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The PhD project, entitled ‘Deeply Infiltrative Endometriosis: Clinical Outcome after Surgery in Adults and Pathways to Potential Prevention in Adolescent’ has two aims. The first aim was to provide a clinical outcome assessment of CO2 laser laparoscopic radical excision of DIE with extension to bowel and/or bladder, in order to monitor the quality of care of the multidisciplinary surgical team developed at the LUFc over the last 15 years. The second aim was to address ways of preventing the development of DIE by documenting the need for early diagnosis and treatment of endometriosis in adolescents and young women with significant menstruation-associated pelvic pain. In a retrospective case series (Chapter 2.2) we reported that in a subset of infertile women with a regular cycle, whose partner has normal semen analysis the prevalence of endometriosis was 47% and was comparable in patients with (54%) and without (40%) pelvic pain. The prevalence of fertility reducing non-endometriotic tubal and/or uterine pathology was 15% in women with and 40% in women without endometriosis. A multivariate logistic regression model including pain, ultrasound data, age, duration of infertility and type of fertility was not or not sufficiently reliable for the prediction of endometriosis rAFS I - II and endometriosis rAFS III - IV, respectively. Therefore we concluded that reproductive surgery is indicated in infertile women belonging to the study population, regardless of pain symptoms or transvaginal ultrasound results, since half of them have endometriosis and 40% of those without endometriosis have fertility reducing pelvic pathology. A systematic review (Chapter 2.7) performed to asses clinical outcome of surgical treatment of DIE with colorectal involvement included 49 studies and a total of 3894 patients with advanced endometriosis and colorectal extension. A large majority of these patients had been treated by bowel resection and reanastomosis (n = 2832, 72.7%), and only a minority had been treated by full-thickness disc excision (n = 383, 9.8%), or shaving/superficial excision (n = 679, 17.4%). Both the total recurrence rate and the visually and/or histologically proven recurrence rate appeared to be lower in the bowel resection anastomosis group (5.8% and 2.5%, respectively) than in the mixed study group (17.6% and 5.7%, respectively). On the other hand, most of the severe complications of this radical type of surgery were related to bowel surgery. In general, data were reported in such a way that comparison of different surgical techniques was not possible. Therefore, we made a first proposal (checklist) in the direction of an international agreement on terms and definitions in clinical outcome studies after endometriosis surgery in order to achieve standardized reporting. This checklist was applied in two retrospective cohort studies (Chapters 2.4, 2.6) and in one prospective follow-up study (Chapter 2.8) in a complex population with predominantly recurrent endometriosis. In these studies, our surgical approach results in a better outcome than reported in our systematic review of clinical outcome after bowel resection and reanastomosis for bowel endometriosis with respect to: complications requiring surgical intervention (3% versus 4.5%), pregnancy rate (50% versus 39%) and endometriosis recurrence rate (5% versus 10%). Additionally, we were the first group to report recurrence data and the second group to report fertility outcome data using life table analysis, generally considered as the best way to calculate reproductive outcome. Furthermore, we used patient-based VAS to assess complaints, an approach used in less than 20% of studies covered in our review, but considered to be superior to physician-based assessment of pain symptoms. Finally, our 3 studies measured patient perception of QOL using validated questionnaires, which has been reported in only 10% of studies covered in our review on surgical treatment for extensive DIE with colorectal involvement. The type and success of our strategic measures to prevent lower limb compartment syndrome, a complication that occurred during complex multidisciplinary laparoscopic surgery before 2004, was reported (Chapter 2.5). Overall, we can conclude that the multidisciplinary surgical team that was built up over the past 15 years, to perform a radical but fertility sparing resection of extensive endometriosis with involvement of surrounding organ systems, realizes a good clinical outcome with low complication and recurrence rate, a very good improvement of QOL and a high pregnancy rate. Moreover, in a first ever Health Economic assessment in a prospective follow-up study a significant difference was demonstrated between the total non-health care costs of patients with a rAFS I, II and III classification and of patients in stage rAFS IV (Chapter 2.9). These cost data (health care and non-health care) can be fed into economic evaluations, so that decision makers can ascertain the cost-effectiveness of various approaches to diagnose and treat endometriosis by examining their effectiveness in relation to their costs. For future research evaluating surgical treatment of extensive endometriosis, it is important to reach agreement on study design and on reporting clinical outcome data. A multicenter study with clear patient identification and well defined outcome parameters, based on the checklist proposed in our systematic review needs to be set up. Moreover, it is important to prevent DIE with colorectal extension, ideally by early identification and management of girls and women at risk. Years of pain and disability as well as a lot of money could be saved when patients, at risk of developing (extensive forms of) endometriosis could be diagnosed during adolescence. In a literature search the prevalence, the pathogenesis and the clinical manifestations of endometriosis in adolescents are reported (Chapter 3.2). The importance of a thorough history taking, a vaginal examination and technical investigations to diagnose endometriosis in adolescents is discussed as well as different options to treat the complaints of the adolescent. A flow chart is proposed for the management of diagnosis and treatment in adolescents with chronic pelvic pain suggestive for the presence of endometriosis. In a systematic review, the prevalence of laparoscopically diagnosed endometriosis in adolescents was 62% (n = 557/893), with a prevalence of 49% in adolescents with chronic pelvic pain, 76% in adolescents with chronic pelvic pain resistant to treatment with oral contraceptives/Non-Steroidal anti-inflammatory drugs and 72% in adolescents with dysmenorrhea (Chapter 3.3). In a subset of children, born in 1996, the prevalence of painful menstruation was 40% (Chapter 3.4), whereas in a sample of third year high-school adolescents and of first year university young women the prevalence of painful menstruation was 40% and 52% respectively (Chapter 3.5). These data suggest that the prevalence of pain increases with increasing age, especially in the menstrual phase. Properly administered NSAIDs, whether or not in combination with oral contraceptives, often alleviate the symptoms. When this treatment appears insufficient in order to relieve pain complaints, the girls should be referred to an endometriosis specialist and offered laparoscopy, which remains the gold standard in the diagnosis of endometriosis. Based on a selection of national and international questionnaires focused on menstrual cycle related pain complaints in adolescent girls, we determined common domains and questions and developed a new screening questionnaire as a case finding instrument for adolescents at risk of endometriosis (Chapter 3.6). Studies that evaluate the effectiveness of this screening instrument including risk factors could lead to a more standardized approach, to define gold standards and acceptable referral criteri