From the Research
There is no conclusive evidence to suggest that removal of endometriomas immediately increases fertility rates, and in fact, the current evidence points towards a potential decrease in ovarian reserve after surgery. The most recent and highest quality study, published in 2020, suggests that surgical excision of endometriomas may not improve fertility outcomes and may even decrease the number of oocytes retrieved in assisted reproductive technology cycles 1. Another study from 2018 also found that prior surgical intervention does not improve assisted reproductive technology outcomes, and that controlled ovarian hyperstimulation does not affect quality of life or pain symptoms 2.
Key Points to Consider
- The presence of endometriomas can impair ovarian reserve and alter ovarian functional anatomy, but surgical removal may not necessarily improve fertility outcomes 2, 1.
- The risk of diminished ovarian reserve from surgery should be carefully considered, particularly for women with bilateral or recurrent endometriomas, those with already compromised ovarian function, or women of advanced reproductive age 3, 4.
- The decision to perform surgery should balance the possible risks of damaging the ovarian reserve with the advantages of surgery in terms of satisfactory pain relief rates and pregnancy rates, and of obtaining tissue specimen for ruling out the rare cases of unexpected ovarian malignancy 5.
Clinical Implications
- For women with endometrioma-associated infertility, the current evidence does not support the postponement of infertility treatment in favor of surgery, except in cases with severe symptoms or to improve follicle accessibility 2.
- In cases of mild- to moderate-stage endometriosis, intrauterine insemination with ovarian stimulation after surgical treatment may increase the likelihood of pregnancy, but this should be carefully weighed against the potential risks of surgery 4.
- A multidisciplinary approach should be taken to determine the prioritization of treatment modalities, including surgical treatment and assisted reproduction methods such as in vitro fertilization, considering the risk of cancer, complications after pregnancy, and infection during oocyte retrieval 4.