{"paper_id":"5da2367a-f30d-4c8d-aa5e-c760dc6021bf","body_text":"26\nYear XIII • No. 49 (3/2025)\ngynecology\nImpact of surgical treatment \nof ovarian endometrioma  \non fertility\nIntroduction. Ovarian endometrioma is a common \nma ni fes ta tion of endometriosis, and it is associated with \ninfertility. Two main surgical treatments have been de­\nscribed: complete laparoscopic excision and conservative \ntech niques. These methods are substantially different \nre gar ding their efficacy and the risk of afflicting the ovarian \nre serve, therefore their impact on fertility requires a critical \nas ses sment. Objective. The aim of the study was to com­\npare the effects of major surgical methods on fertility in \nwo men diagnosed with ovarian endometrioma. Materials \nand method. A systematic literature review, from 2019 to \n2024, was performed, using PubMed, MEDLINE, Scopus, \nCoch rane, and Google Scholar databases, using keywords \nsuch as “ovarian endometrioma” , “surgical treatment” , \n“fertility” and “ovarian reserve” . Thirty­ eight original studies, \ntwelve meta­ analyses and seven review articles were in clu­\nded. The parameters evaluated were the recurrence rate, \nthe anti­Müllerian hormone level and the spontaneous \npreg nancy rate. Chi­square test and Cox proportional ha­\nzard analysis were the statistical tests applied. Results. The \ncom plete laparoscopic excision significantly reduced the \nre cur rence rates compared to drainage or cyst wall ablation \n(12% versus 33%; p<0.01). However, this procedure caused \na more pronounced decrease of ovarian reserve, measured \nby anti­Müllerian hormone (AMH), with a mean reduction \nof 35% compared to 12% after conservative methods \n(p<0.05). The spontaneous pregnancy rate after excision \nwas approximately 50%, higher than the 27% rate observed \nwith conservative techniques (p<0.05). Conclusions. The \ncom plete laparoscopic excision of ovarian endometrioma \npro vi ded a superior disease control and higher spontaneous \npreg nancy rates compared to conservative methods. How­\never, the fertility benefit must be balanced against the risk of \nre duced ovarian reserve. The choice of the surgical method \nshould be individualized, considering age, cyst size and the \nre pro duc tive desire.\nKeywords: ovarian endometrioma, laparoscopic surgery, \nfertility, ovarian reserve, recurrence\nIntroducere. Endometriomul ovarian este o manifestare frec­\nven tă a endometriozei și o cauză importantă de infertilitate. În \nli te ratura de specialitate sunt descrise două metode chirurgicale \nmajore pentru tratamentul acestora: excizia completă lapa­\nro sco pi că și tehnicile conservatoare. Aceste metode diferă \nsub stan țial în ceea ce privește eficacitatea și riscul de afectare \na rezervei ovariene, iar impactul lor asupra fertilității necesită \no evaluare critică. Scopul lucrării. Analiza comparativă a \nim pac tului metodelor chirurgicale majore asupra fertilității \nfe mei lor cu endometriom ovarian. Materiale și metodă. A \nfost realizată o revizuire sistematică a literaturii publicate în \npe rioa da 2019­2024, utilizând bazele de date PubMed, MEDLINE, \nScopus, Cochrane și Google Scholar. Căutarea a fost efectuată \nfolosind termeni specifici: „endometriom ovarian” , „tratament \nchirurgical” , „rezultate asupra fertilității” și „rezervă ovariană” . \nAu fost selectate 38 de studii originale, 12 metaanalize și şapte \narticole de sinteză, iar parametrii analizați au inclus rata re­\ncurenței, nivelul hormonului antimüllerian și rata sarcinilor \nspontane. Testele statistice aplicate au fost testul Chi­pătrat \nși analiza hazardului proporțional Cox. Rezultate. Analiza \ncom pa rativă a tehnicilor chirurgicale evidențiază că excizia \ncom pletă laparoscopică determină o reducere semnificativă a \nrecurenței, față de drenajul sau ablația peretelui chistului (rata \nrecurenței: 12% versus 33%; p<0,01). Totuși, această procedură \neste asociată cu o scădere mai pronunțată a rezervei ovariene, \nmăsurată prin nivelul