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Ankita Ratan, PG*, Sujata Pradhan, M.D.**, Pradip Kumar Panigrahi, M.D.***, Manisha Sahu, MS*, Pratyasha
Peepal, PG*, Somadatta Das, MA****
*Department of Obstetrics and Gynaecology, IMS & SUM Hospital, SOA Deemed to be University, Bhubaneswar, Odisha, India, **Center for Human
Reproduction, Department of Obstetrics & Gynaecology, IMS & SUM Hospital, Siksha ‘O’ Anusandhan Deemed to be University, Bhubaneswar,
Odisha, India, ***Department of Obstetrics and Gynaecology, Sparsh Hospital and critical care, Bhubaneswar, Odisha, India, ****Central Research
Laboratory, IMS & SUM Hospital, SOA Deemed to be University, Bhubaneswar, Odisha, India.
Role of Laparoscopy in Diagnosis and Treatment of
Endometriosis Associated with Infertility:
A Prospective Analysis
ABSTRACT
Objective: Endometriosis is oen considered as an enigma due to its varied clinical presentation and challenges in
diagnosis. e objective of this study is to evaluate the role of laparoscopy in diagnosis and treatment of endometriosis
associated with infertility.
Materials and Methods: Infertile females diagnosed to have endometriosis during or before undergoing laparoscopic
surgery from August 2018 to February 2020 were followed up for spontaneous conception for 6 months following
laparoscopy. Revised American Fertility Society (r-AFS) scoring system was used to score endometriosis and stage
the disease (stage I-IV). Surgical interventions were done on individual case basis following ESHRE guidelines.
Results: Fiy infertile females diagnosed with endometriosis during or before laparoscopy were recruited for the
study. Mean age of patients was 28.58 (±4.21) years. irty-four (68%) patients had primary infertility and 16 (32%)
has secondary infertility. Mean duration infertility was 3.33 (±1.43) years. Only 37 patients (74%) had evidence
of endometriosis in pre-operative ultrasonography. During the follow up period of rst 6 months aer surgery 34
(68%) patients conceived spontaneously. Lower mean endometriosis score (p=0.00) and early stages of endometriosis
(p=0.00) were associated with higher chances of conception. But, female age, duration and type infertility, USG
ndings and type of surgical interventions did not aect pregnancy rate.
Conclusion: Laparoscopy helps in diagnosis of endometriosis. Laparoscopic therapeutic interventions for endometriosis
increase the probability of spontaneous conception in infertile females. Lower surgical score and early stages of
endometriosis are associated with higher chance of conception.
Keyword: Laparoscopy; endometriosis; infertility; diagnosis (Siriraj Med J 2021; 73: 772-776)
Corresponding author: Sujata Pradhan
E-mail: dr.suzzane@gmail.com
Received 21 March 2021 Revised 18 September 2021 Accepted 5 October 2021
ORCID ID: https://orcid.org/0000-0002-3082-0494
http://dx.doi.org/10.33192/Smj.2021.100
INTRODUCTION
Endometriosis is the cause of infertility in 5-15%
of women in reproductive age group.
1
It is diagnosed in
35 to 50 % of women with chronic pelvic pain, infertility
or both.
2
But diagnosis is oen postponed for several
years after symptoms onset.
3
There is no definitive
imaging modality or serum marker for the diagnosis
of endometriosis. While transvaginal scan (TVS) has
recently gained popularity as a rst-line imaging modality
for non-invasive diagnosis of endometriosis,
4
diagnostic
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laparoscopy is required for conrmation of diagnosis
and staging of the disease.
5
A systematic review and
meta-analysis of 13 studies on pelvic endometriosis also
revealed non-invasive imaging modalities particularly
transvaginal ultrasonography to be of lesser accuracy
compared to laparoscopy.
6
Excision and ablation of endometriotic lesions
in mild to severe disease using laparoscopic surgery
enhances fertility.
