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News from practice and research

Important information on endometriosis and related problems such as lower abdominal pain, menstrual cramps and involuntary childlessness are briefly summarized here

Sonographic examination now plays a central role in the diagnosis of endometriosis.

As a result of the efforts of Prof. Dr. J. Keckstein, Dr. med. Sebastian D. Schäfer and Prof. Dr. med. Markus Hoopmann, the AGEM is organizing its first sonography course as an online seminar on 2.9.2023. The event was organized in cooperation with DEGUM, ÖGUM, SGUM, AGE, SEF and EEL.

You can open the program by clicking HERE to view and download the program.

There are still places available – register quickly to secure your place!

#Enzian, the new comprehensive edometriosis classification
As a result of the tireless efforts of Prof. Dr. J. Keckstein and Univ. Doz. Dr. G. Hudelist and other international experts, an endometriosis classification has been developed that combines and optimizes r-ASRM and Enzian. It can be used for non-invasive procedures such as sonography and MRI and, of course, for laparoscopy. It will soon be published in Acta Obstetricia et Gynecologica Scandinavica (AOGS) – probably open access.

You can download the #Enzian under “Downloads” from the SEF page. With one mouse click HERE you can enlarge the picture.

Webinar to obtain the certificate “Special qualification in the field of endometriosis.”
Due to the corona pandemic, we have implemented the idea of offering the proven 7-hour qualification seminar online as a webinar faster than originally planned. You can register by e-mail(kwschweppe@ewetel.net ) and request activation. Once you have received the access data, you can open the seminar under the “Endometriosis Academy” tab on our website and listen to the lectures online at a time that suits you. You must complete and return the CME questionnaire, which you will also receive after registration. If you have answered more than 75% of the questions correctly – which we are convinced you have – you will receive the certificate issued by the SEF and EEL.

Information on MDNA Life Science’s announcement of a new diagnostic test:
In a press release, MDNA Life Sciences (England) has announced that it has developed a blood test that can diagnose endometriosis in nine out of 10 cases.

  1. the original work of the company:
    https://www.futuremedicine.com/doi/pdfplus/10.2217/bmm-2018-0419
  2. the statement of the World Endometriosis Society (WES):
    http://endometriosis.org/news/research/blood-test-to-diagnose-endometriosis/
  3. the statement of the SEF:
    Endometriosis is really too complex to be detected reliably enough with just one genetic factor in a person’s mitochondria. Conspicuous features: The number of cases in the study is very small; the physicians at the clinic who treated the endometriosis patients are not authors/co-authors of the publication but only employees of the company are listed as authors; the price of the test is high; it is not yet available and it has not yet been validated. Unrealistic hopes may be raised in patients.
    The SEF statement was written by Dr. K. Bühler and Prof. Dr. D. Hornung and can be read and downloaded here.

Information about the new homepage:

  1. All advisory board members must sign the declaration of consent to the use of their data (on the list of advisory board members) in accordance with the GDPR and return it to the SEF secretariat (by post or as a pdf attachment by e-mail).
  2. Please check the advisory board list to ensure that your details are still up to date, in particular your telephone number and e-mail address. Please send any necessary corrections by e-mail to kwschweppe@ewetel.net.
  3. Login to the protected member area:
    In the dropdown menu “Foundation” last item: Click on “Login”; in the new screen click on “Register” at the bottom and then fill in the fields for the user account. Prof. Schweppe then receives a request and can activate the advisory board member. You then have access with your chosen password. If you have forgotten it, you can now request a new one yourself and not – as in the past – have a new one programmed for money.
  4. You will only find the forum and the member information item in the drop-down menu when you are logged in!

