Colorectal Endometriosis Responsible for Bowel Occlusion or Subocclusion in Women With Pregnancy Intention: Is the Policy of Primary in Vitro Fertilization Always Safe?

OBJECTIVE: To discuss the risk of bowel occlusion or subocclusion in patients with pregnancy wish and deep colorectal endometriosis, when surgery is postponed until after conception.

DESIGN: A prospective series of consecutive patients managed for occlusion or subocclusion between January 2012 and January 2015 (Canadian Task Force classification II-2). Deep endometriosis had previously been diagnosed in all patients; however, they were advised to postpone surgery until after conception.

SETTING: University tertiary referral center.

PATIENTS: Twelve women with bowel occlusion or subocclusion due to deep endometriosis and desiring pregnancy.

INTERVENTION: Surgical management including colorectal resection.

MAIN OUTCOME MEASURES: Digestive symptoms, including standardized gastrointestinal questionnaires and preoperative imaging assessment of deep endometriosis.

RESULTS: The patients enrolled in the series represent 5% of 241 patients with colorectal endometriosis managed over 37 consecutive months. Major digestive complaints were bloating, defecation pain, constipation, liquid stools, and a feeling of incomplete stool evacuation. The median length of digestive tract stenosis was 50 mm (range, 20-100 mm). In 8 patients (67%), computed tomography-based virtual colonoscopy revealed a virtual digestive lumen. The median length of colorectal specimen removed was 120 mm (range, 60-200 mm). Three patients (25%) had Clavien-Dindo IIIb and IVa postoperative complications with favorable outcomes within up to 20 days after surgery.

CONCLUSION: Given the risk of bowel occlusion or subocclusion in young patients with colorectal endometriosis, an exhaustive assessment of deep disease and advice at a tertiary referral center appears to be mandatory before prioritizing primary in vitro fertilization instead of primary surgery.