AMH, care se reduce, în medie, cu 35% \ndupă excizie, față de o diminuare de aproximativ 12% după \nmetodele conservatoare (p<0,05). Rata sarcinilor spontane \ndupă excizie este semnificativ mai mare, fiind în jur de 50%, \ncomparativ cu 27% după drenaj sau ablație (p<0,05). Concluzii. \nExcizia completă laparoscopică a endometriomului ovarian oferă \nun control superior al bolii și o rată mai mare de sarcini spontane, \ncomparativ cu tehnicile conservatoare. Cu toate acestea, bene­\nfi ciul în ceea ce privește fertilitatea trebuie cântărit în raport cu \nriscul de afectare a rezervei ovariene. Alegerea metodei chi rur­\ngi cale trebuie să fie individualizată, luând în considerare vârsta \npa cientei, dimensiunea chistului și dorința reproductivă.\nCuvinte-cheie: endometriom ovarian, chirurgie \nlaparoscopică, fertilitate, rezervă ovariană, recurență\nAbstract RezumatIrina Burdeniuc,  \nHristiana Caproș,  \nIon Bologan,  \nCorina Darii,  \nIon Burdeniuc\nDepartment of Obstetrics,  \nGynecology and Human  \nReproduction,  \n“Nicolae Testemițanu” State \nUniversity of Medicine  \nand Pharmacy, Chișinău,  \nRepublic of Moldova\nCorresponding author:  \nIrina Burdeniuc \nE-mail: iburdeniuc1@gmail.com\nIntroduction\nEndometriosis is a chronic, estrogen-dependent, in -\nflammatory gynecological disorder defined by the ecto -\npic presence of endometrial glands and stroma outside \nthe uterine cavity. The American College of Obstetri -\ncians and Gynecologists (ACOG) estimates its prevalence \nat 6-10% among women of reproductive age, with rates \nreaching 38% in infertile women and up to 87% in those \nImpactul chirurgiei endometriomului ovarian asupra fertilității\nSuggested citation for this article: Burdeniuc I, Caproș H, Bologan I, Darii C, Burdeniuc I. Impact of surgical treatment of ovarian endometrioma on fertility.  \nGinecologia.ro. 2025;49(3):26-34.\nSubmission date:  \n26.09.2025 \nAcceptance date: \n3.10.2025\n\n27\nginecologia\nYear XIII • No. 49 (3/2025)\nwith chronic pelvic pain (1). The condition substantially \nimpairs the quality of life, presenting with dysmenor -\nrhea, dyspareunia, infertility and chronic pelvic pain.\nOvarian endometriosis, manifesting as endometrio -\nmas, is among the most common and clinically significant \nforms of the disease. Endometriomas are reported in 17-\n44% of patients with endometriosis(2). These cysts, typi-\ncally lined by ectopic endometrial tissue and filled with \nhemolyzed blood, display the characteristic dark brown \nappearance known as “chocolate cysts.” They may involve \none or both ovaries and are associated with subfertility, \nobstetric complications and, rarely, malignant transfor-\nmation, particularly in recurrent or persistent lesions(3).\nSeveral pathogenetic mechanisms have been proposed \nfor endometrioma formation, including retrograde im -\nplantation of endometrial cells on the ovarian surface, \ncoelomic metaplasia and invasion of endometrial tissue \ninto preexisting functional ovarian cysts(4). Nezhat et al. \nhave described two histopathological subtypes: type I \n(primary) endometriomas – small, fibrotic cysts densely \nadherent to the ovarian cortex, and type II (secondary) \nendometriomas, which are larger, thin-walled, and more \neasily resectable (5).\nThe goals of treatment include symptom relief, pre -\nvention of disease progression, fertility preservation and \nrecurrence reduction. Surgical intervention, particularly \nlaparoscopic cystectomy using the stripping technique, \nremains the standard of care for symptomatic or in -\nfertile patients, demonstrating superior outcomes in \nterms of pain control, recurrence rates and spontaneous \nconception compared with drainage or coagulation (6). \nHowever, bilateral cystectomy may compromise ovarian \nreserve, as reflected by postoperative declines in anti-\nMüllerian hormone (AMH) levels (7).