Training:
Prof. Thomas Römer recently held a webinar on the diagnosis and treatment of endometriosis. The approximately one-hour recording is available as a video for continuing education and continuing education points can be earned by answering the CME questions correctly. CME course on endometriosis now available at www.arztcme.de/endometriose-2018.
There is also a CME training course from this year, authored by Prof. Dr. S. Mechsner, which also deals with endometriosis treatment.(https://cme.medlearning.de/jenapharm/therapiekonzepte_endometriose/index.htm)

Selected information on the Weissensee Annual Conference:

  1. Summary of the complications working group SEF meeting 2018

The following points were discussed at this year’s working meeting as part of the “Complications of TIE surgery” working group:

  • Information on the complications of TIE surgery. In this regard, the possibility of fistula formation, anastomotic insufficiency with the need for a stoma, vascular and nerve injuries, bladder emptying disorders, etc. should be pointed out in writing. The addition of “etc.” is recommended in order not to rule out other possible complications.
  • Discussion of the possibility of a visitation of endometriosis centers. A list of the centers and the address of the contact person could be published on the SEF website.
  • Discussion of the recording of complications of TIE-associated bowel surgery and evaluation of the main surgical technique practiced at the centers (shaving, dissection or segment resection).
  1. Summary of the Certification Working Group:

Definition of the areas of responsibility of the AG Certification, the Certification Commission and the group of auditors.

  1. AG Certification:

The Certification Working Group meets regularly on the occasion of the SEF Weissensee Conference; all members of the Certification Commission and all auditors are invited; guests from among the participants of the Weissensee Conference are welcome. The group discusses and develops proposals for changing and optimizing the certification procedure, the certification criteria, etc.. The results are examined by the Certification Commission, modified if necessary and submitted to the SEF Board as a draft resolution. The Board decides on the proposals by simple majority.

  1. Certification Commission:

For day-to-day business (all receive audit reports and must report back): K.-W. Schweppe, A. D. Ebert, U. Ullrich, M. Beckmann, I. Meinhold-Heerlein and in an advisory capacity: L. Mettler, A. E. Schindler

  1. Auditors:

The auditors are selected, trained and appointed by EuroEndoCert in agreement with the certification commission. They should be members of the scientific advisory board, they should know the current routine in the clinic or in practice (no longer than 5 years out of active business), they should have attended a course similar to the OnkoZert training course for auditors.

On the occasion of the 8th German Endometriosis Congress in Münster, the following scientific prizes were awarded for the best presentations and posters:

P. Imesch, Zurich
Histone deacetylase inhibitors reduce proliferation in endometriosis cells via epigenetic mechanisms and have an apoptotic effect.

Poster prize Imesch

Histone deacetylase inhibitors reduce proliferation in endometriosis cells via epigenetic mechanisms and have an apoptotic effect
Patrick Imesch , Michael Schneider, Eleftherios Samartzis, Daniel Fink, André Fedier
University Hospital Zurich, Department of Gynecology, patrick.imesch@usz.ch

The pathogenesis of endometriosis is still not fully understood. Numerous hypotheses and models have been formulated, but many questions remain unanswered. Epigenetic changes such as acetylation of histones are increasingly being discussed as a possible pathomechanism of endometriosis. Histone deacetylase inhibitors (HDACi) are a class of substances that can alter the gene expression pattern by changing the chromatin structure and thus have an epigenetic regulatory effect. It is assumed that 2-5% of the genome can be influenced by HDACi. Interestingly, these are often genes that are involved in proliferation and apoptosis control.
The aim of the work was to find out whether endometriosis cells are in principle target cells for the HDACi romidepsin and whether this has an effect on the proliferation rate and apoptosis behavior. The investigations were carried out using standard cell biology and molecular biology methods (Western blot, RT-PCR, MTT) on an immortalized epithelial endometriosis cell line.
The basic proof of efficacy of romidepsin was clearly demonstrated by the reduction of total histone deacetylase activity on the one hand and by the accumulation of acetylated histones on the other. This resulted in an upregulation of the cell cycle inhibitor p21 and a downregulation of cyclins B1 and D1, which also led to a significant inhibition of proliferation. At higher doses (from 20nM), an activation of the intrinsic apoptosis pathway was also detected. In further studies, some genes important in the pathomechanism were examined with regard to regulation. It could be shown that in subapoptotic doses of romidepsin, a downregulation of the proangiogenic factor VEGF and of the matrix-degrading enzymes MMP-2 and -9 could be achieved. At the same time, E-cadherin, an adhesion molecule with invasion suppressor properties, could be upregulated. The resulting reduced migratory potential was demonstrated in simple wound-healing assays.
The studies show that endometriosis cells are indeed target cells for HDACi and that the regulation of relevant genes can be influenced as a result. HDACi thus represent a new, promising, epigenetically active therapeutic option for the treatment of endometriosis. The results also support the possible importance of epigenetics in the pathogenesis of endometriosis.

