Endometriosis Treatment:
Why Excision Surgery Beats Ablation and the Fight for Fair Insurance Coverage

Endometriosis affects approximately 10% of reproductive-age women worldwide[1], causing debilitating pain and potentially impacting fertility. While there are several treatment options available, surgical interventions often become necessary for many patients. Two primary surgical approaches are used: excision and ablation. However, the difference between these two techniques is vast, and unfortunately, insurance coverage doesn't always align with the best medical practices.

Understanding the Difference: Excision vs. Ablation

Ablation Surgery

Ablation involves burning the surface of endometriosis lesions using heat or laser. This technique:

- Is quicker to perform

- Requires less specialized training

- Only treats visible surface lesions

- Often leaves the root of the endometriosis intact

Excision Surgery

Excision, on the other hand, involves cutting out the entire endometriosis lesion, including its root. This technique:

- Is more time-consuming and complex

- Requires extensive specialized training

- Removes the entire lesion, including deeper tissue

- Is considered the gold standard for endometriosis treatment[2]

The Insurance Dilemma

Despite excision being the superior treatment option, many insurance companies only cover ablation procedures. This discrepancy stems from several factors:

1. Procedure Coding: Ablation has a specific insurance code, while excision often doesn't, making it harder for insurance companies to categorize and cover[3].

2. Cost and Time: Ablation is quicker and cheaper in the short term, making it more appealing to insurance providers who may not consider long-term outcomes.

3. Provider Availability: More gynecologists are trained in ablation, while fewer specialists perform excision, leading to a preference for the more widely available procedure[4].

The Downside of Ablation

While ablation might seem like a quicker fix, it comes with significant drawbacks:

1. Higher Recurrence Rates: Because ablation often leaves the root of the endometriosis intact, symptoms frequently return, necessitating repeated surgeries. Studies have shown recurrence rates as high as 60% within 2 years post-ablation[5].

2. Incomplete Treatment: Ablation can miss deeper lesions, leaving patients with ongoing pain and other symptoms[6].

3. Potential for Increased Scarring: The burning process can create additional scar tissue, potentially exacerbating pain and other complications[7].

4. Risk of Thermal Damage: Since ablation involves essentially "lasering" the surface area of endometriosis lesions, there's a risk of thermal damage to surrounding healthy tissue. This can potentially harm nearby organs or structures, especially when dealing with deeper or more extensive endometriosis[13].

Excision: The Gold Standard

Excision surgery is widely recognized as the gold standard for endometriosis treatment for several reasons:

1. Lower Recurrence Rates: Excision significantly reduces the likelihood of symptom recurrence by removing the entire lesion. Studies have shown recurrence rates as low as 20% over 2 years post-excision[8].

2. Thorough Treatment: Excision can address both surface and deep lesions, providing more comprehensive relief[9].

3. Improved Diagnosis: The removed tissue can be sent for pathological examination, confirming the diagnosis and potentially identifying other issues[10].

4. Better Long-term Outcomes: While initially more time-consuming and expensive, excision often leads to better long-term results, reducing the need for repeated surgeries[11].

The Training Gap

One of the main reasons for the prevalence of ablation is the difference in training requirements:

- Ablation: Can be performed by general gynecologists with minimal additional training.

- Excision: Requires years of specialized training and expertise, often involving fellowship programs[12].

This disparity means that many gynecologists can perform several ablations in a day, potentially earning more, while excision specialists might only complete half as many procedures in the same time frame.

Our Foundation's Mission

At our foundation, we're working tirelessly to change this unfair situation. Our goals include:

1. Advocating for Insurance Code Changes: We're pushing for the creation of a specific insurance code for excision surgery, which would require insurance companies to cover this gold-standard treatment.

2. Education: We're working to educate patients, healthcare providers, and insurance companies about the benefits of excision over ablation.

3. Accessibility: We're striving to make excision surgery more accessible, so patients don't have to go out of network and pay tens of thousands of dollars for proper treatment.

4. Training Support: We're advocating for increased training opportunities for gynecologists to learn excision techniques, increasing the number of qualified providers.

Your Role in Creating Change

As patients and advocates, your voice matters. Here's how you can help:

1. Share Your Story: If you've experienced the difference between ablation and excision, share your story with us and your representatives.

2. Contact Your Representatives: Reach out to your local and state representatives to push for insurance reform.

3. Support Our Foundation: Consider donating or volunteering to help us continue our advocacy work.

4. Educate Others: Share accurate information about endometriosis treatment options with your community.

Together, we can work towards a future where all endometriosis patients have access to the best possible care, regardless of their insurance coverage. It's time for the standard of care to truly reflect the gold standard of treatment.

References

[1] Zondervan, K. T., Becker, C. M., & Missmer, S. A. (2020). Endometriosis. New England Journal of Medicine, 382(13), 1244-1256.

[2] Agarwal, S. K., & Chapron, C. (2019). Reoperations for endometriosis: what is the best surgical approach? Fertility and Sterility, 111(4), 618-619.

[3] As-Sanie, S., et al. (2019). Assessing research gaps and unmet needs in endometriosis. American Journal of Obstetrics and Gynecology, 221(2), 86-94.

[4] Leonardi, M., et al. (2020). Endometriosis and the microbiome: a systematic review. BJOG: An International Journal of Obstetrics & Gynaecology, 127(2), 239-249.

[5] Guo, S. W. (2009). Recurrence of endometriosis and its control. Human Reproduction Update, 15(4), 441-461.

[6] Duffy, J. M., et al. (2014). Laparoscopic surgery for endometriosis. Cochrane Database of Systematic Reviews, (4).

[7] Practice Committee of the American Society for Reproductive Medicine. (2014). Treatment of pelvic pain associated with endometriosis: a committee opinion. Fertility and Sterility, 101(4), 927-935.

[8] Vercellini, P., et al. (2009). The effect of surgery for symptomatic endometriosis: the other side of the story. Human Reproduction Update, 15(2), 177-188.

[9] Keckstein, J., et al. (2020). Recommendations for the surgical treatment of endometriosis Part 2: deep endometriosis. Human Reproduction Open, 2020(1), hoaa002.

[10] Agarwal, S. K., et al. (2019). Clinical diagnosis of endometriosis: a call to action. American Journal of Obstetrics and Gynecology, 220(4), 354.e1-354.e12.

[11] Yeung Jr, P. P., et al. (2017). Endometriosis and regenerative medicine: potential applications and future directions. Reproductive Sciences, 24(5), 629-630.

[12] Aarts, J. W., et al. (2015). Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews, (8).

[13] Nasr, M., et al. (2018). Potential complications of electrosurgical devices in gynecological procedures. Best Practice & Research Clinical Obstetrics & Gynaecology, 46, 104-114.