Endometrioma, Fertility, and the Recommended Surgical Treatment: An Evidence Based Approach

Study Objective To design an evidence-based treatment algorithm for endometriomas in women of reproductive age with a focus on fertility outcomes. Design Comprehensive literature search using PubMed/MEDLINE and Cochrane Review, including reference hand searches. Setting January 1990 - May 2020. Patients or Participants N/A Interventions Search terms “endometriosis”, “endometrioma”, “infertility”, “fertility”, “Assisted Reproductive Technology”, “in vitro fertilization”, “ovarian reserve”, “anti-mullerian hormone”, “antral follicle count”, “pelvic pain” and “surgery”; were utilized alone and in combination. Thirty-five relevant publications were included. Measurements and Main Results Women with endometriomas have lower baseline ovarian reserve compared with controls without disease. Excisional surgery of these tumors, however, confers worse fertility potential compared with conservative management. In women with an endometrioma and pain, excision is recommended. Conservation of the hilum is paramount in protecting ovarian reserve, and the use of non-thermal hemostasic methods will limit ovarian cortex vascular damage. Full excision of cyst wall will render low tumor recurrence rates. In women without pain, conservative management is recommended, especially in the context of patients preparing for in-vitro fertilization. Rates of adverse events at oocyte retrieval for women with endometriomas in situ are low or theoretical at best. Larger-sized tumors and bilaterality may correlate more highly with lower ovarian reserve, but excision does not confer benefit. These outcomes remain true in studies with long term follow-up and in studies in which procedures are performed by surgeons with advanced training. Conclusion Endometrioma excision is not indicated for women without pain, particularly in the context of fertility. If excision becomes necessary, non-thermal hemostatic methods are indicated. There may be a role for partial excision and base ablation or excision with non-thermal hemostatic agents, but the ovarian hilum must be preserved. Further surgical trials comparing excision versus conservative management with long term follow up are needed.