  1. Agic, Lübeck
    Inhibition of cell proliferation, adhesion and invasion with monoclonal antibodies against L1 cell adhesion molecule (L1CAM) in an in vitro endometriosis model.

Poster price Agic

Inhibition of cell proliferation, adhesion and invasion with monoclonal antibody against L1 cell adhesion molecule (L1CAM) in an in vitro endometriosis model


Agic A.1, Diedrich K.1, Altevogt P.2, Starzinski-Powitz A.3, Hornung D.1


1 University of Lübeck, Women’s Clinic, Lübeck, Germany,
2DKFZ, Tumor Immunology Program, Heidelberg, Germany,
3JohannWolfgang Goethe University in Frankfurt am Main, Human Genetics, Frankfurt am Main, Germany

Endometriosis is a benign and usually progressive disease. The cell adhesion molecule L1CAM is overexpressed in ovarian and endometrial cancer and is associated with a poor prognosis. Our previous studies showed increased L1 expression in endometriosis, which prompted us to investigate L1-mediated proliferation, adhesion and invasion in an in vitro endometriosis model. Cell proliferation and survivability were investigated in a proliferation assay using an endometriosis cell line Z12. L1-mediated adhesion and invasion and their inhibition by anti-L1 antibodies were also investigated with the endometriosis cell line Z12 in the so-called “sandwich assay” using Matrigel®. The proliferation of endometrial epithelial cells Z12 decreased significantly after preincubation with monoclonal anti-L1 antibody (10µg/ml) (P< 0.001, 0.95 ± 0.34 x 300,000 cells) compared to preincubation with unspecific IgG-mAb (3.88 ± 1.16 x 300,000 cells) and to untreated cells (3.63 ± 1.12 x 300,000 cells). The relative invasion of Z12 cells through Matrigel® was significantly inhibited (P< 0.001) after preincubation with monoclonal anti-L1 antibody (26.40 ± 13.50 %) compared to preincubation with non-specific IgG-mAb (76.04 ± 24.06 %) and untreated cells (76.30 ± 26.84 %). Monoclonal anti-L1 antibody was also able to inhibit Z12 cell adhesion (P< 0.001, 68.69 ± 16.71 %) compared to non-specific IgG-mAb (89.49 ± 23.78 %) and untreated cells (90.00 ± 21.53 %). Based on our results, we assume that L1 favors the development of endometriosis by increasing cell invasion and adhesion and worsens the prognosis. In further studies, the monoclonal L1 antibody will be tested in an endometriosis animal model.

Wolf, M.*, Schüring, A.N.*, Schulte, N.*, Staebler, A.+, Kiesel, L.*, Buchweitz, O.*, Götte, M.*
(* Frauenklinik Münster, + Inst. f. Pathologie Tübingen)
Altered expression of the pluripotency-associated transcription factor Sox2 in endometriosis.