\nTo minimize ovarian damage, alternative or adjunc -\ntive techniques such as drainage with subsequent cyst \nwall ablation using CO 2 laser, plasma jet or radiofre -\nquency have been investigated. While these methods \nappear less detrimental to ovarian reserve, they carry \nhigher recurrence rates, necessitating careful risk-ben -\nefit evaluation (8).\nThe optimal management of ovarian endometrio -\nmas should be individualized, considering patient age, \nsymptom severity, reproductive goals, lesion laterality \nand prior treatment response. Given its impact on repro-\nductive prognosis and quality of life, a multidisciplinary, \npatient-centered approach is essential in addressing this \ncomplex condition.\nObjective of the study\nThis study aims to evaluate surgical strategies for the \nmanagement of ovarian endometriomas, with a focus on \ntheir effects on ovarian reserve and fertility outcomes. \nSpecifically, it compares the efficacy and safety of laparo-\nscopic cystectomy with conservative approaches such as \ndrainage and ablation, in order to determine an optimal \ntherapeutic balance between disease control, recurrence \nprevention and preservation of reproductive potential. \nThe study underscores the importance of individualized \ntreatment planning, tailored to patient characteristics, \nclinical context and reproductive goals.\nMaterials and method\nA systematic review of the literature published be -\ntween 2019 and 2024 was undertaken in accordance \nwith established methodological standards. Compre -\nhensive searches were performed in PubMed, MEDLINE, \nScopus, Cochrane Library and Google Scholar using com-\nbinations of the following keywords: “ovarian endome -\ntrioma”, “surgical treatment”, “fertility outcomes”, “ovar-\nian reserve”, “AMH levels”, “laparoscopic cystectomy” \nand “recurrence rate”. Search strategies were adapted \nfor each database, and filters were applied to include \nstudies published in English or Romanian that reported \nclinically relevant outcomes.\nIn total, 38 original studies met the eligibility cri -\nteria, comprising 24 prospective and 14 retrospective \ninvestigations, supplemented by 12 meta-analyses and \nseven narrative reviews. Studies were included if they \ninvolved patients with histopathologically confirmed \novarian endometriosis who underwent documented \nsurgical treatment (laparoscopic cystectomy, drainage \nwith subsequent laser ablation, or other conservative \nprocedures), and if they reported pre- and postopera -\ntive anti-Müllerian hormone (AMH) levels, recurrence \nrates and/or spontaneous pregnancy outcomes. Exclu -\nsion criteria encompassed single case reports, studies \nwithout full-text access and those lacking relevant out -\ncome measures.\nPrimary endpoints included recurrence of endo -\nmetriomas, changes in AMH as a surrogate marker of \novarian reserve and rates of spontaneous conception \nduring postoperative follow-up. Statistical analyses were \nperformed using SPSS and R software. The Chi-square \n(χ²) test was applied for categorical comparisons, while \nCox proportional hazards models were employed to as -\nsess recurrence risk according to surgical modality. The \nstatistical significance was set at p<0.05.\nResults\nThe analysis of the included studies revealed con -\nsiderable heterogeneity with respect to the surgical \ntechniques employed, the characteristics of the study \npopulations and the outcome measures assessed. Among \nthe 38 original studies selected, the majority compared \nthe efficacy of laparoscopic cystectomy (stripping of the \ncyst wall) with more conservative approaches, such as \ndrainage followed by ablation of the cyst wall using CO2 \nlaser, argon plasma, or bipolar electrocoagulation.\nImpact on ovarian reserve\nAcross a total of 31 studies published within the \nanalyzed period, anti-Müllerian hormone (AMH) was \nemployed as the primary biomarker for assessing post -\noperative ovarian reserve. This methodological choice is \njustified by the fact that AMH directly reflects granulosa \ncell function within ovarian follicles, and it is considered \na reliable indicator of reproductive potential.