Is removal of a 1 centimeter (cm) mature cystic teratoma (dermoid cyst) of the ovary recommended to improve fertility in a female patient with infertility?

From the Guidelines

Removing a 1 cm dermoid ovarian cyst is generally not recommended solely to improve fertility in a female infertility patient. Small dermoid cysts (under 5-6 cm) typically don't interfere with ovulation, egg quality, or overall fertility potential, as supported by the American College of Radiology's guidelines 1. These benign growths, also called mature teratomas, usually grow slowly and often don't impact reproductive function when they're small.

Key Points to Consider

• Observation with regular ultrasound monitoring every 6-12 months is the standard approach for small, asymptomatic dermoid cysts, as recommended by the ACR O-RADS US Risk Stratification and Management System 1.
• Surgery would only be indicated if the cyst is causing symptoms (pain, pressure), growing rapidly, or if there are concerns about potential torsion or rupture.
• Additionally, surgical removal carries risks including potential damage to ovarian tissue and reduced ovarian reserve, which could paradoxically worsen fertility, as noted in the guidelines 1.
• The patient should continue with appropriate fertility treatments based on her specific diagnosis while monitoring the cyst.
• If other fertility factors have been addressed without success, or if the cyst location specifically interferes with ovulation or follicle development, then reassessment of this approach may be warranted, considering the low risk of malignancy in benign-appearing lesions on US managed conservatively 1.

Risks and Considerations

• The risk of malignancy in these classic “benign”-appearing lesions is < 1% in a cohort of 970 average-risk women, as demonstrated by Gupta et al 1.
• The risk of malignancy in benign-appearing lesions on US managed conservatively with 2-year follow-up was 0.3% to 0.4% for malignancy and 0.2% to 0.4% for acute complications such as torsion or cyst rupture, as reported in the guidelines 1.

From the Research

Removal of Mature Cystic Teratoma and Fertility

• The relationship between ovarian cysts and infertility is a subject of debate, and the impact of surgical treatment on fertility is not clear 2.
• Some studies suggest that surgical treatment of ovarian cysts may not improve pregnancy rates, and the effects of surgery can be more harmful to the ovarian reserve than the cyst itself 2.
• However, laparoscopic removal of benign ovarian teratomas (dermoid cysts) is considered a safe and effective method, with advantages including reduced blood loss, less postoperative pain, and shorter hospital stay 3, 4.

Size of the Cyst and Fertility

• The provided studies do not specifically address the removal of a 1 cm mature cystic teratoma and its impact on fertility.
• However, it is generally recommended that fertility-sparing surgery should be the main concern for presumed benign ovarian tumors 2.

Surgical Approach and Fertility

• Laparoscopic approach is considered the method of choice for the removal of benign ovarian cystic teratomas, as it offers fewer postoperative adhesions, reduced pain, and shorter hospital stay 3, 4.
• Vaginal approach with laparoscopic assistance can also be considered a safe alternative procedure to laparoscopy 4.
• The choice of surgical approach should be made jointly by surgeons and specialists in reproductive medicine, taking into account the context of the infertility 2.