What are the fertility rates after surgical removal or treatment of endometrioma (endometriotic cyst)?

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From the Guidelines

Fertility rates post removal or treatment of endometrioma can be predicted using the Endometriosis Fertility Index (EFI), a simple and validated clinical tool that predicts fertility outcome for women following surgical staging of endometriosis. According to the World Endometriosis Society consensus on the classification of endometriosis 1, the EFI is a robust tool that may have considerable utility in developing treatment plans for infertile women with endometriosis.

Key Points to Consider

  • The EFI score should be completed and documented in the medical/surgical records for women with endometriosis undergoing surgery, particularly those for whom fertility is a future concern 1.
  • Surgical excision of endometriomas can increase spontaneous pregnancy rates, and laparoscopic cystectomy is preferred over drainage or ablation as it better preserves ovarian tissue and function.
  • Medical treatments like GnRH agonists, combined oral contraceptives, or progestins can be used before fertility treatments to suppress endometriosis activity, but these medications don't directly improve fertility and require discontinuation when attempting conception.
  • The impact of endometriomas on fertility stems from multiple mechanisms including inflammatory environment, altered folliculogenesis, reduced ovarian reserve, and anatomical distortions.

Recommendations for Clinical Practice

  • All women with endometriosis undergoing surgery should have a r-ASRM (or possibly, when published, AAGL) score and stage completed, and women with deep endometriosis should have an Enzian classification completed 1.
  • Women for whom fertility is a future concern should have an EFI score completed, and documented in the medical/surgical records 1.
  • Attempting natural conception for 6-12 months before pursuing assisted reproductive technologies is recommended, and prior surgical removal of endometriomas larger than 3-4 cm may improve IVF outcomes.

From the Research

Fertility Rates Post Removal/Treatment of Endometrioma

  • Fertility outcomes after endometrioma removal or treatment are influenced by various factors, including the severity of endometriosis, ovarian reserve, and the surgical approach used 2.
  • Studies have shown that surgery for endometriosis can have a beneficial impact on the chance of spontaneous conception, but the selection of appropriate surgical candidates is crucial 2.
  • The use of GnRH agonists and antagonists in the treatment of endometriosis has been explored, with some studies suggesting that these protocols may be equally effective in patients with mild-to-moderate endometriosis and endometrioma who did and did not undergo ovarian surgery 3, 4.
  • A review of infertility diagnosis and management highlights the importance of identifying the underlying cause of infertility, with endometriosis being a common cause of infertility in women 5.
  • A randomized controlled trial found that 3-months of GnRH agonist treatment before IVF did not improve clinical pregnancy rates in infertile patients with endometriosis, suggesting that this treatment approach may not be beneficial for all patients 6.

Factors Influencing Fertility Outcomes

  • Ovarian reserve is a critical factor in determining fertility outcomes after endometrioma removal or treatment, with patients with low ovarian reserve being at higher risk of poor fertility outcomes 2, 6.
  • The severity of endometriosis also plays a role in determining fertility outcomes, with more severe disease being associated with poorer fertility outcomes 2, 3.
  • Surgical approach and technique can also influence fertility outcomes, with goal-directed surgical treatment being recommended for patients with endometriosis who wish to conceive 2.

Treatment Options

  • GnRH agonists and antagonists are commonly used in the treatment of endometriosis, with these protocols being used to induce ovulation or suppress ovarian function during IVF cycles 3, 4, 6.
  • IVF is a common treatment option for patients with endometriosis-related infertility, with the success of IVF being influenced by factors such as age, ovarian reserve, and the severity of endometriosis 5, 6.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

A Practical Approach to Fertility Considerations in Endometriosis Surgery.

Obstetrics and gynecology clinics of North America, 2022

4
Research

Use of GnRH antagonists in the treatment of endometriosis.

Reproductive biomedicine online, 2002

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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