\n\n28\nYear XIII • No. 49 (3/2025)\ngynecology\nThe comparative analysis of the findings demonstrat-\ned that, in patients undergoing laparoscopic cystectomy, \na significant and consistent decline in AMH levels was \nobserved, with the effect being more pronounced in \ncases of bilateral endometriomas or those exceeding \n5 cm in diameter. According to the data summarized \nin Table 1, the average reduction in AMH during the \nfirst three postoperative months ranged between 38% \nand 58%, indicating a substantial short-term impact on \novarian reserve.\nBy contrast, the application of conservative techniques \n(such as laser ablation, plasma energy or radiofrequency) \nFigure 1. Selection and inclusion of studies in the systematic review\nTable 1 Impact of surgical treatment of ovarian endometriomas on ovarian reserve (AMH)\nNo. Study  \n(author, year)\nType of \nintervention Laterality N  \n(patients)\nAMH preop. \n(ng/mL)\nAMH postop. \n(ng/mL)\nAMH decrease \n(%)\n1 Muzii et al., 2020(9) Laparoscopic \ncystectomy Unilateral 72 3.5 2 -43%\n2 Song et al., 2021(10) Cystectomy Bilateral 64 2.8 1.1 -61%\n3 Li et al., 2020(12) Cystectomy Unilateral 90 2.9 1.9 -34%\n4 Ferrero et al., 2022(13) Cystectomy + \nablation Bilateral 77 2.6 1 -61%\n5 Uncu et al., 2019(14) Cystectomy Unilateral 48 3.2 2.0 -37%\n6 Nisolle et al., 2019(15) Plasma ablation Bilateral 51 2.7 2.3 -15%\n38 studies \n(24 prospective, 14 retrospective)\nExclusion criteria included individual case reports,  \nstudies lacking full-text availability and those  \nnot reporting relevant outcome measures.\nEligibility. Studies with histopathologically confirmed ovarian endometriosis, documented \nsurgical intervention, and reporting of pre- and postoperative AMH levels, recurrence rates  \nand/or spontaneous pregnancy rates. \nInclusion criteria: studies published between 2019 and 2024, available in English or Romanian. \nDatabases: Scopus, Cochrane Library, and Google Scholar. \nSearch terms: “ovarian endometrioma” , “surgical treatment” , “fertility outcomes” ,  \n“ovarian reserve” , “AMH levels” , “laparoscopic cystectomy” and “recurrence rate. ”\n\n29\nginecologia\nYear XIII • No. 49 (3/2025)\nwas associated with a significantly smaller decline in \nAMH, estimated at 10-20% within the same follow-up \nperiod. However, although these organ-sparing proce -\ndures better preserve ovarian reserve, they have been \ncorrelated with higher recurrence rates of endometrio -\nmas, thereby raising a clinical dilemma between fertility \npreservation and the risk of relapse.\nAn important aspect highlighted by a subgroup of 14 \nstudies concerns the role of patient age in ovarian func-\ntion recovery following surgery. It was observed that \nwomen under 30 years of age exhibited a significantly \ngreater capacity to restore AMH levels at 6-12 months \npostoperatively compared with women over 35 years of \nage. This difference may be explained by the initially \nhigher ovarian reserve, greater follicular plasticity, and \nenhanced regenerative capacity of ovarian tissue in \nyounger patients(34).\nRecurrence rate\nEvidence derived from 29 clinical studies included in \nthis analysis and summarized in Table 2 demonstrated \nthat the recurrence rate of ovarian endometriomas fol -\nlowing laparoscopic cystectomy generally ranges from \n10% to 20%, with variability primarily attributable to \nthe duration of follow-up, which extended from 12 to \n60 months. These findings reinforce the notion that, \nalthough cystectomy remains the gold standard in the \nsurgical management of endometriomas, the procedure \nis not devoid of medium- and long-term recurrence risk.\nIn contrast, drainage and ablation techniques (includ-\ning CO 2 laser vaporization, plasma energy and radio -\nfrequency) were associated with substantially higher \nrecurrence rates, reaching 35-40% in certain series. This \ndisparity can be explained by the fact that conserva -\ntive approaches, while conferring the advantage of im -\nproved ovarian reserve preservation, frequently leave \nbehind residual viable endometriotic tissue within the \ncyst wall, thereby serving as a potential source for new \nlesion formation.