Endometriosis is a gynecological condition in which the endometrium, which has a growth function, grows and multiplies outside of the uterine covering. The clinical manifestations of endometriosis are sometimes very inconsistent with the degree of lesions. Patients with very severe clinical manifestations may have mild or limited lesions, while patients with extensive lesions or even severe deformation of the pelvic anatomy have few clinical manifestations. According to statistics, about 70% of patients with endometriosis have typical secondary dysmenorrhea, unpleasant or painful intercourse, infertility and menstrual changes. When endometriosis occurs in other specific sites, many other confusing clinical manifestations can occur. The main symptom in most patients with endometriosis is secondary dysmenorrhea with progressive pain in the lower abdomen and back, often radiating to the legs. The pain often starts on the first 1-2 days of menstruation. It is equivalent to ectopic endometrial bleeding when menstruation begins to reach its peak. Most patients experience pain relief during menstruation. However, pain can persist in advanced patients, especially if there are extensive and significant pelvic adhesions. The typical patient with secondary dysmenorrhea is mostly between 30-45 years of age. In some cases, the endometriotic lesions result in a retroverted uterus. Fixed patients often have dyspareunia, painful intercourse, or even difficulty with intercourse, and about one-third of unexplained infertility is associated with endometriosis. The infertility rate in patients with endometriosis can be as high as 40%. The cause of infertility in patients with severe endometriosis may be related to altered anatomy. The causes of infertility in patients with mild endometriosis are never due to anatomical factors alone, but are now mostly thought to be related to intra-abdominal microenvironmental factors, abnormal ovarian function, etc. Chen Ming, Department of Gynecology, General Hospital of Jinan Military Region
Etiology and pathology
Intrinsic endometriosis is a condition in which the endometrium grows from the base to the muscle layer and is confined to the uterus, hence the name adenomyosis. The ectopic endometrium is often diffused throughout the myometrial wall, and the endometrium invasion causes reactive hyperplasia of fibrous tissue and muscle fibers, resulting in consistent distension of the uterus, but rarely exceeding the size of a full-term fetal head. Uneven or focal distribution is usually seen in the posterior wall, and because it is confined to a part of the uterus, it often causes irregular enlargement of the uterus, resembling fibroids. In the section, the hyperplastic muscle tissue also resembles a myoma with a swirl-like structure, but without the envelope-like tissue that separates the normal muscle fibers from the surrounding myoma. There are softened areas in the middle of the lesion, and occasionally small cavities containing a small amount of old blood may be seen. The endometrial glands seen on microscopy are identical to the endometrial glands and are surrounded by the endometrial mesenchyme. The ectopic endometrium changes with the menstrual cycle but not significantly during the secretory phase, indicating that the ectopic endometrial glands are less affected by progesterone. When conception occurs, the mesenchymal cells of the ectopic endometrium may show obvious metaplastic changes, as already described above.
Secondly, interstitial endometriosis is a special type of intrinsic endometriosis, which is less common, that is, the ectopic endometrium has only endometrial interstitial tissue, or the development of interstitial tissue after endometrial invasion of the myometrium far exceeds the glandular component in scope and extent. The diagnosis can be established when the uterus generally increases in consistency, the ectopic cells are scattered in the myometrium or concentrated in a certain area, yellow in color, often with elastic rubber-like hardness, softer than myomas, and small worm-like protrusions in the form of cords can often be seen in the cut surface. The ectopic tissue can also develop into the uterine cavity as a polyp-like mass, with multiple, smooth surfaces and a large area of direct connection with the uterine wall, and can protrude from the uterine wall into the uterine cavity or along the uterine vessels into the broad ligament. The protrusion into the uterine cavity can lead to excessive menstruation or even postmenopausal bleeding; the protrusion into the broad ligament can be detected by gynecological double examination. Interstitial endometriosis can have pulmonary dissemination and can occur even years after hysterectomy. Because of this feature, it has been suggested that mesenchymal endometriosis is a low-bottom malignant sarcoma.
Third, the endometrium of extrinsic endometriosis invades tissues (including ectopic endometrium invading the plasma layer of the uterus from the pelvis) or organs outside the uterus, often involving multiple organs or tissues.
