Can having an ovarian cyst affect fertility?

Impact of Ovarian Cysts on Fertility

Yes, ovarian cysts can affect fertility, but the impact varies significantly depending on the type of cyst, its size, location, and underlying cause. The relationship between ovarian cysts and fertility is complex and requires careful evaluation to determine appropriate management.

Types of Ovarian Cysts and Their Impact on Fertility

Functional Cysts

• Follicular and corpus luteum cysts: Generally resolve spontaneously within 1-3 menstrual cycles
• Fertility impact: Minimal to none when small and transient
• Concern: May reduce ovulation rates during treatment cycles with clomiphene citrate (80.9% vs 97.6% ovulation rate in patients with vs. without basal ovarian cysts) 1

Endometriomas

• Fertility impact: Moderate to significant
• Mechanisms:
  • Distort ovarian anatomy
  • Cause inflammation
  • Reduce ovarian reserve through direct damage to ovarian tissue
  • May interfere with follicular development and ovulation

Polycystic Ovary Syndrome (PCOS)

• Fertility impact: Significant
• Mechanisms:
  • Chronic anovulation due to hormonal imbalances
  • Insulin resistance (affects 50-70% of women with PCOS)
  • Hyperandrogenism
  • Multiple small follicular cysts (≥20 follicles per ovary measuring 2-9mm) 2

Dermoid Cysts and Cystadenomas

• Fertility impact: Variable
• Mechanisms:
  • May cause mechanical obstruction
  • Can displace normal ovarian tissue
  • Most common persistent masses found during pregnancy 3

Evidence on Surgical Management and Fertility

Recent evidence shows that surgical treatment of ovarian cysts may actually harm fertility more than the cysts themselves:

• Women with a history of ovarian cyst surgery have a 2.41 times higher risk of infertility compared to age-matched women without surgery history 4
• Surgical excision of cysts, particularly endometriomas, can damage healthy ovarian tissue and reduce ovarian reserve 5
• Surgery does not appear to improve pregnancy rates in most cases 5

Management Approach Based on Cyst Type

Functional Cysts

1. Observation: Monitor for 2-3 menstrual cycles as most resolve spontaneously
2. Hormonal therapy: Consider oral contraceptives to prevent new cyst formation
3. Avoid clomiphene citrate in fertility treatment cycles with existing ovarian cysts >10mm, as they reduce ovulation rates 1

PCOS

1. Lifestyle modifications: First-line approach focusing on weight management
2. Medication: Consider insulin-sensitizing agents like metformin
3. Ovulation induction: Carefully monitored clomiphene citrate or letrozole
4. Warning: PCOS patients may be unusually sensitive to ovulation induction medications and at risk for ovarian hyperstimulation syndrome 6

Endometriomas and Other Persistent Cysts

1. Conservative approach: For small (<4cm), asymptomatic cysts in women actively trying to conceive
2. Surgical options (when necessary):
   • Laparoscopic cystectomy with maximal preservation of ovarian tissue
   • Consider sclerotherapy or plasma vaporization techniques that better preserve ovarian parenchyma 5
   • Avoid repeated surgeries on the same ovary

Important Considerations and Pitfalls

• Ovarian reserve assessment: Evaluate AMH levels and antral follicle count before any surgical intervention
• Timing is critical: If surgery is necessary, perform it as far as possible from planned fertility treatments
• Avoid repeated surgeries: Multiple operations on the same ovary significantly reduce ovarian reserve
• Consider age and reproductive goals: More conservative management is warranted in younger women with future fertility desires
• Warning: Ovarian hyperstimulation syndrome is a serious risk in fertility treatment, especially in PCOS patients 6

In conclusion, while ovarian cysts can impact fertility through various mechanisms, the decision to surgically treat them should be carefully weighed against the potential harm to ovarian reserve and future fertility. A conservative approach is often preferable for women planning future pregnancies, with surgical intervention reserved for specific indications where benefits clearly outweigh risks.