How does an endometrioma affect fertility in women of reproductive age?

Effect of Endometrioma on Fertility

Direct Impact on Reproductive Capacity

Endometriomas impair fertility through multiple mechanisms including ovarian reserve damage, altered ovarian physiology, and reduced oocyte quality, with approximately 50% of women with endometriosis experiencing infertility. 1, 2

Mechanisms of Fertility Impairment

Endometriomas damage fertility through several pathways:

• Ovarian reserve depletion occurs from the endometrioma itself through spatial occupation and local inflammatory reactions affecting surrounding ovarian cortex 3, 4
• Oocyte quality deterioration results from the toxic microenvironment created by the endometrioma 3
• Ovarian physiology disruption impairs normal follicular development, though spontaneous ovulation typically remains intact 5
• Associated pelvic pathology is common, with endometriomas significantly associated with deep infiltrating endometriosis (44% of cases), ovarian adhesions, and pouch of Douglas obliteration 2

Clinical Fertility Outcomes

The actual clinical impact on fertility outcomes shows important nuances:

• Spontaneous conception is not significantly impaired by the endometrioma alone, despite measurable biological effects on ovarian reserve 5
• IVF/ICSI outcomes (implantation rates, clinical pregnancy rates, live birth rates) are similar between women with untreated endometriomas and controls 5, 4
• Natural conception rates can be enhanced by surgical removal at any stage of endometriosis, based largely on uncontrolled data 6

Surgical Management Considerations

Impact of Surgery on Ovarian Reserve

Surgical excision of endometriomas consistently reduces ovarian reserve markers, particularly anti-Müllerian hormone (AMH) levels, raising concerns about iatrogenic fertility damage. 2, 5

• Ovarian cystectomy is superior to ablation for reducing endometrioma recurrence and pain symptoms, and increases spontaneous conception rates in subfertile patients 2
• Bipolar hemostasis causes the most ovarian reserve damage and should be avoided during endometrioma surgery 2
• Prior surgery for endometrioma does not improve assisted reproductive technology outcomes and may further decrease the number of oocytes retrieved 4

When to Operate vs. Proceed Directly to ART

The decision algorithm depends on specific clinical parameters:

Proceed directly to ART without surgery when:

• Patient has bilateral endometriomas 6
• History of previous ovarian surgery exists 6
• Ovarian reserve is already compromised (low AMH, elevated FSH, advanced age) 2, 6
• Time to conception is limited due to age or other factors 6

Consider surgery before attempting conception when:

• Patient is young with good ovarian reserve, allowing time for natural conception attempts 6
• Significant pain symptoms are present 6
• Very large endometriomas (>4-6 cm) are present 6
• Hydrosalpinges coexist 6

The optimal strategy for young patients with adequate ovarian reserve is immediate surgery to maximize time for natural conception attempts, rather than defaulting to medical treatment first. 6

Medical Management and ART Optimization

• GnRH analogues administered for 3-6 months before ART improve outcomes, though they do not eradicate endometriotic lesions 6
• Medical treatments (GnRH agonists, progestins) are contraceptive and reduce lesion size but do not prevent adhesion-related complications 7, 6
• Preoperative ovarian reserve assessment is essential before performing ovarian cystectomy to guide surgical decision-making 2

Critical Clinical Pitfalls

• Do not assume surgery improves ART outcomes—current evidence shows similar IVF success rates with or without prior endometrioma surgery 5, 4
• Do not perform routine bilateral endometrioma surgery in women with already compromised ovarian reserve, as this may eliminate remaining fertility potential 6
• Do not delay fertility treatment indefinitely with repeated medical suppression—up to 44% of women experience symptom recurrence within one year despite treatment 1, 7
• Do not overlook associated deep infiltrating endometriosis—preoperative transvaginal ultrasound with expanded protocol or MRI identifies bowel/bladder involvement requiring specialized surgical planning 1, 2