From the Guidelines
The best approach for ovarian cystectomy to preserve fertility is through laparoscopic surgery with careful cyst excision while preserving normal ovarian tissue, as recommended by the most recent guidelines 1. This approach should begin with identification of the cyst and injection of dilute vasopressin into the ovarian tissue surrounding the cyst to reduce bleeding.
- The ovarian cortex should be incised away from the hilum using either sharp scissors or monopolar energy, and the cyst wall should be meticulously dissected from the surrounding ovarian tissue using gentle traction and counter-traction techniques.
- Hemostasis should be achieved with precise bipolar coagulation rather than extensive suturing, minimizing thermal damage to the ovarian reserve.
- The ovary can be left to heal by secondary intention without suturing if the defect is small, or closed with absorbable sutures in an interrupted fashion for larger defects, taking care to avoid excessive tension or strangulation of tissue. This approach maximizes preservation of ovarian follicles and minimizes adhesion formation, as supported by recent guidelines 1.
- Surgeons should avoid excessive coagulation, unnecessary manipulation of the ovary, and prolonged ovarian compression, as these can damage the ovarian blood supply and follicular reserve. The laparoscopic approach is preferred over laparotomy because it results in less postoperative adhesion formation, faster recovery, and comparable reproductive outcomes with less impact on ovarian reserve, as noted in previous studies 1. However, the most recent and highest quality study 1 should be prioritized, which recommends ovarian tissue cryopreservation as a viable option for fertility preservation in female cancer patients, with over 300 women worldwide having undergone the procedure and achieving ovarian function restoration in 95% of cases.
From the Research
Fertility-Preserving Approaches for Ovarian Cystectomy
- The optimal time for recovery of ovarian reserve after laparoscopic unilateral ovarian cystectomy is estimated to be 6 months 2.
- Surgical techniques to optimize ovarian reserve during laparoscopic cystectomy for ovarian endometrioma include limiting iatrogenic surgical damage to the ovarian cortex and strategically assessing and responding to genital tract patency 3.
- Minimally invasive single-port laparoscopic ovarian cystectomy may be offered as a surgical alternative for patients who want to preserve their fertility, although it may result in higher blood loss and longer operative time 4.
Factors Affecting Ovarian Reserve
- Certain cyst characteristics, such as endometrioma pathology, large cyst size, and bilateral presentation, are associated with a greater decline in ovarian reserve after cystectomy 5.
- The surgical technique of endometrioma excision, including the use of bipolar coagulation, can impact the ovarian reserve 6.
- Single-port access laparoscopy may not be recommended for patients undergoing surgery for endometrioma excision who want to preserve their fertility, due to a statistically significant decrease in ovarian reserve compared to conventional laparoscopy 6.