What is the recommended treatment for a patient with a 5cm endometrioma on the right ovary who is trying to conceive without In Vitro Fertilization (IVF)?

Treatment of 5cm Endometrioma in Patient Trying to Conceive Without IVF

For a patient with a 5cm endometrioma who is trying to conceive and refuses IVF, laparoscopic cystectomy (complete excision of the endometrioma wall) is the recommended treatment, as it provides the best balance of pain relief, pregnancy rates, and lower recurrence compared to other surgical approaches. 1, 2

Rationale for Surgical Intervention

• Endometriomas do not respond to medical treatment, which only addresses associated pain symptoms but does not improve fertility outcomes or eliminate the cyst. 1
• Surgery is preferred over expectant management when fertility is the goal, as endometriomas themselves damage ovarian reserve and impair fertility independent of any surgical intervention. 1, 2
• At 5cm size, the endometrioma may interfere with follicle access during any future assisted reproductive procedures and likely impairs ovarian response to natural ovulation. 3

Surgical Approach: Laparoscopic Cystectomy

• Laparoscopic excision of the endometrioma wall is the procedure of choice, offering superior outcomes in terms of spontaneous pregnancy rates and lower recurrence rates compared to ablative techniques or drainage alone. 1, 2
• The surgical technique must be meticulous, particularly respecting the ovarian hilum to minimize damage to normal ovarian tissue and preserve ovarian reserve. 4
• Hemostasis should be achieved spontaneously or with minimal bipolar coagulation, as excessive use of bipolar energy damages ovarian reserve; ovarian suture is an alternative hemostatic option. 4
• A hybrid technique combining cystectomy with vaporization (laser or plasma energy) at the ovarian hilum may be considered to minimize damage to healthy ovarian tissue while ensuring complete disease removal. 4

Critical Surgical Considerations

• All extra-ovarian endometriotic lesions must be identified and treated during the same procedure, as these contribute to infertility and pain. 4
• Anti-adhesion products should be applied at the conclusion of surgery to minimize postoperative adhesion formation. 4
• Cystectomy carries a risk of diminished ovarian reserve but has the lowest recurrence rate (compared to ablation or sclerotherapy), making it the optimal choice for a patient desiring pregnancy. 2

Alternative Surgical Options (Less Preferred)

• Ablation with laser or plasma energy appears to have minimal effect on ovarian reserve with low recurrence rates, but cystectomy remains superior for obtaining tissue diagnosis and ensuring complete disease removal. 2
• Sclerotherapy has mixed results regarding both ovarian reserve preservation and recurrence rates, making it a less reliable option. 2

Postoperative Management

• Postoperative medical treatment with hormonal suppression decreases recurrence and should be initiated after the patient completes childbearing or if conception does not occur within a reasonable timeframe. 4
• Medical treatment does not improve fertility outcomes and should not be used in women actively trying to conceive. 5
• Fertility preservation counseling should be offered preoperatively, particularly regarding the risk of diminished ovarian reserve from both the disease and surgery. 2, 6

Important Pitfalls to Avoid

• Do not perform preoperative medical treatment, as it has not been shown to improve surgical outcomes or fertility and only delays definitive management. 4
• Avoid exclusive coagulation using bipolar energy, as this significantly damages ovarian reserve without providing the benefits of complete cyst wall removal. 4
• Do not recommend IVF as first-line when the patient refuses it and has a surgically treatable condition that impairs natural fertility. 1
• Ensure surgery is performed by an experienced surgeon with expertise in endometriosis, as surgical technique directly impacts both ovarian reserve preservation and recurrence rates. 6