{"paper_id":"645e7158-814c-48cd-90e8-a46142d2db25","body_text":"RESEARCH Open Access\n© The Author(s) 2025. Open Access  This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 \nInternational License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you \ngive appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the \nlicensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or \nother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the \nmaterial. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or \nexceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit  h t t p  : / /  c r e a  t i  \nv e c  o m m  o n s .  o r  g / l  i c e  n s e s  / b  y - n c - n d / 4 . 0 /.\nÖzkan et al. BMC Pregnancy and Childbirth          (2025) 25:824 \nhttps://doi.org/10.1186/s12884-025-07988-0\nBMC Pregnancy and Childbirth\n*Correspondence:\nHalis Doğukan Özkan\nhdogukanozkan@gmail.com\n1Department of Obstetrics and Gynecology, Ankara Lösante Children and \nAdult Hospital, Ankara 06830, Turkey\n2Department of Perinatology, Ankara Etlik City Hospital, Ankara, Turkey\n3Department of Obstetrics and Gynecology, Ankara Etlik City Hospital, \nAnkara, Turkey\n4Department of Obstetric and Gynecology, Ankara Etlik Zübeyde Hanım \nTraining and Research Hospital, Ankara, Turkey\nAbstract\nBackground Endometriomas may adversely affect fertility; however, the necessity of its surgical management \nis a controversial subject. The aim of this study was to compare the time to conception, mode of conception, \nand pregnancy outcomes between two groups of patients diagnosed with endometriomas: those managed \nconservatively and those who laparoscopic cystectomy.\nMethods This retrospective study included patients diagnosed with endometriomas who are seeking pregnancy. All \npatients who conceived were categorized into the following two groups: those who underwent surgical intervention \nfor treating endometriomas and those who did not. Demographic data, time to conception (months), and pregnancy \noutcomes were recorded.\nResults A total of 5444 patients were screened, and data for 226 patients meeting the inclusion criteria were \nanalyzed (80 in the surgical group and 146 in the nonsurgical group). Age and body mass index were comparable \nbetween the groups. Time to conception (months) was significantly different between the surgical and nonsurgical \ngroups (24 [12–51] vs. 18 [6.5–36], p = 0.030). Further, the probability of conception over time was significantly higher \nin the nonsurgical group (p = 0.002). The live birth rate was 78.8% (n = 63) in the surgical group and 69.2% (n = 101) in \nthe nonsurgical group, with no significant difference between the groups (p = 0.220).\nConclusions Endometrioma surgery was associated with a longer time to conception but had no effect on live birth \nrate or delivery outcome. Patient selection is critical and further investigation is needed to determine who will benefit \nfrom surgery.\nKeywords Endometrioma, Time to pregnancy, Fertility\nThe impact of surgical intervention on time \nto conception and obstetric outcomes \nin women with endometriomas: a retrospective \ncohort study\nHalis Doğukan Özkan 1* , Merve Ayas Özkan2 , Ayşe Gizem Yıldız3 , Neval Çayönü Kahraman2  and  \nYaprak Engin-Üstün4\n\nPage 2 of 10\nÖzkan et al. BMC Pregnancy and Childbirth           (2025) 25:824 \nBackground\nEndometriosis is defined as the presence of endome -\ntrium-like tissue outside the uterine cavity. It is a chronic \ncondition affecting approximately 10% of women of \nreproductive age [ 1]. Retrograde menstruation is con -\nsidered the most common potential cause for its patho -\ngenesis [ 2]. The ovaries are the most commonly known \nlocation for the development of endometriosis, where it \npresents as an endometrioma. Endometriomas are found \nin 17–44% of patients with endometriosis and are con -\nsidered an indicator of advanced disease [ 3, 4]. Endome-\ntriomas can impair fertility; however, they do not always \ncause infertility [5].