The ovaries are the most frequent site of extrinsic endometriosis, accounting for 80% of cases, followed by the peritoneum of the rectal fossa, including the uterosacral ligament, the anterior wall of the rectal fossa corresponding to the posterior vaginal fornix, and the posterior wall of the cervix corresponding to the internal cervical os. Sometimes the ectopic endometrium invades the anterior wall of the rectum, causing the intestinal wall to form dense adhesions with the posterior wall of the uterus and the ovaries, which are difficult to separate during surgery. Extrinsic endometriosis can also invade the rectovaginal septum and form scattered black and purple dots on the mucosa of the posterior vaginal fornix, or even cauliflower-like protrusions that resemble cancerous tumors, which can only be confirmed as endometriosis by biopsy. In addition, as mentioned above, ectopic endometriosis may be present in the fallopian tubes, cervix, vulva, appendix, umbilicus, abdominal wall incision, hernia sac, bladder, lymph nodes, and even in the pleura and pericardium, upper extremities, thighs, and skin.
Ectopic endometrium in the rectal fossa of the uterus may also form purple-black hemorrhagic spots or vesicles on the peritoneum, which are embedded in heavily adherent fibrous tissue and can be seen on microscopic examination as typical endometrium. The ectopic endometrial tissue may also extend into the rectovaginal septum and uterosacral ligament to form a firm nodule that is painful to palpation. Or it may penetrate the mucosa of the posterior vaginal fornix and form a blue-purple papillary mass, which may show many small bleeding spots during menstruation. If the anterior rectal wall is involved, painful menstrual stools may occur. Sometimes the endometrial lesion extends around the rectum to form a narrow ring, which is very similar to a carcinoma, and intestinal invasion accounts for about 10% of endometriosis. The lesions are often located in the plasma membrane and muscle layer, and rarely ulcers occur due to mucosal invasion. Occasionally, intestinal obstruction may occur due to the formation of masses in the intestinal wall or fibrous stenosis or adhesions causing hyperflexion of the intestinal canal, and irritation symptoms may occur, such as intermittent diarrhea, which is more severe during menstruation.
Clinical manifestations
The signs and symptoms of endometriosis vary with the location of the ectopic endometrium and are closely related to the menstrual cycle.
I. Symptoms
1. Dysmenorrhea: It is a common and prominent symptom, mostly secondary, i.e. since the occurrence of endometriosis, the patient complains that there was no pain at the time of menstruation in the past, but dysmenorrhea started to appear from a certain period. It can occur before, during and after menstruation. In some cases, the dysmenorrhea is more severe and unbearable, requiring bed rest or medication for pain relief. The pain often worsens with the menstrual cycle. Due to the rising estrogen level, the ectopic endometrium proliferates and swells, and then bleeds under the influence of progesterone, irritating the local tissues and causing pain. In cases of intrinsic endometriosis, the contracture of the uterine muscles may be induced, and the painful menstruation is bound to be more pronounced. In cases of ectopic tissue without bleeding, the dysmenorrhea may be caused by vascular congestion. After menstruation, the ectopic endometrium gradually atrophies and the dysmenorrhea disappears. In addition, many inflammatory processes can be identified in pelvic endometriosis, and it is likely that the local inflammatory process is accompanied by active peritoneal lesions, resulting in the production of prostaglandins, kinins and other peptides causing pain or tenderness. However, the degree of pain often does not reflect the extent of disease detected by laparoscopy. Clinically significant endometriosis, but without dysmenorrhea, accounts for about 25% of cases. The psychological condition of the woman can also influence the pain sensation.
2. Excessive menstruation: In intrinsic endometriosis, menstrual flow tends to increase and periods are prolonged. It may be due to increased endometrium, but is mostly accompanied by ovarian dysfunction.
3. Infertility: Patients with endometriosis are often accompanied by infertility. According to reports from Tianjin and Shanghai, primary infertility accounts for 41.5 to 43.3% and secondary infertility accounts for 46.6 to 47.3%. The causal relationship between infertility and endometriosis is still debated. Pelvic endometriosis can often cause adhesions around the fallopian tubes affecting oocyte pick-up or leading to blockage of the tube lumen. It may also cause infertility due to ovarian lesions affecting the normal process of ovulation. However, it is also believed that long-term infertility and menstrual periods without closure can cause endometriosis; and once pregnant, the ectopic endometrium is inhibited and shrinks.
4. Painful intercourse: endometriosis occurring in the rectal fossa of the uterus and the vaginal rectal septum can affect sexual life due to swelling of the surrounding tissues and aggravate sexual discomfort in the premenstrual period.
