'Seeing is believing': arguing for diagnostic laparoscopy as a diagnostic test for endometriosis

Jason Mak, Mak J, Mathew Leonardi, George Condous
Reproduction & fertility · 2022 · vol. 3(3) , pp. C23–C28 · doi:10.1530/raf-21-0117 · PMID:35794928 · PMC9254269 · W4281759485
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⚙ AI-generated summary by claude@2026-06, 2026-06-07 ⓘ

This debate article argues for the use of diagnostic laparoscopy as the preferred method for definitively diagnosing endometriosis due to its safety and superior detection capabilities compared to medical imaging.

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⚙ AI-generated deep summary by claude@2026-06, 2026-06-07 · read from full text ⓘ

This commentary argues for diagnostic laparoscopy as a diagnostic test for endometriosis in people with chronic pelvic pain and/or infertility, reviewing evidence on procedural safety, diagnostic accuracy compared with imaging, and the value of both positive and negative findings. It cites low overall laparoscopic mortality and low complication rates from broad reviews and large cohorts, notes that diagnosis can validate patients’ symptom experiences and reduce diagnostic delay, and emphasizes that even a negative laparoscopy can expedite evaluation for non-endometriosis causes. The authors also summarize that while ultrasound and MRI can be used to help rule in endometriosis, a Cochrane review found neither imaging modality has sufficient accuracy to replace surgery for overall pelvic endometriosis, with performance varying by lesion depth and with ongoing advances for superficial disease; a key limitation is that much of the risk/accuracy evidence is drawn from heterogeneous studies and depends on individualized risk stratification and evolving techniques. This paper is centrally about endometriosis — it specifically argues that diagnostic laparoscopy should be maintained (including its role for both ruling in and ruling out endometriosis) as a diagnostic standard.

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Abstract

Endometriosis is a benign disease that can cause pain and infertility in women. Debate exists over how endometriosis should best be diagnosed. On one hand, endometriosis can be diagnosed by directly examining pelvic anatomy via a surgical procedure known as diagnostic laparoscopy. On the other hand, the disease can be diagnosed via non-surgical means such as using medical imaging, the symptoms described by the patient and whether the patient responds to non-surgical therapies such as medication. In this debate article, we argue in favour of diagnostic laparoscopy. We review the safety of the procedure, compare the ability of diagnostic laparoscopy vs medical imaging to detect endometriosis and consider the benefits of formally diagnosing or ruling out the condition.
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Author

All listed authors contributed to the conceptualization, writing and editing of this piece.

Funding

This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Argument

Endometriosis is a double-edged disease. Alongside pain, infertility is also an important implication. Whether excision of endometriosis improves fertility outcomes is still highly debated ( Gordts 2021 , Leonardi 2021 ) and that debate should not be confused with the value of diagnosis. What is not controversial is the fact that endometriosis has a very strong association with infertility. In women undergoing laparoscopy for unexplained infertility, 60% are found to have endometriosis, making it a high-yield diagnostic tool ( Pantou et al. 2019 ). A retrospective cohort study of 1322 women using self-reported outcomes found that one-third of women undergoing assisted reproductive technologies (ART) had a diagnosis of endometriosis. It also identified an interesting difference between women who were diagnosed with endometriosis before vs after commencing ART. Women who were diagnosed after commencing ART required more in vitro fertilization cycles and were less likely to report a birth than women who were diagnosed with endometriosis before commencing ART ( Moss et al. 2021 ). Whether endometriosis is identified or not, diagnostic laparoscopy provides valuable information for the infertile couple.

Conclusion

For the sufferer of chronic pelvic pain or the infertile couple, diagnostic laparoscopy provides the answers that are desperately sought. Whether endometriosis is diagnosed or not and whether treatment is triggered or not are irrelevant to this debate. The reality is laparoscopy is safe and is irreplaceable. We have argued that diagnostic laparoscopy plays a critical role in diagnosing endometriosis, but the surgeon should never fly blind. Pre-operative assessment with history-taking, physical examination and imaging provides an important triage and clinical decision-making role. While the benefits of a positive laparoscopy are obvious, the importance of a negative laparoscopy is often an undervalued key step in redirecting investigations and treatment. Despite advances in diagnostic imaging for endometriosis, the data demonstrate the disease cannot be ruled out until the pelvis and abdomen are directly visualized, with biopsies taken of abnormal areas. Diagnostic laparoscopy is not yet antiquated. While it should not be considered mandatory, it remains the gold standard for diagnosis and an important gateway to treatment.

Declaration

The authors declare that they are both gynaecology surgeons and sonologists: distinctiona that carry mutually exclusive risks of bias in this debate. J M has no funding or sponsorship to report. M L reports grants from OZWAC, Endometriosis Australia, AbbVie, CanSAGE, MRFF, HHS; honoraria for lectures/writing from GE Healthcare, Bayer, AbbVie, TerSera, consulting fees from Imagendo, outside the submitted work. G C reports grants from Endometriosis Australia and MRFF; honoraria for lectures from G E Healthcare and Imperial College London. Mathew Leonardi is an Associate Editor of Reproduction and Fertility. Mathew Leonardi was not involved in the review or editorial process for this paper, on which he is listed as an author.

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Condition tags

endometriosischronic_pelvic_paininfertility

MeSH descriptors

Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis

Citation neighborhood

Papers in the corpus that this work cites (lower rings, blue) and that cite this one (upper rings, green). Dot size scales with the paper's in-corpus citation count — bigger dot = more influential within the endo/adeno field. Click a dot to open that paper. [ expand to 2 hops ] — adds papers reached through this work's immediate citers/citees. Heavier; up to 60 extra dots.

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