\nAdvanced statistical analysis using the Cox propor -\ntional hazards model further confirmed a significantly \nelevated relative risk of recurrence with conservative \napproaches compared to conventional cystectomy. Spe-\ncifically, a hazard ratio (HR) of 2.3 (95% confidence in -\nterval; 1.6-3.4; p<0.01) was identified, indicating that \norgan-sparing methods are associated with more than \na twofold higher likelihood of lesion recurrence.\nThe data presented in Figure 2 indicate marked differ-\nences in endometrioma recurrence rates according to the \nsurgical technique employed. The lowest recurrence was \ndocumented in patients undergoing cystectomy com -\nbined with in vitro  fertilization (IVF), with a mean rate \nof approximately 9%, followed by simple cystectomy \nat around 13%. These outcomes suggest that complete \nexcision of the endometrioma capsule, particularly when \nincorporated into assisted reproduction protocols, offers \nthe most durable disease control.\nConversely, the highest recurrence rates were ob -\nserved after incomplete or partial procedures, such as \nsimple drainage (mean recurrence: approximately 40%) \nand plasma ablation (28-30%). These findings support \nthe concept that conservative techniques, although less \ndetrimental to ovarian parenchyma, are associated with \nresidual viable endometriotic tissue, thereby conferring \na substantially increased risk of relapse.\nOverall, the comparative analysis underscores that \nminimally invasive or incomplete approaches (drain -\nage, ablation modalities) are consistently inferior to \ncomplete excision in terms of recurrence prevention, \nlimiting their role as definitive therapeutic strategies. \nNonetheless, such techniques may retain selective ap -\nplicability in young patients with diminished ovarian \nreserve or in those prioritizing preservation of healthy \novarian tissue, provided that the risk-benefit profile is \ncarefully weighed.\nThe comparative analysis of the studies included in \nthis systematic review highlights a significant differ -\nence in postoperative recurrence rates according to the \nTable 2 Recurrence rate of ovarian endometriomas after surgical treatment\nNo. Author, year Intervention Laterality N Follow-up \n(months)\nRecurrence rate  \n(%)\n1 Muzii et al., 2020(9) Laparoscopic cystectomy Unilateral 72 36 14\n2 Song et al., 2021(10) Cystectomy Bilateral 64 48 18\n3 Li et al., 2020(12) Cystectomy Unilateral 90 30 12\n4 Ferrero et al., 2022(13) Cystectomy + coagulation Bilateral 77 60 22\n5 Nisolle et al., 2019(15) Plasma ablation Bilateral 51 18 28\n6 Vercellini et al., 2019(18) Cystectomy + hormone therapy Unilateral 55 48 8\n7 Wang et al., 2019(19) Radiofrequency ablation Bilateral 66 18 26\n\n30\nYear XIII • No. 49 (3/2025)\ngynecology\nlaterality of endometriomas. As shown in Figure 3, the \nmean recurrence rate for unilateral lesions was approxi-\nmately 15.4%, whereas for bilateral endometriomas it \nreached 24%.\nThis difference may be explained by several clini -\ncal and technical factors. Bilateral endometriomas are \nassociated with more extensive ovarian involvement, \nwhich can complicate surgical management and increase \nthe likelihood of residual disease. Furthermore, inter -\nventions involving both ovaries require more cautious \npreservation of healthy parenchyma, thereby limiting \nthe radicality of excision. In addition, bilateral disease \nmay represent a more aggressive or advanced form of \nendometriosis, inherently associated with a higher risk \nof recurrence.\nThese findings underscore the need for careful preop-\nerative assessment and an individualized surgical strat -\negy, particularly in patients with bilateral disease, where \nthe balance between surgical radicality and preservation \nof ovarian reserve must be judiciously considered.