Dr Sujoy Dasgupta participated in an invited debate FOR the motion "Radical excision of DIE in subferile women with deep infiltrating endometriosis is not recommended" in ENDOGYN 2024, organized by the IAGE (Indian Association of Gynaecological Endoscopists) and the BOGS (Bengal Obstetric and Gynaecological Society) on 10 February 2024.

1. Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (New Delhi)
MRCOG (London)
Advanced ART Course for Clinicians (NUHS, Singapore)
M Sc, Sexual and Reproductive Medicine (South Wales, UK)
Clinical Director, Genome Fertility Centre, Kolkata
Managing Committee Member, BOGS, 2023-24
Executive Committee Member, ISAR Bengal, 2022-24
Clinical Examiner, MRCOG Part 3 Examination
Winner, Prof Geoffrey Chamberlain Award, RCOG World Congress, London,
2019
Radical Surgery in Infertile patients
with DIE is NOT
recommended

2. For the motion?

3. Everyone’s cup of tea?
DIE surgery should be performed ONLY be
persons
• Having adequate training and expertise
(ESHRE, 2022; NICE, 2017; RCOG, 2017; ETIC, 2018)
• In the MDT setup- urologists and colorectal
surgeons
(Leylandet al., 2010; Brown and Farquhar, 2014; Dunselmann et al., 2014)

4. Inappropriate surgery
• May incompletely relieve or even worsen bowel
symptoms (Berlanda et al., 2016).

5. Difference between
“what we can” and “what we
should”.

6. DIE- Surgery reduces pain

7. • Literature regarding
treatment and outcome of
DIE surgery should be
interpreted with caution.
• Lack of consistency in the
way the studies reported
outcome
• Systematic review on this
topic was based on small
studies and case reports
• Heterogeneity of patient
population, surgical
approaches, preferences, and
techniques- ??? (ESHRE, 2022)

8. Fertility outcome

9. Extrapolating…….

10. • Extrapolation of the evidence derived from
application of medical measures to specific
clinical sub-groups is inappropriate and may
be encouraged by financial incentives

12. Take with pinch of salt
• In most studies, reproductive plan of women is
not clear
• Mean periods for conception following surgery
are often NOT reported (Meuleman, et al., 2011).
• Lack of comparative studies evaluating
spontaneous conception after surgery compared
to no surgery
• Decision to perform surgery should be guided by
other factors

13. Example
• Mrs FR, 32 years, has been trying for
pregnancy for last 2 years. AMH, AFC, HSG
all normal.
• Husband- severe oligospermia. Donor sperm is
no acceptable. Opts for IVF-ICSI.
• Minimum dysmenorrhoea
• TVS suggested rectal wall endometriosis
(sensitivity and specificity 91% and 98%,
respectively- Hudelist et al., 2011)

14. Surgery may improve chance of
natural conception, but NOT the
success of ART

15. IVF can NOT be the only treatment
in DIE
Medical Overuse
• a combination of overtesting/overdiagnosis
with overtreatment that results in an
unfavorable balance between
1. incremental benefits
2. risk of harms
3. cost of healthcare interventions
Moynihan et al., 2012; Colla, 2014; Morgan et al., 2016

16. • 3-10% chances of damaging the
surrounding organs- bladder,
bowel, ureter, nerves
 neurogenic bowel and bladder
dysfunction
 For colorectal resection →
anastomotic dehiscence, RV
fistula
• Complete excision of
endometriotic tissue not possible
• May not reverse the
inflammatory and biomolecular
changes shown to influence
fertilisation and implantation
Vercellini et al., 2009; Lebovic, 2016

17. Expectation vs reality

18. Deep endometriosis - asymptomatic
• Uncommon to be
asymptomatic
• 9 out of 10 will not
progress
• Uncomplicated- If
no symptoms of
ureter/ bowel
stenosis- No need of
surgery
Dunselman et al., 2014; Berlanda et al.,
2016; ETIC, 2018

19. Deep endometriosis- when to operate
Only when-
1. Occlusive disease (ureter/ bowel)
2. Wishing natural conception, declining IVF
Dunselman et al., 2014; Berlanda et al., 2016; ETIC, 2018

21. Our Limitations
• Live creating- but not
life saving
• We manage but we
cannot treat
• Prevention of
recurrence ????

22. One size fits for all

23. Patient's age
Pain symptoms
Extent of disease
Patient's
reproductive
plans
Treatment risks
Side effects
Cost
considerations
Every
endometriosis
is different

24. Individualization is the Key

25. Conclusion
• Decision to perform
surgery in DIE should
be guided by
1. pain symptoms
2. patient age
3. preference
4. previous surgery
5. other infertility factors
6. ovarian reserve
(ESHRE, 2022)
• ‘Endometriosis should
not be treated just
because it’s there’
(Thomas, 1993).