5. Swelling in stool: It usually occurs in the premenstrual period or after menstruation. Patients feel painful when passing stool through the rectum, but not at other times, which is a typical symptom of endometriosis near the uterine rectal fossa and rectum. Occasionally, the ectopic endometrium reaches deep into the rectal mucosa and there is rectal bleeding during menstruation. If the endometriotic lesion forms stenosis around the rectum, there are symptoms of urgency and obstruction, so it is similar to cancerous tumor.
6. Bladder symptoms: Mostly seen in those with endometriosis to the bladder, there are symptoms of periodic urinary frequency and painful urination; when invading the bladder mucosa, periodic hematuria may occur.
Endometriosis in the scar of the abdominal wall and umbilicus presents with periodic localized masses and pain.
It has been reported that of 490 laparoscopic cases of infertility, 229 cases were different grades of endometriosis. There were 50 cases (21.8%) of bilateral patency of the fallopian tubes, 73 cases (31.7%) of patency on one side and lack of patency or obstruction on the other side, 72 cases (31.3%) of bilateral lack of patency or lack of patency on one side and obstruction on the other side, and 49 cases (21.3%) of bilateral incompetence. Bilateral incompetence of the fallopian tubes definitely cannot lead to natural pregnancy, accounting for 1/5 of endometriosis infertility; 1/3 of those with bilateral or one-sided patency accounted for 1/3 of weakness; 1/5 of those with both sides patency or one-sided patency accounted for 1/3 of weakness. Obstruction of the fallopian tube or the obstruction of the tube, as well as adhesions around the umbilical end, all affect the entry of oocytes into the fallopian tube. However, infertility also occurs in those with one or both open tubes. In addition, destruction of the ovaries by ectopic endometrium also affects oocyte development or ovulation and luteal failure. These changes can easily explain the mechanism of infertility. The autoimmune response in patients with endometriosis is also detrimental to sperm and fertilized eggs.
The rate of miscarriage is also higher in patients with endometriosis. Naples also reported that the rate of miscarriage in patients with endometriosis decreased to 8% after surgical treatment.
II. Physical signs
Patients with intrinsic endometriosis tend to have a distended uterus, but rarely beyond 3 months of gestation. It is mostly uniformly distended and may also feel more prominent in one part as if it were a fibroid. In the case of a posterior uterus, adhesions are often fixed. One or two or more small hard nodules, the size of a green or yellow bean, are often palpable in the rectal fossa, the uterosacral ligament or the posterior wall of the cervix, and are often painful to palpation and more obvious on anal examination, which is important. Occasionally, large black and purple bleeding spots or nodules may be seen in the posterior vaginal vault. If there are more lesions in the rectum, a hard mass may be palpated and even misdiagnosed as rectal cancer.
Ovarian hematoma is often adherent and fixed to the surrounding area, and a mass with greater tension and pressure pain can be palpated during gynecological double examination. After rupture, internal bleeding occurs, manifesting as acute abdominal pain.
Experts point out that endometriosis can be accompanied by anovulation, and it has been reported that 17%-27% of endometriosis is not ovulated, and the mechanism is related to the low number of LH receptors in the follicular cells of the patient. Generally, there are no obvious signs of endometriosis infertility, and the gynecological diagnosis should pay attention to the rectal trap of the uterus and the area of the fundic ligament.
1. Infertility: about 50% of patients with endometriosis are accompanied by infertility, and among patients with unexplained infertility, about 30-40% suffer from endometriosis. Infertility in endo is often caused by pelvic masses, adhesions, poor follicular development or ovulation disorders caused by lesions; and once pregnant, ectopic endometrium is suppressed and atrophied, which is a good treatment for endo, and some of the cases of habitual abortion are caused by endometriosis.
2. Dysmenorrhea: The clinical feature of endometriosis is progressive dysmenorrhea, which is a common and prominent feature, mostly secondary, that is, since the occurrence of endometriosis, the patient complains that there was no pain at the time of menstruation in the past, but dysmenorrhea starts to appear from a certain period, which can occur before, during and after menstruation. The pain often increases with the menstrual cycle and disappears at the end of menstruation, but it is reported in China that about 21% of patients do not have dysmenorrhea.
