Guidance
Rationale and impact
This section briefly explains why the committee made the recommendations and how they might affect practice. They link to details of the evidence and a full description of the committee's discussion.
Treatment of endometriosis when fertility is a priority
Recommendations 1.11.2 to 1.11.4
Why the committee made the recommendations
There was no evidence of an important difference in the pregnancy rate between laparoscopic cystectomy and laparoscopic ablation and drainage of ovarian endometriomas larger than 3 cm, but drainage and ablation may lead to increased ovarian reserve (measured in terms of anti-Mullerian hormone levels, ovarian volume and antral follicle count) compared to laparoscopic cystectomy, so ablation and drainage has been included as an option if ovarian reserve is a priority.
Based on the committee's knowledge and experience and stakeholder feedback, the definition of deep endometriosis has been clarified to state that it includes endometriosis involving the bowel, bladder or ureter but is not limited to these sites, so that people are not excluded from treatment inappropriately. The need to discuss that deep endometriosis can impact on pregnancy outcomes has been added to the topics to discuss to provide a broader consideration of the benefits and risks of surgery.
There was some limited evidence of increased rates of clinical pregnancy and live birth with combinations of hormonal treatments with laparoscopic surgery compared to surgery alone, but the evidence was mixed, with other evidence showing no difference. As there was mixed evidence, the committee made a recommendation for research on hormonal treatments. The committee clarified that this recommendation applied to hormonal treatment alone or in combination with surgery.
How the recommendations might affect practice
The inclusion of ablation and drainage as a treatment option is not expected to have a resource impact as the cost of the 2 treatment options (cystectomy and ablation/drainage) are similar. This change will allow the option of a treatment which may have less of an impact on ovarian reserve.