Endometriosis Treatment in Pune: Surgery, Hormones, and Fertility Planning

Endometriosis is a chronic, relapsing condition — one of the most challenging in all of gynaecology. Its management requires both a long-term strategic perspective and short-term tactical decisions that depend critically on the individual woman's priorities: Is the primary goal pain relief? Fertility? Both? Is she trying to conceive now, or in 5 years? Has she already had surgery?

The treatment landscape for endometriosis in 2025 has never been richer — from advanced laparoscopic excision surgery to modern hormonal agents to carefully coordinated IVF protocols. This guide explains each option, when each is appropriate, and how the treatment plan should evolve across different life stages.

Confirming the Diagnosis and Staging

Endometriosis is definitively diagnosed at laparoscopy — direct visualisation of the pelvis with biopsy of suspicious deposits. Ultrasound can detect endometriomas (ovarian cysts filled with old blood) and sometimes deep infiltrating endometriosis, but cannot visualise peritoneal deposits or early-stage disease. A normal ultrasound does not exclude endometriosis.

Staging uses the revised ASRM classification: Stage I (minimal, superficial deposits) to Stage IV (severe, with endometriomas, dense adhesions, and distorted anatomy). Crucially, stage does not reliably predict symptom severity or fertility impact — some Stage IV patients have managed well with treatment; some Stage I patients have severe pain and poor fertility.

Surgical Treatment: Laparoscopic Excision

Surgery is the only treatment that physically removes endometriosis from the body. The evidence strongly favours excision (cutting out deposits) over ablation (burning them) for:

• Better symptom relief — excision removes the entire lesion including deeper infiltrating tissue; ablation only destroys the superficial surface.
• Lower recurrence rates — completely excised lesions are less likely to regrow than partially ablated ones.
• Histological confirmation — excision provides tissue for biopsy; ablation does not.

For endometriomas — ovarian cysts caused by endometriosis — laparoscopic cystectomy (removing the cyst wall while preserving healthy ovarian cortex) is the standard. This requires skilled surgical technique: aggressive cystectomy removes healthy ovarian tissue along with the cyst, permanently reducing AMH. The goal is maximal cyst removal with minimal collateral damage.

Dr. Sunita Tandulwadkar has performed advanced laparoscopic endometriosis surgery for over 35 years — including excision of deep infiltrating endometriosis involving the rectovaginal septum, bladder, and bowel in multi-disciplinary cases. This level of surgical expertise is critical for complete disease removal in advanced endometriosis.

The Goal of Surgery: Fertility Preservation vs Pain Relief

Surgery for endometriosis serves two broad purposes that sometimes align and sometimes conflict:

Surgery for Fertility

For women trying to conceive, the surgical goal is restoration of normal pelvic anatomy — releasing adhesions, removing endometriomas, clearing deposits that create a hostile pelvic environment. Evidence shows that surgery for Stage I to II endometriosis in infertile women improves natural conception rates (Marcoux trial, ESHRE guidelines). For more severe disease with distorted anatomy, surgery can significantly improve the pelvic environment for either natural conception or IVF.

The important caveat: operating on endometriomas carries a real risk of reducing ovarian reserve. Each surgery removes some healthy ovarian cortex along with the cyst. For a 38-year-old with already low AMH and bilateral endometriomas, the risk-benefit calculation often favours going directly to IVF rather than operating and potentially further compromising reserve.

Surgery for Pain

For women not trying to conceive, laparoscopic excision provides significant pain relief in the majority of patients — typically 70 to 80% report meaningful improvement in dysmenorrhoea and pelvic pain. This relief is more durable with complete excision than with ablation or hormonal suppression alone, though recurrence remains a reality.

Hormonal Treatment: Suppression Without Surgery

Hormonal treatments do not cure endometriosis — they suppress it. They work by eliminating the menstrual cyclicity that drives endometriosis activity, reducing inflammation, and providing pain relief. They are not contraceptives in the sense of being permanent, but they prevent pregnancy during use. They are therefore used primarily in women who are not currently trying to conceive.