7
Surgery improves the probability of
conception by restoring the anatomical distortion caused
by the disease and removing the endometriotic implants,
thereby reducing the inammatory peritoneal response.
Existing literature shows diversities regarding the benecial
eect of therapeutic laparoscopy in infertile females with
dierent stages of the disease. In a retrospective cohort
study, patients with severe endometriosis were followed up
for natural as well as assisted conceptions.
8
Reproductive
outcomes in infertile women with advanced endometriosis
and repeated IVF failures were also observed.
9,10
In a
retrospective study by Ekine et al. infertility patients
with all stages of endometriosis were followed up for
pregnancy following surgery.
11
But the pregnancies
resulted from IUI and ART were also included. e
current study was intended to determine the ecacy of
laparoscopic surgery for diagnosis as well as treatment
of pelvic endometriosis in infertile females. It observes
the chances of spontaneous conception for all stages of
endometriosis.
MATERIALS AND METHODS
is prospective study was carried out in a teaching
hospital of Odisha, India. Institutional Ethical Committee
approval was obtained for the study. For all the patients
attending infertility clinic, detail history taking and relevant
clinical examinations were performed. As a part of routine
infertility evaluation, baseline transvaginal ultrasonography,
thyroid function test and male partner’s semen analysis
were done. Patients with clinical and /or ultrasonographic
features of endometriosis without previous history of
surgery for endometriosis were planned for laparoscopy.
Dysmenorrhoea, dyspareunia and chronic pelvic pain
were considered as relevant symptoms for diagnosis of
endometriosis. Similarly, presence of endometriotic cyst in
one or both ovaries or features suggestive of utero-ovarian
adhesions in transvaginal ultrasonography were presumed
to be features of endometriosis. Revised AFS scoring
system was used for scoring and staging endometriosis
during surgery. Chromopertubation was done for all
the patients. erapeutic interventions were done as
per ESHRE guidelines for endometriosis management.
Complete cystectomy was preferred to partial cystectomy
or cyst drainage for ovarian endometriomas. Supercial
endometriotic lesions were fulgurated. Adhesiolysis
was done for pelvic adhesions for restoration of tubo-
ovarian relationship. Surgical specimens were sent for
histopathological conrmation of endometriosis.
Patients with laparoscopic features suggestive of
endometriosis were considered for the study. Females aged
more than 37 years, with polycystic ovarian syndrome
(PCOS) or decreased ovarian reserve were excluded.
Similarly, patients with abnormal male factors and bilateral
tubal block as observed during laparoscopy were also
excluded from the study. Diagnosis of PCOS was done
as per Rotterdam criteria. Similarly, decreased ovarian
reserve was dened as antral follicle count (AFC) < 7
combined in both ovaries or anti-Mullerian hormone
(AMH) < 1.1 ng/ml. Abnormal semen parameters were
dened by sperm concentration < 10 million/ml and /
or progressive motility < 10%.
e study subjects were followed up for 6 months
post-intervention for spontaneous conception. Clinical
pregnancy was considered as the outcome measure of the
study. It was dened by the presence of ultrasonographic
evidence of gestational sac with or without fetal pole at
7
th
week of amenorrhoea.
Considering the total number of patients attending
infertility clinic in our hospital and the prevalence of
endometriosis in infertile females, the sample size was
decided to be at least 50 as this is a part of post-graduate
level dissertation with a xed duration for the study.
Data analysis
The data obtained were tabulated in Microsoft
Excel. Statistical analysis was carried out with the aid
of statistical programme SPSS 20.0. Quantitative data
were expressed in mean and standard deviation. e
percentages and proportions were used to express the
categorical results. A Chi-square test was performed to
compare the proportion in two groups for a categorical
variable. An independent t-test was performed to look
for the dierence in the means of two groups with a
quantitative variable, p-value of 0.05 was considered to
be the degree of statistical signicance.
