A 40 year old primiparous woman suspected to be suffering from endometriosis is subjected to diagnostic laparoscopy. Findings indicate uterus normal, both the ovaries show presence of chocolate cysts; endometriotic deposits are seen on the round ligament right side, both the fallopian tubes and the pouch of Douglas; moderately dense adhesions are present between the fallopian tubes and the pouch of Douglas. The treatment of choice in this case is:
In the question it is given, dense adhesions and chocolate cyst are present which cannot be fully treated by medical therapy and so, some form of surgery is required.
Main question is whether we would like to go for conservative surgery or radical surgery (i.e. TAH with BSO)
Remember: mostly in endometriosis conservative surgery is done.
Conservative surgery: The clinical situations involving conservative surgery include ovarian endometrioma, pelvic adhesions, peritoneal implants and deep infiltrative rectovaginal septum disease. In addition, laser laparoscopy can be used in order to perform uterine nerve ablation.
“Hysterectomy with bilateral oopherectomy should be reserved for women who have completed childbearing and recognise the risk of premature hypoestrogenism including possible osteoporosis and decrease libido.”
 
Diagnostic and treatment algorithm for women with presumptive or proven endometriosis.
Total hysterectomy with bilateral salpingo-oophorectomy
Danazol therapy
Progesterone therapy
Fulguration of endometriotic deposits