Wolf poster prize

Altered expression of the pluripotency-associated transcription factor Sox2 in endometriosis

Wolf, M.1, Schüring A.1, Schulte N.1, Staebler A.2, Kiesel L.1, Buchweitz

O., Götte M.1

1Clinic and Polyclinic for Gynecology and Obstetrics, University Hospital Münster, Albert-Schweitzer-Str. 33, D-48149 Münster; 2Instituteof Pathology; University Hospital Tübingen; Contact: Maria_Wolf@email.de; mgotte@uni-muenster.de

Cyclical processes of regeneration, cell differentiation and desquamation take place in the human endometrium during the menstrual cycle. The basis of this high regenerative capacity is assumed to be the involvement of stem cells. The involvement of endometrial stem cells in the pathogenesis of endometriosis and endometrial carcinoma is also being discussed. Since endometrial stem cell populations are poorly characterized, there is a need to identify molecular markers of endometrial progenitor cells. One possible candidate is the transcription factor Sox2.
This is essential for maintaining the self-renewal potential in undifferentiated embryonic stem cells and is one of the key factors for the production of induced pluripotent stem cells. In this study, the expression of Sox2 in the human endometrium was characterized in order to investigate a possible stem cell involvement in the pathogenesis of endometriosis.
Conventional immunohistochemistry, quantitative real-time PCR (qPCR) and double immunofluorescence studies of physiological and pathologically altered endometrial biopsies (n = 49 patients) were used to comparatively characterize Sox2 expression.
Quantitative rt-PCR was used to detect the expression of Sox2 in the endo- and myometrium. A partial co-expression of Sox2 and telomerase was detected by immunofluorescence microscopy. Using immunohistochemical staining, Sox2-positive single cells and cell groups were identified in the endometrial stroma, as well as single cells in glands and diffuse glandular staining. Quantification using standardized visual field analysis showed a significant increase in Sox2 expression by a factor of 2.1 in proliferative vs. secretory tissue. In contrast, the number of Sox2-expressing stromal cells/facial field was significantly reduced by a factor of 0.50 in endometrial cancer tissue compared to proliferative endometrium. Sox2 expression in endometriosis biopsies was ambivalent. The number of Sox2-positive cells was significantly increased in the stroma compared to the secretory tissue, while the Sox2-positive glands were significantly reduced by 70% compared to endometrial carcinoma.
The high proliferative and pluripotent potential of Sox2-positive cells could lead to cells that have entered the abdominal cavity during retrograde menstruation adhering, implanting and manifesting endometroid lesions. The reduced expression of the transcription factor Sox2 in endometrial carcinoma corresponds to current studies on the function of Sox2 as a tumor suppressor gene in gastric carcinogenesis. Further histopathological studies on larger patient collectives to analyze the prognostic value of the Sox2 marker appear worthwhile in order to demonstrate its clinical relevance for the pathogenesis of endometriosis.

Complaints and quality of life in women with suspected
Endometriosis

Dear colleagues,

Beata Seeber, in collaboration with Rene Wenzl, supported by Sebastian Schäfer and Steffi Burghaus, developed the protocol for a prospective multi-center observational study and prepared the documents for it. As summarized in the description in the downloadable appendix, this is an evaluation of the correlation between the patients’ complaints and the #ENZIAN (and its individual compartments). In addition, QOL questionnaires are compared pre- and post-operatively.

The vote of the ethics committee of the Medical University of Innsbruck (lead committee) can be found here. Interested centers can contact Beata Seeber or Rene Wenzl to receive the complete documentation. A vote of the respective local ethics committee is required before the start of the study.

We hope for active participation from the endometriosis centers and thank you in advance for your support of this important project. The first project that SEF and AGEM support together must be a success!

Archimetrosis: the evolution of and its extant presentation.

Leyendecker G, Wildt L, Laschke MW, Mall G.

The fundamental work of this year’s Rokitansky Prize winner – Prof. Dr. G. Leyendecker – has just been published online “open access”.

https://www.springermedizin.de/archimetrosis-the-evolution-of-a-disease-and-its-extant-presenta/22168760

Please be sure to read it, as it is an excellent presentation of the facts and thoughts on pathogenesis. This work should be required reading for all those who deal with endometriosis scientifically and clinically!