RESULTS
During the study period, y infertile patients
with endometriosis were followed up for spontaneous
conception aer laparoscopy. Mean age of participants
was 28.5 (±4.21) years. Mean duration of infertility was
3.33 (±1.43) years. Majority of them had primary infertility
(68%). Pre-Operative ultrasonography showed evidence
of endometriosis only in 37 (74%) patients. Among the
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patients who had ultrasonographic abnormalities, the
most common nding was a right ovarian chocolate cyst
(26%) followed by bilateral chocolate cysts (24%).
Intraoperatively, the minimum r-AFS score was 2
and the maximum score was 88 with mean (±SD) score
of 23.76 (±19.9). Stage III endometriosis was observed in
majority of these patients followed by stage I endometriosis
(20%). Unilateral cystectomy was the most common
intervention done in 48% of the patients, followed by
bilateral cystectomy (24%) and adhesiolysis alone (12%).
Other interventions were fulguration of endometriotic
spots (8%), myomectomy (6%), and oophorectomy (2%).
irty-four patients (68%) conceived spontaneously
at the end of 6 months and 16(32%) patients failed to
conceive. General characteristics of these patients are
compared and represented (Table 1). e mean age
of patients with successful pregnancies was similar to
those who failed to conceive (27.82±4.71 vs 30.18±3.35,
p=0.06). Similarly, there was no dierence in duration
of infertility in these patients (Mean ± SD 3.35±1.45 vs
3.28±1.46, p=0.88). Among 34 patients with primary
infertility, 24 (70.5%) conceived and 10 (62.5%) patients
with secondary infertility conceived in the predened
postoperative period. ere was, however, no statistically
signicant association of infertility type with the status
of conception within 6 months (p=0.56).
Ultrasonographic and operative characteristics of
the patients were compared and represented (Table 2).
Ultrasonography ndings did not aect the chances of
conception (p=0.86). Majority of patients in both categories
had unilateral endometriomas (15/34 vs 15/16) followed
by bilateral endometriomas (9/34 vs 3/16). e mean
score of endometriosis in the conceived patients was
signicantly lower compared to the patients who failed
to conceive spontaneously (16.94±10.58 vs 38.25±26.93,
p=0.00). A similar observation was also noted for stage
of endometriosis. e proportion of study participants
getting pregnant at the end of 6 months was higher
in patients with lower stages of endometriosis than
those with the higher stage (p=0.00). All the participants
with stage-II endometriosis conceived and 80% with
stage-I endometriosis conceived at the end of 6 months.
Similarly, 76.7% of patients with stage-III endometriosis
conceived but, none with stage-IV endometriosis. Out of
24 patients undergoing unilateral cystectomy, 15 (62.5%)
patients conceived. Five out of 6 patients conceived
where adhesiolysis was done. Successful conception
was observed in all four patients aer fulguration of
endometriotic spots. However, there was no statistically
signicant association between the type of intervention
done and the conception status of the study subjects
(p=0.35).
DISCUSSION
In our study, 74% of patients with laparoscopically
conrmed endometriosis had a preoperative diagnosis of
endometriosis through transvaginal 2D ultrasonography
indicating 74% sensitivity for detection of endometriosis.
A similar observation was noted in a prospective study
where transvaginal ultrasonography had a sensitivity
of 75% for detection of endometrioma.
13
About 68%
of the participants conceived spontaneously following
laparoscopic intervention within 6 months. A similar
spontaneous pregnancy rate (65%) was also observed
in a study by Fuchs F 2007, over a follow-up period of
8.5 months. In this study, assisted conceptions were also
observed.
14
e follow-up period also varied from one
to two years in dierent studies.
15,16
TABLE 1. Comparison of general characteristics.
Characteristics Status of conception in 6 months Total (n=50) p-value
Not Conceived Conceived
n=16, (%) n=34, (%)
Age (Years) 30.18 ± 3.35 27.82 ± 4.41 28.58 ± 4.21 0.06
(Mean ± SD)
Year of infertility (Years) 3.28 ± 1.46 3.35 ± 1.45 3.33 ± 1.43 0.88
(Mean ± SD)
Infertility type
Primary 10 (29.4) 24 (70.5) 34 0.56
Secondary 6 (37.5) 10 (62.5) 16
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TABLE 2. Comparison of USG and Operative characteristics.
