Fulguration, also called ablation, is one type of endometriosis surgery involving a technique to burn away the lesions (implants) present outside the uterus. These lesions react like the uterus lining during your period or menstrual bleeding. They grow and bleed, causing inflammation, pain, and heavy menstrual bleeding.

This article reviews what fulguration and excision are, who performs these surgeries, and the differences between the two. You will also learn about the cost, effectiveness, and more. 

Two Surgical Techniques for Endometriosis

There is currently no cure for endometriosis. However, there are treatments to improve symptoms, reduce pain, decrease new growth, preserve fertility, and treat infertility. Treatment may include medications, surgery, or a combination of both. 

Fulguration vs. Excision

Fulguration uses intense heat to burn and melt away endometrial lesions, starting at the lesion’s surface. Excision means surgically removing the implant using a cutting tool.

Fulguration and excision are two minimally invasive surgical techniques used to treat endometriosis. Surgery is often used when other treatments are not working.

Fulguration (Ablation)

“Fulgurate” means “to burn,” giving this surgery its name. Fulguration (ablation) is a type of electrosurgery that melts away endometrial lesions. It uses intense heat from electricity, ultrasound, or a laser to burn away or cauterize endometriosis implants starting at the lesion’s surface. 

Excision

“Excision” means “to remove surgically.” It indicates removing a growth, tissue, organ, or bone using a scalpel, laser, or another cutting tool.

Surgical excision of endometriosis is the cutting away of visible endometrial implants. The goal is to remove the entire lesion, including the root while avoiding damage to any organs. However, removing all implants for those with stage 4 endometriosis can be challenging.

A laparoscopic technique is commonly used for surgical excision of endometriosis. Many surgeons use robot-assisted technology, which is minimally invasive and provides faster recovery, less pain, and a smaller incision.

Who Performs Fulguration of Endometriosis?

An endometriosis specialist is a highly trained obstetrician-gynecologist (ob-gyn) and a skilled surgeon. While endometriosis is a gynecological issue, not all ob-gyns specialize in treating it. An endometriosis specialist performs fulguration.

Laparoscopy

A laparoscope is a surgical instrument with a thin tube and a camera. It is inserted through the abdomen through a small incision during laparoscopic surgery. 

Questions to Ask Before Surgery

Before undergoing surgery, you should feel confident in your healthcare provider. It’s also essential to understand the procedure you are giving consent to and what to expect after surgery. If you don’t have answers to the following questions, don’t hesitate to talk to your surgeon or healthcare team before the procedure:

Why Surgical Techniques Vary

Both fulguration and excision techniques differ from surgeon to surgeon, depending on the provider, their training, their access to surgical equipment, and the facility where they perform surgery.

For example, some surgeons train through fellowships or residencies and specialize in minimally invasive surgery techniques. For surgeons to transition to robotic surgery, they need access to the equipment and training. Learning to use the robot to perform surgery requires observation, training, assisting, performing with supervision, and then independent surgery. 

  • What is the method or technique you use for the surgery?Will you be doing all of the surgery, or will there be a team?How many incisions will you make?What is the goal of surgery?Is the surgery treating superficial (shallow) or infiltrating (deep) endometriosis?How should you prepare for surgery?How long will the surgery take?What is the typical recovery time?Will it affect your chances of getting pregnant (if that is a desire for the future)?Will surgery eliminate the endometriosis?What are the chances that the endometriosis will come back (recur)?When should you expect to return to normal activities, including exercise, work, and sexual intercourse?If the pain continues after surgery, what are the next steps?

Where to Find a Specialist 

Endometriosis specialists are ob-gyns and surgeons with access to modern surgical equipment. They typically work in medical centers, teaching hospitals, or private practices that utilize gynecological surgeons. 

Look for a surgeon with training and expertise in treating and removing endometriosis. Endometriosis specialists often work with a team of other healthcare professionals, including physical therapists, other surgical specialists, and pain management providers. 

When Endometriosis Would Be Ablated

Fulguration, or ablation, is a superficial treatment that is beneficial for small lesions. It partially treats endometriosis as it leaves the root of the implant. Because the burning starts at the surface of lesions, it doesn’t remove the entire implant. 

Finding the Best Specialist for You

Finding a provider who shows respect, listens to your concerns, takes your symptoms seriously, and explains the treatment plan clearly is essential. An excellent place to find a referral is from your primary healthcare provider or in endometriosis support groups. 

Don’t hesitate to get a second opinion if you feel your provider is dismissive, has a poor attitude, or does not include you in care planning. Being your own advocate often includes getting a second or third opinion. 

Superficial Peritoneal

The peritoneum is the tissue in the pelvic cavity or the internal area between the hips. It covers the reproductive organs, digestive tract, and liver. 

Superficial peritoneal lesions are small patches of endometrial-type tissue found in the peritoneum. They are the most common type of endometrial lesion, as 80% fall in this category. 