\nThere is no consensus on the optimal management \nstrategy for endometriomas in patients planning preg -\nnancy. Depending on the patients’ symptoms and clinical \npresentations, endometriomas may be managed conser -\nvatively or surgically [ 5]. However, surgical treatment \ncarry potential risks, such as reduced ovarian reserve [ 6]. \nSome studies have suggested that surgical treatment of \nendometriomas may improve spontaneous conception \nrates [ 7, 8]. According to the revised American Society \nfor Reproductive Medicine (rASRM) guidelines, opera -\ntive laparoscopic surgery may enhance the likelihood of \nsuccessful conception in patients with stage 1–2 endome-\ntriosis [9, 10]. Surgical intervention remains a controver -\nsial alternative in patients with endometriosis due to the \nuncertainty of the balance between the risk of reduced \novarian reserve and the possibility of a favorable impact \non pregnancy by the reduction in levels of inflamma -\ntory factors [ 11, 12]. Because of this uncertainty, surgery \nis often recommended for patients with considerable \nsymptoms, such as pain or mass effect, that compromise \ntheir quality of life [ 5, 12]. Among surgical options, lapa -\nroscopic cyst excision is preferred over other techniques, \nas it is associated with a lower risk of recurrence [ 13– 16] \nand higher pregnancy rates [13, 14, 16].\nSeveral studies have compared pregnancy rates and \noutcomes between patients with endometriomas who are \ntreated conservatively and those treated surgically. The \nachievement of pregnancy and the time to conception are \ncrucial in women desiring pregnancy. Time to concep -\ntion is also a critical clinical parameter for clinicians to \nprovide appropriate counseling and plan individualized \ntreatment strategies. Although previous studies [ 17, 18] \nhave evaluated time to conception following different \nsurgical techniques for endometriomas, to our knowl -\nedge, no study has directly compared time to conception \nbetween surgically and nonsurgically managed patients. \nThe aim of this study was to compare the time to con -\nception, mode of conception, and pregnancy outcomes \nbetween the patients with endometriomas who were \nmanaged conservatively and those who underwent surgi -\ncal intervention.\nMaterials and methods\nSample collection\nThis retrospective cohort study was conducted between \nJanuary 2014 and December 2023 at the Ankara Etlik \nZübeyde Hanım Gynecology and Obstetrics Training \nand Research Hospital among women diagnosed with \nendometriomas who subsequently conceived. This hos -\npital is one of Turkey’s most specialized women’s health \nand obstetrics centers, with approximately 15,000 births \nannually. Ethical approval for the study was obtained \nfrom the Etlik Zübeyde Hanım Training and Research \nHospital Ethics Committee (decision number 2024/12, \ndated 09.10.2024). The study was conducted in accor -\ndance with the Declaration of Helsinki.\nPatients who wished to conceive and who visited for \nroutine preconceptional gynecologic examinations were \nconsidered for the study. The patients selected for the \nstudy were those diagnosed with endometriomas dur -\ning routine examinations and actively planning preg -\nnancy. A total of 226 patients aged 18–35 years who were \ndiagnosed with endometriomas, continued unprotected \nintercourse without interrupting the conception process, \nand eventually became pregnant were included in the \nstudy. All patients who met the inclusion and exclusion \ncriteria were consecutively enrolled during the specified \nstudy period. Patients with infertility; who interrupted \npregnancy planning; or underwent laparotomic sur -\ngery, laparoscopic ablation, or drainage were excluded. \nPatients with severe systemic disease and incomplete \nmedical records were also excluded. Further, patients \nwith an antral follicle count (AFC) < 5 at the first pre-\npregnancy evaluation (during the ultrasound at the time \nof endometrioma diagnosis) were excluded. In our clinic, \nthe AFC count is routinely examined at the first precon -\nceptional visit. The AFC limit was selected according to \nEuropean Society of Human Reproduction and Embryol -\nogy (ESHRE) guidelines [19].