Periodic rectal irritation symptoms: Progressively increasing periodic rectal irritation symptoms are rare in other gynecological diseases, which is the most valuable symptom for diagnosing this disease. The rectum, anus and vulva are swollen, painful, and the feeling of urgency and increased frequency of stool. When the lesion is gradually aggravated, the symptoms become more and more obvious, while the symptoms disappear after menstruation.
4.Menstrual irregularities: Patients with endometriosis often have shortened menstrual cycle, increased menstrual volume or prolonged menstrual period, indicating that the patient has ovarian dysfunction performance. Irregular menstruation can be used as a diagnostic reference, but has no value in differential diagnosis.
5. Painful intercourse: painful intercourse can be produced when ectopic endometrial nodules, rectal recessed nodules or adhesions are present in the vaginal vault, or when ovarian adhesions are present in the pelvic floor. When fibroplasia and contraction of the posterior lobe of broad ligament lesions are obvious, they can exogenously compress the ureter and make it narrow and obstructed, and urinary symptoms may also occur, and in severe cases, ureteral effusion or hydronephrosis may occur.
6, periodic bladder irritation symptoms: when the endoheterosis lesion involves the bladder peritoneal reflexion or invades the bladder muscle layer, symptoms such as menstrual urinary urgency and frequency will appear at the same time. If the lesion invades the bladder mucosa (endometriosis of the bladder), there is periodic hematuria and pain.
7. Acute abdomen during menstruation or around menstruation: usually ovarian endometrial cysts with penetrating features. Most patients have emergency surgery for ovarian cyst torsion or ectopic pregnancy. If they get better without surgery, the pelvic adhesions will worsen and recurrent ruptures will occur in the future with acute abdomen.
8. Periodic lower abdominal discomfort: The occurrence of this symptom is higher than that of dysmenorrhea, and it is often present in patients with endometriosis without dysmenorrhea. It appears in patients with mild disease, or in some lesions that are more severe but do not produce dysmenorrhea symptoms but only menstrual back pain and lower abdominal cramping discomfort due to individual differences in pain threshold or other reasons.
9. Endometriosis in the scar of the abdominal wall and umbilicus presents with periodic localized masses and pain.
10. Patients with intrinsic endometriosis tend to have a distended uterus, but rarely more than 3 months of pregnancy. In case of posterior uterus, adhesions are often fixed.
11. It is important to note that 1-2 or more small hard nodules, such as the size of a mung bean or soybean, are often palpable in the rectal fossa, uterosacral ligament or the posterior wall of the cervix, and mostly have significant tenderness, which is more obvious on anal examination. Ovarian cysts can grow to the size of a fist, and due to frequent spillage of cyst contents and ectopic endothelial bleeding, pelvic organ adhesions are aggravated into a frozen pelvic shape, which is known as extensive endoheterosis. The severity of the lesion varies greatly with the signs.
12. Ultrasound sonogram: Ultrasound imaging is currently an effective method to assist in the diagnosis of endometriosis and is mainly used to observe ovarian endometriotic cysts, which are characterized by the following sonogram features.
(1) cystic masses with clear or indistinct borders. If the adhesions around the cyst are heavy, the border is unclear; if the cyst has few adhesions to the uterus or surrounding tissues, the border is clear. The cysts are mostly of medium size and granular fine echogenicity is seen in the cysts, which is a manifestation of cystic fluid viscosity. Sometimes there are denser coarse light dot images in the form of mixed masses due to concentrated mechanization of old clots.
(2) The mass is often located on the posterior side of the uterus, and concomitant cystic uterine syndrome is seen.
3) In case of spontaneous rupture of the cyst, the sonogram shows a posterior depression and a smaller cyst than before.
(4) Laparoscopy: laparoscopy is currently the new standard for diagnosing endometriosis. Through laparoscopy, the pelvic cavity can be directly visualized and a clear diagnosis can be made when ectopic lesions are seen, and clinical staging can be performed to determine treatment options.
Diagnosis and differentiation
I. Uterine fibroids
Uterine fibroids often show similar symptoms. Generally endometriosis is more painful, secondary and progressive. The uterus is uniformly distended, but not very large. It is helpful to differentiate when accompanied by ectopic endometrium from other sites. Those who do have difficulty may try medication, and if symptoms improve rapidly (1 to 2 months with medication), the diagnosis favors endometriosis. It should be noted that adenomyosis can coexist with uterine fibroids (about 10%). It is generally difficult to identify preoperatively and is subject to pathological examination pending surgical removal of the uterus.
