Endometriosis: frightening the patients is not an acceptable alternative to inadequate surgical management and or pathophysiology ignorance - Fertility and Sterility

Endometriosis management is a permanent controversy. Based on the concept that the disease is chronic and will inevitably recur if a permanent amenorrhea is not obtained, and assuming that surgery may induce severe complications, many investigators have proposed long-term medical management of all patients diagnosed and or suspected to have endometriosis (1x1Casper, R.F. Introduction: a focus on the medical management of endometriosis. Fertil Steril. 2017; 107: 521–522 Abstract | Full Text | Full Text PDF | PubMed | Scopus (8) | Google ScholarSee all References)(1). Surgery would be reserved for a failure with medical treatment: persistent pain despite amenorrhea being attained. This “all-medical approach” may also be favored by the patients who have been extensively counseled about surgical complications. As a result, surgery, which is the standard treatment for symptomatic deep endometriosis, is perceived to be dangerous and somewhat useless because the disease is supposed to always recur after surgery. However, for the patients with persistent pain and those who wish to become pregnant, surgery is indicated. Vallée et al. (2x2Vallée, A., Ploteau, S., Abo, C., Stochino-Loi, E., Moatassim-Drissa, S., Marty, N. et al. Surgery for deep endometriosis without involvement of digestive or urinary tract: don't worry the patients. Fertil Steril. 2018; 109: 1079–1085.e1 Abstract | Full Text | Full Text PDF | Scopus (1) | Google ScholarSee all References)(2) reported on a large group of patients with deep infiltrating disease with no or minimal bowel involvement for whom the risk of complications was low. Surgical treatment in these cases can be very effective, with good fertility outcomes, significant pain relief, and a low recurrence rate of deep disease (1.2%). These patients should not be unnecessarily worried (2x2Vallée, A., Ploteau, S., Abo, C., Stochino-Loi, E., Moatassim-Drissa, S., Marty, N. et al. Surgery for deep endometriosis without involvement of digestive or urinary tract: don't worry the patients. Fertil Steril. 2018; 109: 1079–1085.e1 Abstract | Full Text | Full Text PDF | Scopus (1) | Google ScholarSee all References)(2). Based on our own learning curve, radiological and surgical expertise are required to properly reassure the patients. A reliable radiologic evaluation is key to the effective management of deep disease. Indeed, at the beginning of our experience, complications were more extensively discussed with all patients because we knew that radiologists were not able to reliably exclude bowel and urinary tract involvement. But unnecessary