The (Cost-)Effectiveness of Surgical Excision of Colorectal Endometriosis Compared to ART Treatment Trajectory

Inclusion Criteria:

• Colorectal endometriosis defined as endometriosis involving the (colo)rectum:

#Enzian classification score C1,C2,C3 (C=rectum) or FI (F=far locations, I=sigmoidcolon) detected with ultrasound or MRI;

• Women in a heterosexual or in a same-sex relationship;

• The patient has an active wish to conceive and experiences at least one of thefollowing criteria:

• At least one year of non-conception (either spontaneous of after intra uterineinseminations)

• Inability to have timed intercourse because of pain (dyspareunia and/or chronicpelvic pain)

• Severe complaints (expectant management is not acceptable (anymore)

• The patients has an indication for IVF/ICSI according to Dutch guidelines (Werkgroepnetwerkrichtlijn, december 2010);

• failed intra uterine insemination

• male factor subfertility (oligoasthenoteratozoospermia defined as VCM <1million)

• bilateral tubal pathology (e.g. bilateral hydrosalpinx, bilateral tubalocclusion)

• age > 38 years and (unexplained) subfertility

• severe endometriosis in case of subfertility

• The patient is faces the choice between IVF/ICSI or laparoscopic (colorectal)endometriosis or is on the waiting list for a respective treatment at T=0 (at thebeginning of the treatment trajectory), T=1 (after one unsuccessful IVF/ICSI cycle)or T=2 (after 2 unsuccessful IVF/ICSI cycles)

Exclusion Criteria:

• Patients with deep endometriosis without colorectal involvement;

• Patients who conceive spontaneously prior to intervention;

• Patients requiring surgery on short notice and therefore unable to opt for IVF/ICSI (e.g. in case of unilateral or bilateral hydronephrosis, severe bowel stenosis andsuspicion of an impending ileus);

• Patients with a contra-indication for IVF/ICSI (e.g. diminished ovarian reserve (premature ovarian failure) (AMH (when available) <p10 adjusted for age), untreatedcongenital uterine abnormalities, maltreated/untreated systemic or malignant diseaseor severe risk factors for oocyte aspiration);

• Patients diagnosed with other diseases causing infertility (e.g. recurrentmiscarriages, antiphospholipid syndrome);

• Not able to read and understand Dutch or English.