EEL webinars have started

The monthly international EEL webinars launched last year were very successful. They will be continued on relevant topics of endometriosis and adenomyosis. You can find the program here! Registration required.

Please make active use of it!

EEL webinars have started

From now on, an international EEL webinar on relevant endometriosis and adenomyosis topics will take place once a month. You can find the program here! Registration required.

Please make active use of it!

Guidelines published by the DGGG.

After intensive work under the leadership of Prof. Dr. Ulrich, Berlin, the following authors have

Dr. D. Arndt, Greifswald
Dr. P. Brandner, Saarbrücken
Priv. Doz. Dr. O. Buchweitz, Münster
Prof. Dr. Dr. Dr. A.E. Ebert, Berlin
Priv. Doz. Dr. R. Greb, Dortmund
Prof. Dr. J. Hucke, Wuppertal
Prof. Dr. J. Keckstein, Villach
Priv. Doz. Dr. P. Oppelt, Erlangen
Prof. Dr. M. Possover, Cologne
Dr. S. P. Renner, Erlangen
Priv. Doz. Dr. M. Sillem, Emmendingen
Prof. Dr. Dr. K.-W. Schweppe, Westerstede

updated the guidelines on the diagnosis and treatment of endometriosis in 2013 on behalf of the SEF and the AGE. These are now officially accepted as S2k guidelines by the DGGG and can be viewed and downloaded from the DGGG website:
DGGG guideline Diagnosis and treatment of endometriosis

Certified endometriosis centers 2006

In the course of 2006, endometriosis centers will be reviewed for the first time according to the quality criteria defined by the SEF and then certified according to a step-by-step concept. We hope that this will lead to an improvement in the diagnosis and treatment of the disease, more transparency and information for patients and more attention from the public and health policy makers.

The following criteria have been defined for the individual performance levels in order to be recognized as
” Endometriosis Center recognized by the Scientific Endometriosis Foundation”
to be certified.

Level I
Part of an endometriosis network
Participation in a gynecological quality circle (endometriosis topics)
Examination, sonography and consultation from a single source

Intensive and comprehensive support
Openness to complementary therapy approaches (acupuncture, etc.)
Supporting the patient with administrative measures (rehab application, etc.)
Cooperation with the Endometriosis Association Germany e.V. and also with local self-help groups
Level II
includes level I and additionally
Invasive diagnostics (endoscopy, histology)
Surgical treatment options (endoscopy, MIS, laparotomy)

Interdisciplinary collaboration (radiology, general surgery, urology)
Cooperation with Stage I as a partner in the endometriosis network
Membership of the Scientific Endometriosis Foundation
Level III
includes in addition to level II
Organization of an endometriosis network
Organization of a quality circle on the topic of endometriosis
Cooperation with pain outpatient clinic, reproduction medicine center and rehabilitation facility
Annual report on the performance of your own center and, if possible, for the entire network
Transmission of the data to the SEF and the Endometriosis Association Germany e.V. for the purpose of state-wide and nationwide evaluations
Information events for doctors and laypeople

The following information must be updated every six months regardless of the level:
1. name of the doctor who is the primary contact person and his/her possible deputy
2. telephone number for appointments in the endometriosis consultation hour
3. fax no. and e-mail for the transmission of findings and written inquiries

Applications must be submitted to the SEF Board of Directors.