When Endometriosis Would Be Excised

While fulguration (ablation) can be helpful for small lesions, it only burns away the surface of the lesions. Healthcare providers treat deep infiltrating endometriosis (DIE) and endometriomas with excision surgery. For those who wish to get pregnant, excision also helps preserve fertility as it causes less damage to ovarian tissue.

Endometriomas and Deep Infiltrating Endometriosis (DIE)

Endometriomas, or chocolate cysts (which get their name from their brown-like appearance), are a type of cyst most commonly found on the ovaries. Deep infiltrating endometriosis (DIE) is aggressive and affects 5 millimeters (mm) or more of the tissue. It grows deep in the peritoneum. 

The goal of excision is the complete removal of deep lesions and the cyst wall (for endometriomas). It also helps preserve ovarian tissue to help prevent infertility. 

Efficacy of Ablation

The efficacy or effectiveness of ablation varies. Some people who have had ablation surgery report that pain relief begins right after surgery, while others note it takes a few days. Talk with your healthcare provider if you don’t have pain relief after a few weeks. Even small amounts of remaining lesions can cause pain.

Cost and Insurance

The average ablation cost varies from $1,500 to $2,900 before insurance. Check with your insurance company before the procedure, as cost varies based on in-network vs. out-of-network providers. Ask about any deductibles that may apply and what your maximum out-of-pocket expenses include. 

Length of Ablation Procedure

The ablation procedure for endometriosis lesions ranges from 30 minutes to a couple of hours. This depends on the number of lesions, scarring, and structures involved. 

Recovery

Most people go home on the day of surgery. You may feel crampy, tired, sore, or bloated the first few days. Most people start feeling more like themselves within the first week. 

Recovery time can take several weeks for some. It depends on your overall health, how you handle anesthesia, nutrition, and activity level. While this is a less invasive procedure, it is still surgery. Your body needs time to rest and heal. 

Recurrence Rates After Ablation 

Many studies note that endometriosis’ recurrence (return) after ablation is between 6% and 67%. A recent literature review found an average of 40% to 50% recurrence within five years of surgery. 

Most studies found that complete excision results in lower rates of recurrence for both deeply infiltrating endometriosis (DIE) and ovarian disease. 

The considerable variation in these rates could be due to the definition of recurrence in these studies. Some may use pain as an indicator, while others may define recurrence as continued infertility or the reappearance of lesions. 

Summary 

Endometriosis is a condition that occurs when endometrial-like tissue or lesions are present outside the uterus. These lesions grow and bleed, causing inflammation, pain, and heavy menstrual bleeding.

While there is no cure for endometriosis, there are treatments. Fulguration (ablation) is a type of endometriosis surgery that involves burning away these lesions. It treats small, superficial lesions but not larger, deeper lesions or endometriomas.

A Word From Verywell

Endometriosis can cause discomfort and stress that may affect your activities of daily living, work, relationships, and quality of life. 

When seeking a diagnosis or treatment, you should find a healthcare provider specializing in endometriosis. If you need surgery, look for a surgeon who has experience removing lesions with minimally invasive gynecologic surgery (MIGS) techniques.

Frequently Asked Questions

  • Which is better, fulguration or excision for endo?
  • Fulguration is more beneficial for smaller, superficial endometriosis lesions. Excision is usually the treatment of choice for endometriomas and deeper or larger lesions.
  • Does endometriosis always come back after surgery?
  • No, not always, but the recurrence rate is relatively high. It depends on the stage of endometriosis, the type of surgery, and other treatments besides surgery.
  • How can you manage chronic endo pain?
  • You can try heat or ice, topical medications or pain patches, Boiron, Naturopathica (arnica), and exercise for mild symptoms. If your healthcare provider approves, you can also try over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDS), such as Advil or Motrin (ibuprofen) and Aleve (naproxen). Moderate cases may require prescription medications such as hormonal birth control or those that control inflammation and pain.
  • Learn More:
  • Can Depo-Provera Treat Endometriosis?
  • Are there other options besides birth control for endo?
  • Yes. While there is no cure for endometriosis, lifestyle modifications, medications (including other hormone treatments outside of birth control), and surgical procedures can treat it.

Fulguration is more beneficial for smaller, superficial endometriosis lesions. Excision is usually the treatment of choice for endometriomas and deeper or larger lesions. 

No, not always, but the recurrence rate is relatively high. It depends on the stage of endometriosis, the type of surgery, and other treatments besides surgery.

You can try heat or ice, topical medications or pain patches, Boiron, Naturopathica (arnica), and exercise for mild symptoms. If your healthcare provider approves, you can also try over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDS), such as Advil or Motrin (ibuprofen) and Aleve (naproxen). Moderate cases may require prescription medications such as hormonal birth control or those that control inflammation and pain.

Yes. While there is no cure for endometriosis, lifestyle modifications, medications (including other hormone treatments outside of birth control), and surgical procedures can treat it.