\nPatients who were planning pregnancy and were diag -\nnosed with endometriomas during routine preconception \nexaminations were included, based on the study criteria \nstated above (n = 226). Group 1 consisted of patients who \nwere managed conservatively without planned surgery \nand subsequently conceived (nonsurgical group, n = 146). \nGroup 2 included patients who underwent surgical inter -\nvention for endometriomas and later conceived (surgical \ngroup, n = 80). Diagnosis was confirmed through histo -\npathological examination in the surgical group. In the \nnonsurgical group, transvaginal ultrasonography served \nas the principal imaging technique for diagnosis. Mag -\nnetic resonance imaging (MRI) was conducted selectively \nat instances when the ultrasound results were incon -\nclusive. Diagnostic criteria included low-level internal \nechoes, multilocular cystic structures, and hyperechoic \nfoci within the cyst wall [ 20, 21]. Only patients who \n\nPage 3 of 10\nÖzkan et al. BMC Pregnancy and Childbirth           (2025) 25:824 \nunderwent laparoscopic cystectomy were included in the \nsurgical group. All surgical procedures were planned and \nperformed by experienced surgeons specializing in endo -\nmetrioma and infertility. Only patients actively attempt -\ning to conceive were selected.\nFor both groups, maternal demographic characteris -\ntics, obstetric history, preconception body mass index \n(BMI), cancer antigen-125 (CA-125) levels (U/mL), \nendometrioma ultrasound findings, time to conception \n(months) after diagnosis or surgery, mode of concep -\ntion, gestational age at delivery, mode of delivery, and \npregnancy complications in viable pregnancies were \nrecorded. Time to conception was measured from the \nfirst medical consultation for pregnancy planning in the \nnonsurgical group. In the surgical group, it was measured \nbeginning from two menstrual cycles after surgery (the \nrecommended contraception period). In clinical prac -\ntice, patients are advised to avoid pregnancy for two \nmenstrual cycles after surgery to allow adequate heal -\ning and recovery. Therefore, in the surgical group, time \nto conception was measured beginning from two men -\nstrual cycles after surgery. Pregnancy complications \nrecorded were placenta previa, gestational hypertension, \ngestational diabetes mellitus, multiple pregnancy, intra -\nhepatic cholestasis of pregnancy, polyhydramnios, oligo -\nhydramnios, fetal growth retardation, premature rupture \nof membranes, preterm premature rupture of mem -\nbranes, and postpartum neonatal death. As the number \nof cases was not adequate for comprehensive analysis \nof individual complications, pregnancy complications \nwere combined and statistically compared between the \ntwo groups (presence and absence of any complication). \nDemographic data, maternal obstetric history, and other \nparameters were retrospectively obtained from the hos -\npital records.\nStatistical analysis\nData analysis was performed using Jamovi version 2.3.38 \n(www.jamovi.org) and Python version 3.11. The normal -\nity of continuous variables was assessed using the Sha -\npiro-Wilk test, histograms, and Q–Q plots. Continuous \nvariables were presented as mean ± standard deviation \nor median with interquartile range (25th–75th percen -\ntile), depending on the distribution. Categorical variables \nwere summarized as counts and percentages. The Mann-\nWhitney U test was used to compare continuous vari -\nables between the two groups. The Chi-square (χ2) test \nwas applied to compare categorical variables. Kaplan–\nMeier analysis and survival curves were used to visualize \nthe time to conception between surgical and non-surgi -\ncal groups. Since all participants eventually conceived, \nno censoring was applied in the Kaplan–Meier analysis. \nThe log-rank test was used to compare survival curves \nbetween the groups. A multivariate linear regression \nanalysis was conducted to evaluate the impact of poten -\ntial predictors on time to conception (in months). The \nindependent variables included age, gravida, parity, pre-\npregnancy BMI, cyst size measured by ultrasound, use \nof ART, and surgical treatment for endometrioma. The \nresults of the regression analysis were reported as coef -\nficients (β) with corresponding standard errors, t-values, \nand p-values. A p-value of < 0.05 was considered statis -\ntically significant unless otherwise specified. There were \nno missing data for the variables analyzed in this study; \nthus, no imputation methods were required.