Combined Oral Contraceptive Pill

The simplest and most accessible option. Continuous use (no hormone-free interval) most effectively suppresses menstrual cyclicity. The pill can be used indefinitely as long-term suppression. It does not treat endometriosis — it manages it — but for many women with mild to moderate disease, long-term OCP use provides adequate symptom control.

Progestogens: Dienogest

Dienogest (2 mg daily) is currently the most evidence-based progestogen for endometriosis. It directly suppresses endometriotic tissue through progesterone receptor activation and anti-angiogenic effects, with a good tolerability profile and no significant bone loss concerns with long-term use. It is increasingly preferred over the OCP for endometriosis-specific treatment in India.

GnRH Agonists and Antagonists

GnRH agonists (leuprolide, nafarelin, buserelin) suppress pituitary gonadotrophin secretion, inducing a medical menopause. Effective for pain and disease suppression, but the hypoestrogenic state causes hot flushes, bone loss, and is not sustainable long-term without hormonal add-back therapy. Used for 3 to 6 month courses before surgery (to shrink disease and reduce vascularity) or post-surgically.

GnRH antagonists (relugolix, elagolix) provide rapid, reversible suppression without the initial flare seen with agonists, and offer dose-dependent oestrogen management. Emerging agents in this class are expanding treatment options for endometriosis.

The IVF Decision in Endometriosis

For infertile women with endometriosis, the most important clinical decision is whether to proceed to IVF directly or to operate first. The factors that drive this decision:

• Age and ovarian reserve: An older woman (above 36) with already reduced AMH should not sacrifice further reserve to surgery if the primary goal is now conception. IVF bypasses the hostile pelvic environment.
• Structural anatomy: If tubes are completely blocked, adhesions prevent ovum capture, or a large hydrosalpinx is present — surgery or IVF become complementary rather than alternatives.
• Endometrioma size: Endometriomas above 4 cm may impair access to follicles at egg collection. For these, surgery before IVF may be appropriate — with careful technique to minimise reserve loss.
• Previous IVF failure: If previous IVF cycles have shown poor implantation despite good embryos, endometriosis-related endometrial receptivity should be considered — some evidence supports GnRH agonist pre-treatment before IVF to improve implantation in endometriosis.

Post-Surgical Management: Preventing Recurrence

After surgery for endometriosis, the natural history without further treatment is significant recurrence — approximately 20 to 30% within 5 years. For women not immediately trying to conceive, hormonal suppression after surgery (OCP, dienogest, or Mirena IUS) significantly reduces recurrence risk and is recommended. For women who conceive after surgery, the hormonal environment of pregnancy itself suppresses endometriosis activity — many women report significant improvement in symptoms for several years post-pregnancy.

Frequently Asked Questions

Q1. I have Stage IV endometriosis. Does this mean IVF definitely won't work?

No. Women with Stage IV endometriosis have lower IVF success rates than women without endometriosis on average — primarily due to reduced ovarian reserve from endometriomas and the inflammatory pelvic environment. But many women with Stage IV disease do achieve successful pregnancies through IVF. The key factors are the woman's age, remaining ovarian reserve, the quality of the IVF programme, and whether a GnRH agonist downregulation protocol is used before stimulation to reduce the inflammatory burden.

Q2. How long should I wait after endometriosis surgery before starting IVF?

The general guidance is 3 to 6 months after laparoscopic surgery before starting IVF stimulation — to allow pelvic healing and reduction of post-surgical inflammation. For simple procedures (adhesiolysis without cavity entry), the wait may be shorter. For extensive excision or myometrial entry, longer healing is appropriate. Your surgeon and IVF specialist should agree on the timing in the context of your specific procedure and clinical situation.

Q3. Should I freeze my eggs before endometriosis surgery?

For women with significant endometriomas planning to undergo ovarian surgery, egg freezing before the operation is a fertility preservation strategy worth discussing — particularly if reserve is already reduced or if this is a second or third endometrioma operation. Collecting and freezing eggs before surgery ensures that reserve is not further depleted by the procedure before family building is complete.