Preoperative preparation of the bowel with an oral purgative such as magnesium citrate followed by antibiotics and cleansing enemas Endometriosis of the rectum, recto-vaginal septum appendix or sigmoid colon are frequently seen and may result in entry into the bowel lumen.

What is your practice regarding bowel preparation?
Bowel prep should be ordered for:

1. the majority of patients undergoing diagnostic laparoscopy.
2. restricted to patients where endometriosis is suspected
3. only when bowel surgery is anticipated
4. rarely

It is not unusual for patients with endometriosis and pelvic pain to present with a history of repeated surgical procedures and courses of hormonal therapy. It has been suggested that surgical excision of all visible disease may provide better relief of pain.

Indicate whether you agree or disagree with the following statements:

1. Laser vaporization of endometriosis and excisional therapy are equally effective.
   AGREE, DISAGREE
2. Laser vaporization of the this disease (click here for photo) would be more likely to result in recurrence than excisional therapy.
   AGREE, DISAGREE
3. With involvement of the uterosacral ligament and culdesac, a six month course of GnRH-a therapy can provide prolonged relief equal to surgery.
   AGREE, DISAGREE
4. Aggressive surgical excision will usually cure endometriosis.
   AGREE, DISAGREE

Minimal endometriosis is frequently noted at the time of diagnostic laparoscopy performed during an infertility evaluation. Assuming a 38 year old female with 3 years of unexplained infertility, normal ovulatory cycles, negative cultures, normal HSG, semen analysis and hormonal studies, and laparoscopy reveals patent normal appearing fallopian tubes and ovaries with minimal peritoneal and cul-de-sac retroperitoneal endometriosis.

Select all of the following treatments you would consider:

1. Laser vaporization of visible lesions
2. Surgical excision of all visible lesions
3. Adjunctive GnRH-a therapy for: (choose one)
   • No agonist therapy
   • 1-3 months
   • 6 months of therapy
   • only treat patients with residual disease
4. After the treatment chosen in 1-3 above, the most appropriate therapy for this couple would be: (choose one)
   • Up to 6 months of urinary LH timed intercourse prior to further medical therapy
   • Clomiphene and intrauterine insemination (IUI).for 3-6 cycles
   • Gonadotropin therapy and IUI
   • GnRH-a, gonadotropin stimulation and IUI
   • IVF

Studies looking at the role of immune system and endometriosis have provided conflicting information. It has been suggested that endometrial cells recovered from the peritoneal fluid in women with endometriosis are less immunogenic and not as easily cleared by peritoneal macrophages. Other studies have shown that peritoneal macrophages from women with endometriosis are less competent when it comes to clearing endometrial cells. Peritoneal NK-cell numbers are reduced as the severity of endometriosis increases. Women with endometriosis are more likely to demonstrate autoantibodies to phopholipids.

Indicate whether you agree or disagree with the following statements:

1. Endometriosis is due to a disorder of the immune system
   AGREE, DISAGREE, DON'T KNOW
2. The immune system abnormalities are caused by endometriosis rather than a cause of this disorder.
   AGREE, DISAGREE, DON'T KNOW
3. More studies are necessary to explore the relationship between the immune system and endometriosis.
   AGREE, DISAGREE, NO OPINION

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