1. Superficial peritoneal endometriosis
Stage I–II disease with peritoneal implants, often presenting with dysmenorrhoea, dyspareunia or subfertility. Laparoscopic excisional ablation of peritoneal disease. Combined with medical management or fertility planning depending on patient goals. Outcomes generally excellent with appropriate technique.
2. Ovarian endometriomas
Unilateral or bilateral endometriomas (chocolate cysts). Careful preoperative AMH measurement. Sharp stripping technique with minimal cortical coagulation. Decisions on cystectomy versus IVF-first based on size, symptoms, fertility plans and reserve. Per ESHRE 2022 guidance, asymptomatic small endometriomas in IVF-bound patients may be left.
3. Deep infiltrating endometriosis (DIE)
Lesions infiltrating over 5 mm into pelvic structures — uterosacral ligaments, rectovaginal septum, posterior vaginal fornix. Comprehensive preoperative mapping by expert ultrasound (IDEA protocol) plus MRI. ESGE / #Enzian 2021 classification used for surgical planning. Nerve-sparing excisional technique with 3D Karl Storz precision.
4. Bowel endometriosis
Superficial bowel-wall disease (shaving), discoid resection for focal full-thickness lesions, segmental resection only for symptomatic transmural multifocal disease. Multidisciplinary planning with colorectal surgery. Selective intraoperative protection of the inferior mesenteric and superior rectal vasculature.
5. Bladder and ureteric endometriosis
Bladder DIE managed by partial cystectomy with watertight closure. Ureteric endometriosis evaluated for intrinsic versus extrinsic involvement; ureterolysis, segmental resection or reimplantation as required, often with urology team. Renal protection through pre-operative MRI urography to detect silent hydronephrosis.
6. Frozen pelvis and recurrent disease
Severe Stage IV disease with obliterated cul-de-sac, dense adhesions, multi-compartment involvement. Stepwise restoration of anatomy. Recurrent disease after prior surgery requires honest counselling — additional surgery may not always help; integrated medical and pain management often more appropriate.
7. Complex IVF — endometriosis-associated, RIF, RPL
Endometriosis-associated infertility with adenomyosis. Recurrent implantation failure workup (hysteroscopy with CD138, ERA, PGT-A in selected cases). Recurrent pregnancy loss with antiphospholipid syndrome, parental karyotype, anatomical evaluation. Individualised protocol design from the patient and disease realities.
8. Fertility preservation
Egg freezing before significant ovarian surgery, before chemotherapy, before pregnancy delay. Embryo freezing for couples. AMH below 1.0 ng/ml or family history of premature ovarian insufficiency are particularly strong indications. Counselling about realistic outcomes from frozen oocytes given age at preservation.