\nFigure 3. Mean recurrence rate stratified by surgical laterality\nFigure 2. Average recurrence rate according to the type of surgical intervention for ovarian endometriomas\n\n31\nginecologia\nYear XIII • No. 49 (3/2025)\nFertility outcomes\nA total of 21 studies, summarized in Table 3, evalu -\nated spontaneous pregnancy rates following surgical \ntreatment of endometriomas. The results suggest that \npatients treated with laparoscopic cystectomy achieved \nsignificantly higher spontaneous pregnancy rates, rang-\ning from 35% to 50%, compared with those who under-\nwent conservative techniques (ablation, drainage), where \nrates ranged from 20% to 30%.\nHowever, the data also reveal an important clinical \nnuance: in patients with low preoperative AMH levels \nor already compromised ovarian reserve, conservative \nprocedures may represent a reasonable option. Although \nassociated with higher recurrence rates, such approaches \nminimize additional loss of healthy ovarian tissue and \nmay thus preserve, at least partially, short-term repro -\nductive potential.\nIn addition, nine studies included patients under -\ngoing assisted reproductive technology (IVF/ICSI) and \nassessed the impact of surgical treatment on controlled \novarian response. Findings indicated that untreated en-\ndometriomas may be associated with a reduced num -\nber of oocytes retrieved, possibly due to mechanisms \ninvolving ovarian architectural distortion and chronic \nlocal inflammation. Nevertheless, surgical excision \n– particularly in bilateral cases – may exert an even \nmore pronounced effect through inadvertent removal \nof primordial follicles and disruption of cortical vascu -\nlarization. This phenomenon leads to a further decline \nin ovarian reserve, reflected in a diminished ovarian \nresponse to stimulation and, consequently, lower rates \nof mature oocyte retrieval.\nAccording to Figure 4, cystectomy alone is associated \nwith a mean spontaneous pregnancy rate ranging from \n39% to 46%, demonstrating greater effectiveness com -\npared with conservative techniques. Ablation methods \n(laser, plasma, radiofrequency) show lower efficacy with \nrespect to fertility, with reported rates between 28% \nand 31%. Combined approaches (cystectomy plus abla -\ntion) appear to yield the most favorable reproductive \noutcomes, with rates reaching up to 48.3%.\nThe comparative analysis of the 20 included stud -\nies revealed significant differences in postoperative \nspontaneous pregnancy rates according to the surgical \ntechnique employed for the management of ovarian en-\ndometriomas. The mean pregnancy rate among patients \ntreated with ablation was 29.2%, representing the lowest \nof the approaches evaluated. By contrast, cystectomy \nwas associated with a mean pregnancy rate of 41.2%, \nsuggesting superior benefit in restoring fertility, albeit \nNo. Study Treatment method Spontaneous pregnancy rate (%)\n1 Mehdizadeh et al., 2022(22) Ablation 31.2\n2 Yoshino et al., 2021(23) Cystectomy 45.6\n3 Barri et al., 2020(24) Ablation 28\n4 Pundir et al., 2023(25) Cystectomy + ablation 48.3\n5 Muzii et al., 2022(9) Cystectomy 4 0.1\n6 Huang et al., 2023(26) Ablation 29.5\n7 Vercellini et al., 2020(18) Cystectomy + ablation 46.2\n8 Tsolakidis et al., 2021(27) Cystectomy 43.3\n9 Ghezzi et al., 2019(28) Ablation 27. 8\n10 Ferrero et al., 2023(13) Cystectomy 41.5\n11 Canis et al., 2022(29) Cystectomy 38.9\n12 Nisolle et al., 2019(15) Cystectomy + ablation 47. 2\n13 Audebert et al., 2019(30) Ablation 30.4\n14 Song et al., 2021(10) Cystectomy 43.9\n15 Ceccaroni et al., 2022(32) Cystectomy 40.7\nTable 3 Surgical management of ovarian endometriomas and spontaneous fertility outcomes\n\n32\nYear XIII • No. 49 (3/2025)\ngynecology\nat the expense of a higher risk of healthy ovarian tissue \nloss. The highest pregnancy rate, 47.7%, was observed \nin the group managed with combined techniques (cys -\ntectomy plus ablation), indicating a potential optimal \nbalance between therapeutic efficacy and preservation \nof ovarian function.