This study reviews the most recent literature regarding the impact of endometriomas on ovarian reserve and the pros and cons of surgical management.
Why Surgical Excision?
- Primary benefit of surgical treatment of endometriosis – relief of pelvic pain.
- Laparoscopic excision of an endometrioma – decrease in symptoms of dysmenorrhea, dyspareunia, and nonmenstrual pelvic pain (Cochrane review 2008).
- Endometriomas in situ show progressive smooth muscle cell metaplasia and fibrosis of the cortical layer. No correlation found between the size of the endometrioma and the degree of ovarian pathology.
- It is recommended that ectopic endometrial tissue should be removed sooner rather than later irrespective of the cyst size.
- Transvaginal hydrolaparoscopy can be used to diagnose an endometrioma and also ablate the cyst at an early stage in a minimally invasive fashion.
- Expectant management of infertile women with endometriomas – associated with a pregnancy rate of 12% whereas a conception rate of 54.2% is seen in women who had surgical removal of their cysts (Barri et al).
- Expectant management poses dangers such as ovarian torsion, cyst rupture, progression of endometriosis, or the threat of ovarian malignancy.
- Removal of endometriomas may allow for better access of follicles at the time of oocyte retrieval.
- The 2014 guideline of European Human Reproduction and Embryology (ESHRE) guidelines for the management of women with endometriosis says that antibiotics should be given prior to transvaginal oocyte retrieval in patients with endometriomas.
Cons of Surgical excision:
- Preoperative reduction in ovarian reserve has been studied by analyzing the commonly anti-Müllerian hormone (AMH) levels.
- Preoperative AMH levels were significantly lower in women with Stage IV endometriosis who had endometriomas.
- It is recommended to check the preoperative AMH before performing an ovarian cystectomy and use this information when counseling women before surgery, especially in those with low baseline AMH.
- There is a concern over the deleterious effects of ovarian cystectomy on ovarian reserve because studies show that surgical excision of endometriomas leads to a decline in AMH.
- Laparoscopic cystectomy may worsen ovarian reserve including accidental removal of healthy ovarian cortex, thermal damage from coagulation of bleeding vessels, and surgical-related local inflammation.
- Surgical removal of ovarian endometrioma cysts carries a significant risk of reduced fertility
Nevertheless, the presence of an endometrioma does not appear to adversely affect IVF outcomes, and surgical excision of endometriomas does not appear to improve IVF outcomes. Regardless of treatment plan, infertile patients with endometriomas must be counseled appropriately before choosing either treatment path.