think the 30-year-old we would be more inclined to manage expectantly and the 40-year-old more aggressively. There has been a lot of controversy recently as to whether patients with minimal disease require or benefit by medical therapy postoperatively. There are a certain percentage of physicians that are assuming this could be a systemic disease and the local manifestations of that disease are sort of "the tip of the ice berg". They tend to want to manage all patients medically regardless of the appearance laparoscopically of the disease. On the other hand, if there's no other evidence of disease present, it's probably - particularly in the older patient - not rational to give them any significant amount of time of postoperative suppression.

So I think that it's a question that is a bit of an enigma to us clinically. We don't have a good handle on any set management scheme, and I think there's a certain art to medicine that comes in here in individualizing all of the treatment of your patient with minimal endometriosis."