Characteristics Category Status of conception in 6 months Total n=50 p-value
No Conceived Conceived
n=16 (%) n=34 (%)
B/L chocolate cyst 3 (25) 9 (75) 12 0.63
Left chocolate cyst 4 (36.4) 7 (63.6) 11
USG Findings Myoma 1 (33.3) 2 (66.7) 3
No abnormality 2 (20) 8 (80) 10
Right chocolate cyst 5 (38.5) 8 (61.5) 13
Right tubo-oyarian mass, 1 (100) 0 1
Score of endometrioses (Mean ± SD) 38.25 ± 26.93 16.94 ± 10.58 23.76 ± 19.95 0.00
I 2 (20.0%) 8 (80.0%) 10 0.00
Endometriosis stage
II 0 (0.0%) 3 (100.0%) 3
III 7 (23.3%) 23 (76.7%) 30
IV 7 (100.0%) 0 (0.0%) 7
Unilateral 09 (37.5%) 15 (62.5%) 24 0.35
Cystectomy
B/LCystectomy 5 (41.6%) 7 (58.3%) 12
Adhesiolysis 1 (16.6%) 5 (83.3%) 6
Interventions done Fulguration 0 (0.0%) 4 (100%) 4
Myomectomy with 1 (25%) 2 (75%) 3
adhesiolysis
Right oophorectomy 0 (0.0%) 1 (100%) 1
with adhesiolysis
Baseline characteristics of patients with and without
successful spontaneous conception were similar. ere
was no dierence in the age of females, type of infertility,
duration of infertility and preoperative ultrasonographic
ndings making the comparison more logical and acceptable.
is eliminates the probability of bias due to eect of
major confounders like age on pregnancy rate.
In the present study, pregnancy rate aer laparoscopy
was lower in patients higher r-AFS score and advanced
stages of endometriosis. is reects the adverse eect of
severity of endometriosis on the probability of spontaneous
conception aer therapeutic surgery. e implications of
this study will help the clinicians to counsel the patients with
advanced endometriosis regarding the poor prognosis for
spontaneous conception following laparoscopy. It agrees
with the study by Fuchs et al. 2007 where the incidence
of pregnancy was signicantly higher in patients with
stage I /II disease than stage III/IV (89% vs 56%). In
contrast, staging and scoring of endometriosis, had no
association with pregnancy rate in the study by Porpora
et al. 2002.
17
In that study, adnexal adhesion and tubal
condition inuenced the chances of conception.
e current study was undertaken at a single centre.
e study followed up only cases with spontaneous
conception and excluded methods of assisted reproduction
as in the later cases, direct benet of laparoscopic surgery
on chances of conception would have been dicult to
demonstrate. e sample size of the study was limited
to only 50 patients and the follow-up duration of study
participants was only 6 months which was less as compared
to other studies of this nature. e limited-time period
for follow-up is considered for the study as this is part
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of a post-graduate dissertation that has to be completed
in a limited time frame. us, there is a need for further
studies with a larger sample size and long duration follow-
up to support the observations of our study and ensure
generalisability of the study for the overall population
of infertile females with endometriosis.
CONCLUSION
Laparoscopy helps in the diagnosis of pelvic
endometriosis especially in patients without ultrasonographic
abnormalities. In infertile females with endometriosis
undergoing laparoscopy, individualized surgical interventions
are warranted for better fertility outcomes. Successful
spontaneous conception following surgery depends
on the r-AFS score, and stage of endometriosis. Lower
score and early stage of endometriosis are associated
with higher chances of conception.
Ethical consideration: e study was approved by the
Institutional ethical committee (IEC).
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Ratan et al.