\nThese findings underscore the importance of a per -\nsonalized approach that accounts not only for disease \nseverity and bilaterality but also for the patient’s re -\nproductive goals. Combined surgical strategies appear \nto represent a promising alternative for optimizing \nreproductive outcomes; however, additional prospec -\ntive, randomized studies are required to confirm their \nsuperiority.\nDiscussion\nThe findings presented in the reviewed studies high -\nlight a major clinical dilemma in the management of \novarian endometriomas: the need to achieve effective \ndisease control while simultaneously preserving ovarian \nfunction and maintaining fertility.\nFertility preservation represents a fundamental ob -\njective in all gynecological interventions, particularly \namong young women of reproductive age who desire a \nfuture pregnancy. The impact of surgical procedures on \novarian reserve is well documented, and the loss of ovar-\nian function may be irreversible. Consequently, contem-\nporary therapeutic strategies emphasize the identifica -\ntion of effective solutions that allow optimal treatment \nof endometriomas, reduction of recurrence risk and, at \nthe same time, preservation of reproductive potential.\nOocyte or embryo cryopreservation constitutes the \nmost reliable and well-documented fertility preserva -\ntion strategy for patients with ovarian endometriomas, \nparticularly in bilateral cases or in women with low \nAMH levels. Studies have demonstrated that patients \nwho underwent cryopreservation prior to surgery had \nreproductive outcomes comparable to women without \nendometriomas. International societies, such as ESHRE, \nrecommend the integration of this method in women at \nhigh risk of diminished ovarian reserve (36).\nIntraoperative hemostasis plays a critical role in \nmaintaining ovarian integrity. The use of bipolar elec -\ntrocoagulation is associated with greater destruction \nof ovarian tissue compared with suturing techniques \nor laser application. Daniilidis et al. demonstrated that \nthe use of hemostatic sutures leads to a significantly \nsmaller postoperative decline in AMH levels, confirming \nthe superiority of this approach in preserving ovarian \nfunction(11). \nPostoperative hormonal therapy, including GnRH \nanalogs, combined oral contraceptives or progestins \n(e.g., dienogest), contributes to reducing endometrioma \nrecurrence and stabilizing ovarian function. A meta-\nanalysis showed that suppressive hormonal therapy ad-\nministered for at least six months significantly reduces \nthe risk of recurrence and allows the postponement of \nassisted reproductive technology (ART) interventions(37).\nFor patients with persistent infertility or preexist -\ning diminished ovarian reserve, an integrated approach \n– consisting of limited excision of the endometrioma \nfollowed by prompt in vitro  fertilization (IVF) – may \nincrease the chances of achieving pregnancy. Studies \nsuggest that live birth rates are comparable between \npatients in whom the endometrioma was excised and \nthose in whom it was left in situ , although the risk of \nreduced ovarian reserve following surgery remains a \ncritical factor to consider (38).\nRecent studies indicate that the use of anti-adhesion \nagents in patients with endometriosis following surgical \nFigure 4. Mean rate of spontaneous pregnancies by treatment modality\n\n33\nginecologia\nYear XIII • No. 49 (3/2025)\nintervention significantly decreases the risk of pelvic \nadhesion formation, a factor recognized for its nega -\ntive impact on fertility. By preventing adhesions, these \nagents help maintain ovarian and tubal mobility, thereby \nsafeguarding the patient’s reproductive capacity and \noptimizing both spontaneous fertility and the success \nof assisted reproductive procedures (35).\nConclusions\nOvarian endometriomas represent a frequent and \nchallenging manifestation of endometriosis, with major \nimplications for reproductive health and the quality of \nlife of women of reproductive age. Surgical treatment \nremains an essential component in the management of \nsymptomatic or infertile patients; however, the choice \nof surgical technique requires a careful balance between \ntherapeutic efficacy and preservation of ovarian reserve.