Poster Prize Congress 2005

Investigation of the neurotropic properties of endometriosis
Schwarz J, Mechsner S, Bartley J, Thode J, Ebert AD
Endometriosis Center, Clinic for Gynecology with University Outpatient Clinic
Charité-Universitätsmedizin Berlin, CBF
Hindenburgdamm 30, 12200 Berlin,
Tel. +49 30 8445 2494, Fax +49 30 84454477
E-mail: jessica.schwarz@charite.de

Objective: Endometriosis (EM) is typically associated with lower abdominal pain, although the etiology of the pain is still unclear. The aim of the studies was to investigate the histomorphological relationships between peritoneal EM lesions and the surrounding nerve fibers (NF). In addition, these NFs should be characterized in terms of their quality. EM cells express nerve growth factors such as nerve growth factor (NGF). Therefore, we additionally investigated the role of NGF secreted by EM cells in the potentially directed nerve growth towards or into the lesions.

Material and methods: 121 peritoneal EM lesions from 77 patients were analyzed immunohistochemically with antibodies against neurofilament, Substance P (Sub P), a marker molecule for sensory nerves, and NGF. Western blot analyses were performed to detect the presence of NGF in primary cell cultures of EM lesions and in the Douglas fluid of EM patients. To investigate the interactions between nerves and the NGF produced by EM cells, we cultured neurons from the dorsal root ganglia (DRG) of chicken embryos in medium conditioned by EM cells (neuronal-growth-assay).

Results: In 54 of 77 patients (70.1%), NF could be demonstrated in the stroma or near (<1.5 mm) the EM lesion. All examined sections showed NF with Sub P positive proportions. In addition, all EM foci have medium to strong NGF expression. Using Western blot analysis, the NGF-specific band at 14 kDa was detected both in the primary cell cultures of EM lesions and in the Douglas fluid of EM patients. In the neuronal-growth assay, the conditioned medium induced the sprouting of neurites and the formation of cell-cell contacts. This cell growth is similar to the growth induced by the addition of exogenous NGF.

Conclusion: In this study, NF was detected for the first time in the stroma and in the vicinity of peritoneal EM lesions. We were also able to prove that these NFs carry sensitive components. Previous studies have shown no difference in the number of nerves between healthy peritoneum and that of EM patients (Tulandi et al., 2001). In contrast, the localization of NF in the stroma and near the lesions shown in our work suggests an important role of these NF in the etiology of EM-associated pain. Preliminary results of the neuronal-growth-assay indicate neurotrophic properties, i.e. a stimulating effect of the EM cells on nerve cell growth towards or even into the lesion.

German Endometriosis Competence and Expert Network (DEKEN) funded by the Foundation for German Science

Endometriosis Seminar 2004

On the occasion of the congress of the German Society of Gynecology in Hamburg, Prof. Schweppe (Westerstede) and Prof. Küpker (Bremen) held an endometriosis seminar on practically relevant topics for gynecologists. The following problem areas were discussed with regard to their past, present and future therapy recommendations: drug therapy – sterility – recurrences.
(see also under: Conferences/Seminar 2004)

Over the last ten years, considerable progress has been made in the diagnosis and treatment of endometriosis. The increase and technical improvement of pelviscopic instruments have opened up surgical treatment options by endoscopic means – even for the most severe stages – and the development of GnRH agonists with addback medication has expanded the range of drug treatments. Nevertheless, some prospective randomized studies of the last decade indicate that the success of treatment is limited in time, that the disease is characterized by a high recurrence rate and that, in addition, especially low-grade endometriosis and the resulting functional sterility measured against the ultimate goal of pregnancy is influenced just as successfully by a wait-and-see approach as by surgical or medical measures. As a result, there are currently three topics that are important for day-to-day practice and will be discussed in the seminar under the aspects of what experiences we have had in the past, what the current standard is and what options the future holds.

1) If drug treatment is indicated after a diagnostic and therapeutic laparoscopy, which substance is used in which dose and for how long?

2) What should the treatment plan look like for an infertility patient with endometriosis; are there stage-related differences?

3) How can success rates be improved, recurrence-free intervals extended and recurrence rates reduced in advanced stages and in cases of deep infiltration?

1. targeted use of substances in drug-based endometriosis treatment
In order to be able to use the various therapeutic options in the individual case in a more targeted manner, increased demands must be placed on the diagnosis of endometriosis.

