Excision or Ablation- How Should My Endometriosis Be Treated?

Miss Deepika Pannu, MRCOG

Endometriosis Specialist Consultant

If you’ve reached the point where medications aren’t controlling your endometriosis symptoms, surgery isn’t just the next step but it’s a critical opportunity to reclaim your health. But not all surgeries are equal. As gynaecologist, I prioritize precision – the goal isn’t just to treat what we see, but to remove endometriosis completely to prevent its return. That’s why understanding your two main options—excision and ablation is the foundation of your long-term relief.

How is ablation treatment different from excision?

Ablation, sometimes called “burning” or “fulguration,” uses heat, laser, or electrical energy to destroy visible endometriosis tissue. In this method, the surgeon burns or vaporizes the surface of the lesions.

Excision, on the other hand, involves cutting out the endometriosis completely—even the deeper portions that may lie beneath the surface. Surgeons can do this with scissors, energy devices, or other surgical tools. Gynaecologists who offer this treatment require to undergo specialized surgeon training.

Why shouldn’t I opt for easy ablation treatment for endometriosis?

For very mild, surface-level endometriosis, either technique can improve symptoms. In fact, studies show that about two-thirds of women feel better after surgery, regardless of the method used. But endometriosis can be deceiving. Lesions that look small and superficial on the surface may actually run much deeper. Burning deep disease usually doesn’t reach its full extent, meaning tissue may be left behind. Patients who undergo ablation are more likely to need additional surgeries within 5 years.

If the tissue is only burned, hidden disease can remain behind. This is why specialists recommend removing the lining of the pelvis (called the peritoneum) around visible spots, since tiny, invisible lesions can also be present.

The type of endometriosis lesion often determines which surgery is best. If there is a deep implant or an ovarian cyst (endometrioma), most gynaecologists prefer excision. And when it comes to ovarian cysts, burning can sometimes damage healthy ovarian tissue and reduce fertility potential. Instead, surgeons usually remove the entire cyst wall.

This excision technique not only provides more effective pain relief but also protects the healthy ovary—something that’s crucial for women who want to preserve fertility. More importantly excised tissue can be tested by pathology to confirm endometriosis.

Does excisional treatment give better symptom control?

Research and clinical experience show that excision tends to provide longer-lasting relief from pain compared to ablation. By removing the disease completely, excision lowers the risk of persistent symptoms and reduces the chances of recurrence.

How is fertility affected after endometriosis surgery?

Both types of surgery can improve fertility compared to doing nothing, but excision may give an extra boost if pregnancy is a goal. Women who have cysts fully excised are more likely to conceive naturally than those whose cysts were only drained and burned.

Even with smaller lesions, complete removal may help improve chances of pregnancy. Reviews of research confirm that excision of ovarian cysts is linked to better natural pregnancy rates and fewer recurrences of pain than ablative surgery.

• Excision is generally preferred for:

• Deep infiltrating endometriosis (DIE)
• Endometriomas (ovarian cysts)
• Patients seeking long-term symptom control
• Those prioritizing fertility preservation
• Ablation may be used for:
  • Superficial (mild) lesions
  • When specialist laparoscopic surgeon isn’t accessible or feasible

• Research confirms that complete removal of endometriosis (via excision) offers the best chance for lasting relief. Advocate for a surgeon skilled in this approach.
• Surgeon expertise matters most and always choose a surgeon highly experienced in advanced laparoscopic excision.