II. Adnexitis
Endometriosis of the ovaries is often misdiagnosed as adnexal inflammatory disease. Both can form a solid mass with pressure and pain in the pelvis. However, patients with endometriosis do not have a history of acute infection, and patients are often treated with various anti-inflammatory treatments to no avail. Detailed questions should also be asked about the period of onset of dysmenorrhea and the degree of pain. Such cases often have ectopic endometrial nodules in the rectal fossa of the uterus, which can be detected on close examination and help in diagnosis. If necessary, the diagnosis can be made by trial treatment with medication and observation of the efficacy. Generally in endometriosis in the ovaries, the fallopian tubes are often patent. Therefore, a tubal lavage test can be tried. If the tubes are patent, tubal inflammation can be excluded.
Ovarian malignant tumor
If ovarian cancer is misdiagnosed as endometriosis of the ovary, treatment will be delayed, so caution must be taken. Ovarian cancer does not necessarily have abdominal pain symptoms, and if it does, it is often persistent, unlike the periodic abdominal pain of endometriosis. On examination, ovarian cancer is parenchymal, with an uneven surface and a large volume. Endometriosis of the ovary may also be associated with other sites of endometriosis and have the signs and symptoms of each site of the disease. For patients who cannot be identified, older patients should undergo a caesarean section, while younger patients can be treated as endometriosis for a short period of time to observe the efficacy.
IV. Rectal cancer
When endometriosis invades the rectum and sigmoid colon to a wider extent, a hard mass is often formed there, causing partial obstruction, and in some cases, the ectopic endometrium invades the intestinal mucosa and causes bleeding, which is more like rectal cancer. However, the incidence of rectal cancer is much higher than the incidence of intestinal endometriosis. Generally, patients with rectal cancer have obvious weight loss, more frequent intestinal bleeding, not related to menstruation and no dysmenorrhea. During anal examination, the tumor is fixed in the intestinal wall, and the intestinal wall is narrowed all around. Barium enema shows that the intestinal mucosa is not flat, and the scope of poor barium filling is small. Sigmoidoscopy shows ulceration and bleeding, and biopsy can confirm the diagnosis. Intestinal endometriosis does not lose weight, the intestine rarely bleeds, individual bleeding also occurs during menstruation, and dysmenorrhea is heavy. On anal examination the mucosa is not adherent to the mass at its base, and only the anterior wall is hardened. Barium enema shows smooth intestinal mucosa and wide range of barium malfilling.
Treatment and prevention
Treatment
Before treatment, the diagnosis should be made as clear as possible, and the patient’s age, fertility requirements, severity of the disease, symptoms and the extent of the lesion should be considered comprehensively.
I. Hormone therapy
1.Gonadotropin-releasing hormone agonist (GnRHa): In 1982, Meldtum and Lemay reported that LHRHa had good effect on the pituitary gland, which has a biphasic effect on the pituitary gland, and when LHRH is applied continuously in large quantities, the pituitary cells show a down-regulation reaction, that is, the pituitary cell receptors are filled with hormones and cannot synthesize and release FSH and LH, which play a counter-regulatory role. The side effects are hot flashes, vaginal dryness, headache, and small amount of vaginal bleeding.
2.Nemestran: It is a 19-nortestosterone derivative with high anti-progestational activity and moderate anti-estrogenic effect, which inhibits the secretion of FSH and LH, decreases the level of estrogen in the body and causes the atrophy and absorption of ectopic endometrium.
3.Danazol: It is a derivative of the synthetic steroid 17α-ethinyl testosterone. Its main effect is to inhibit the production of hypothalamic GnRH, thus reducing the synthesis and release of FSH and LH, resulting in the inhibition of ovarian function. It can also directly inhibit the synthesis of ovarian steroid hormones or compete with estrogen and progesterone receptors, resulting in ectopic endometrial atrophy, non-ovulation and amenorrhea. Danazol also has a mild androgenic effect, producing masculine manifestations such as increased hair, lowered voice, smaller breasts and the appearance of acne. Another common side effect of danazol is water retention and weight gain. It is not recommended for people with high blood pressure, heart disease or renal insufficiency. Danazol is mainly metabolized by the liver and may cause some damage to liver cells, so it is contraindicated in women with liver disease.