In addition to the classic five criteria, the consideration of which led to “stage-appropriate endometriosis therapy” in the 1980s, it is particularly important to consider macroscopic and microscopic criteria, which contain information about the degree of activity of the implants and the clinical relevance of the endometriosis.

Based on this differentiated diagnosis, endocrine ablative or symptomatic measures are then considered, depending on the treatment objective. As endocrine forms of treatment, we basically have various gestagens and various GnRH agonists at our disposal.

2. endometriosis and functional sterility
When assessing the numerous experimental and clinical studies on this problem, it must be borne in mind that sterility and endometriosis are associated with each other with above-average frequency, but that in many cases several sterility factors are also present in both men and women. However, the crucial question is: how relevant are the individual diagnostic disorders, and at what point in the treatment plan must endometriosis treatment take place?

In advanced stages, there are mechanical causes of infertility due to endometriosis or secondary damage to the reproductive organs. In these cases, surgical correction or assisted reproduction is indicated. Whether active endometriosis reduces fertility in the early stages through changes in the Douglas environment, egg maturation, tubal motility or implantation disorders is a controversial issue.

Depending on the population, endometriosis treatment with medication does not lead to any improvement in fertility or to the desired pregnancy in up to two thirds of cases. Depending on the severity of the endometriosis, subsequent pregnancies of 20 to 80 % have also been documented for surgical treatments using microsurgical techniques. Modern laparoscopic procedures provide equally good or even better results. However, the disadvantage of these studies, some of which are quite large in number, is the lack of a control group and the lack of prospective randomization.

3. deep infiltrating endometriosis
In Douglas endometriosis, a distinction must be made between type 1, i.e. superficially extending peritoneal endometriosis with its vesicular and polypous structures, and type 2, i.e. deeply infiltrating subperitoneal nodular endometriosis. The rectovaginal septum, the posterior vaginal fornix and the rectum are mainly affected. It has been suggested that the “deep infiltrating type of endometriosis” should be called adenomyosis extra genitalis, as morphologically and therapeutically it is in many ways more similar to adenomyosis uteri than to endometriosis genitalis externa (Donnez, 1996). Daily experience in practice and clinic shows that this deeply infiltrating endometriosis responds poorly to drug therapy, especially when the bowel, bladder and ureter are affected, tends to recur in the short term and also causes considerable problems during surgery due to the lack of dissection planum and the accompanying inflammation and massive fibrosis. Our own experience has shown that the best results with the lowest recurrence rates were achieved when pre-treatment with medication, either with a GnRH agonist, was carried out prior to sufficient surgical treatment in healthy patients.

Conclusion
The following recommendations can be made in practice, taking into account the questions raised at the beginning:

1) Endometriosis treatment with medication is indicated for active, proliferating disease, especially prostoperatively in the case of persistent or recurrent symptoms; but also preoperatively with subsequent laparoscopic repair of the regressively altered ovarian cysts – even in infertility patients if other causes of infertility have been ruled out or corrected.

2) The treatment plan for an infertility patient with minimal endometriosis must be determined individually. After a complete diagnosis of infertility, the relevance of possible concurrent causes that reduce fertility must be assessed. Only if active endometriosis is of central importance or if it is the only diagnosed infertility factor should medical treatment be carried out.
3) In the case of extensive, deep infiltrating infestation of the pelvic organs, drug treatment favors organ preservation and reduces the risk of recurrence, even if surgical treatment is the decisive therapeutic step. Drug treatment is primarily indicated for recurrent symptoms, to slow progression and for symptomatic therapy: The spectrum of medication ranges from prostaglandin synthesis inhibitors to oral contraceptives (preferably taken as a long cycle) and various progestins to intermittent GnRH agonist administration with addback medication. In the future, COX-2 inhibitors, aromatase inhibitors or oxytocin receptor antagonists may be other effective options.

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