\nFindings from this systematic review indicate that \nlaparoscopic cystectomy is associated with lower recur -\nrence rates and higher spontaneous pregnancy rates \ncompared with conservative approaches, but at the cost \nof a more pronounced negative impact on ovarian re -\nserve, as reflected by decreased AMH levels. Alternative \nmethods such as ablation or vaporization, while less det-\nrimental to ovarian function, demonstrate reduced ef -\nficacy in preventing recurrence and achieving pregnancy.\nThe analyzed data suggest that combined approaches, \nwhich integrate tissue-preserving techniques with the \nexcision of pathological tissue, may provide superior \nreproductive outcomes and a favorable compromise be-\ntween radicality and conservation. Furthermore, the \nlaterality of disease (unilateral versus bilateral) signifi -\ncantly influences both the recurrence risk and ovarian \nfunction loss, underscoring the importance of individu-\nalized preoperative assessment.\nFertility preservation must remain a central objec -\ntive in all gynecological interventions performed in \nwomen of reproductive age. Contemporary strategies \nfor safeguarding reproductive potential include several \ncomplementary approaches. First, oocyte and embryo \ncryopreservation represent an effective prophylac -\ntic measure, particularly for patients with bilateral \nendometriomas or low anti-Müllerian hormone levels. \nSecond, fertility-sparing surgical techniques, such as \npartial excision combined with laser vaporization, can \nlimit cortical ovarian damage while maintaining tissue \nintegrity.\nIn addition, the application of protective hemostatic \nstrategies – such as microsurgical suturing – minimizes \ntrauma and tissue destruction compared with electro -\ncoagulation, thereby contributing to ovarian reserve \npreservation. Postoperative hormonal therapy, including \nGnRH analogs, combined oral contraceptives or pro -\ngestins, further reduces recurrence risk and stabilizes \novarian function.\nFor patients with persistent infertility or compro -\nmised ovarian reserve, combining surgical management \nwith assisted reproductive technologies represents an \neffective strategy, optimizing reproductive outcomes. \nMoreover, the use of anti-adhesion barriers prevents the \nformation of pelvic adhesions, thereby reducing fertility-\nimpairing complications and indirectly contributing to \nreproductive preservation.\nBy integrating these measures into an individual -\nized, multidisciplinary and evidence-based approach, \nclinicians can ensure both optimal disease control and \npreservation of fertility in patients with ovarian endo -\nmetriomas. The evidence highlights that a comprehen -\nsive strategy – combining surgery, preventive measures \nand assisted reproductive interventions – maximizes \nreproductive success while minimizing long-term risks. \nThis requires an individualized evaluation of each pa -\ntient, taking into account the age, the hormonal status, \nendometrioma size and location, and reproductive inten-\ntions, to determine the optimal balance between disease \ncontrol and fertility preservation.\nIn conclusion, the management of ovarian endome -\ntriomas must be personalized, evidence-based and \nfertility-oriented, integrating surgical and nonsurgical \nmodalities, reproductive planning and patient coun -\nseling. Such an approach ensures not only optimal dis -\nease control but also the maximization of reproductive \npotential, offering patients a realistic chance of achiev -\ning pregnancy, whether spontaneous or assisted.   n\n1. Practice Bulletin No. 114: Management of Endometriosis. 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Int J Environ Res Public Health. \n2022;19(10):6162. \nReferences\nReclamă GIN(49)0105","source_license":"CC0","license_restricted":false}