The usual dose is 400mg/d, 2-4 times orally, starting from menstruation, and the symptoms will be reduced in about 1 month. If it is not effective, it can be increased to 600-800mg/d, and then gradually reduced to 400mg/d. The course of treatment is generally 6 months, and 90-100% of the effect of amenorrhea is achieved.
Danazol is more effective for endo-peritoneal pelvic ectopia, but less effective for ovarian ectopic masses larger than 1cm in diameter.
4. Triamcinolone acetonide (Tamoxifen, TMX): It is a bisphenoxy derivative. The dose is 10mg×2/d, starting on the fifth day of menstruation, 20 days as a course of treatment.
5.Synthetic progesterone: Ethinylestradiol, ethinylestradiol or methandrostenolone (Amnestic progesterone) can be used for cyclic treatment to degenerate ectopic endometrium. The course of treatment depends on the effect of treatment, and this method can inhibit ovulation. Therefore, for those who wish to have children, kynurenine or kynurenine 10mg can be applied daily starting from day 16 to day 25 of the menstrual cycle. this will control the endometriosis without affecting ovulation. In some cases, there are heavy side effects during the treatment period, such as nausea, vomiting, headache and swelling, uterine cramps, breast pain and excessive weight gain due to water retention and improved appetite, which can be alleviated by giving sedatives, antiemetics, diuretics and a low salt diet.
Testosterone: It is also effective for this condition. The dose should be determined by the patient’s tolerance. The best starting dose is 10 mg orally twice daily, starting 2 weeks after the menstrual cycle. This dose rarely affects the menstrual cycle and masculinizing side effects occur. However, several cycles of continuous dosing are often required to achieve pain relief. Thereafter, the dose may be reduced for another period of maintenance treatment and then discontinued for observation. If pregnancy is possible, the disease can be cured.
Surgical treatment
Surgery is the main method for endometriosis because the scope and nature of the lesion can be clarified under direct vision, and it is more effective in relieving pain and promoting fertility. In larger ovarian endometrioid cysts, where drug therapy is ineffective, surgery may still preserve effective ovarian tissue. Surgery can be divided into 3 types: conservative surgery, semi-radical surgery and radical surgery.
1. Conservative surgery: mainly used for young people with fertility requirements. The uterus and adnexa are preserved (bilateral as much as possible), only the lesions are removed, adhesions are separated, ovaries are reconstructed, and tissues are repaired. In recent years, microsurgery has been applied to remove the ectopic lesion, carefully suture the wound, reconstruct the pelvic peritoneum, carefully stop the bleeding, and thoroughly flush it, so as to perfect the surgical results, improve the success rate of pregnancy after surgery, and reduce the recurrence rate.
(1) Laparoscopic surgery: Through laparoscopic examination, the diagnosis can be clarified, and specially designed knives, scissors and forceps can be used to excise the lesion and separate the adhesions. The lesion can be cauterized under laparoscopy with a CO2 laser or a helium-neon laser, i.e., a second incision is made 2 cm above the pubic symphysis, and the laser knife enters the pelvis through the trocar of this incision and cauterizes the lesion under direct laparoscopic view. The cystic fluid can also be aspirated by laparoscopic puncture, then rinsed with saline, then injected with 5-10 ml of anhydrous ethanol, fixed for 5-10 minutes and then aspirated, and finally rinsed with saline and aspirated.
Tubal lavage is also feasible under laparoscopy.
(2) B-ultrasound endometrioid cyst puncture: for recurrent cases after surgical debulking or laparoscopic puncture, ultrasound puncture and drug treatment can be considered.
(3) Conservative dissection: for patients with more severe focal adhesions, especially in medical institutions without laparoscopic equipment or those who are not skilled in laparoscopy, dissection can be performed to separate the adhesions and excavate the ovarian endometrioid cysts, preserving as much normal ovarian tissue as possible, or if the lesion is limited to one side and is heavy and the other side is normal, some people advocate excision of the diseased adnexa. This has a higher pregnancy rate than that with preservation of the diseased ovary. A simple uterine suspension can also be performed. Whether to do an anterior sacral nerve resection is debatable.
One of the important goals of conservative surgery is to achieve a full term delivery, so both partners should be thoroughly screened for infertility before surgery. Those who recur after surgery can still use conservative surgery again and can still get results.
2.Semi-radical surgery: those who have no fertility requirements and have serious lesions but are young in age (