\nResults\nDuring the study period, a total of 226 patients with \nendometriomas who met the inclusion criteria and con -\nceived were included in the analysis. Of these, 80 patients \nwho underwent laparoscopic surgery comprised the sur -\ngical group, and 146 patients who were managed con -\nservatively comprised the nonsurgical group. The study \nflowchart (Fig. 1) provides details of the patient selection \nprocess.\nA total of, 226 patients were included in the study. The \nmedian age of the patients who participated in the study \nwas 26 years (23–29). The median gravida was 1 (1, 2), \nand the median pre-pregnancy BMI was 24 (22–27). Of \nthe patients, 146 had not undergone surgery, whereas \n80 had undergone surgery due to endometrioma. A \ntotal of 75.7% of the patients conceived spontaneously. \nThe median time to conception was 24 (8–48) months. \nAmong the patients, 164 (72.1%) had live births, whereas \n62 (27.9%) pregnancies did not reach viability. Other \npatient characteristics are summarized in Table 1.\nWhen the surgical and nonsurgical groups were com -\npared, the median age was 26 years (23–30) in the surgi -\ncal group and 26 years (22–28) in the nonsurgical group, \nwith no statistically significant difference ( p = 0.146). \nSimilarly, the median BMI was 25 (22–28) in the surgical \ngroup and 24 (22–26) in the nonsurgical group. The BMI \nwas not significantly different between groups (p = 0.335). \nHowever, median gravida was 1 (1, 2) in the surgical \ngroup compared to 1 (1, 1) in the nonsurgical group. \nMedian gravida was significantly higher in the surgi -\ncal group ( p = 0.040). The median parity was 1 (0–2) in \nthe surgical group and 0 (0–1) in the nonsurgical group. \nMedian parity was significantly lower in the surgical \ngroup (p = 0.003). History of Cesarean section (CS) was 0 \n(0–0) in the nonsurgical group and 0 (0–1) in the surgical \ngroup. History of CS was significantly higher in the surgi-\ncal group ( p = 0.005). In the surgical group, 28.7% of the \nwomen and in the nonsurgical group, 13.0% had a his -\ntory of previous CS, indicating that not all CS deliveries \nobserved in this study were primary procedures. Other \ncharacteristics of the groups are summarized in Table 2.\n\nPage 4 of 10\nÖzkan et al. BMC Pregnancy and Childbirth           (2025) 25:824 \nThe distribution of cyst sizes according to surgical \nmanagement is presented in Table  3. The proportion \nof patients with cysts > 4  cm was significantly higher \nin the surgical group (87.5%) than in the nonsurgical \ngroup (64.4%) ( p = 0.001; OR: 3.87, 95% CI: 1.84–8.16). \nAlthough the proportion of patients with cysts > 4 cm was \nsignificantly higher in the surgical group, the majority of \npatients (57.3%) with cysts > 4 cm were managed conser -\nvatively. The median time to conception was 24 (12–51) \nin the surgical group and 18 (6.5–36) in the nonsurgical \ngroup. The median time to conception was significantly \nlonger in the surgical group than in the nonsurgical group \n(p = 0.030). The number of live births was 63 (78.8%) in \nthe surgical group and 101 (69.2%) in the nonsurgical \ngroup, with no significant difference between the groups \n(p = 0.220; OR: 1.76, 95% CI: 0.95–3.27). No significant \ndifferences were observed between the groups in terms \nof term/preterm delivery (OR: 0.45, 95% CI: 0.17–1.21), \npregnancy complications (OR: 0.70, 95% CI: 0.35–1.42), \nmode of delivery (OR: 1.13, 95% CI: 0.59–2.14), or mode \nof conception (OR: 1.76, 95% CI: 0.95–3.27). These data \nare presented in Table 3.\nKaplan–Meier survival analysis was used to assess \nthe probability of conception over time. The cumulative \nprobability of conception was significantly higher in the \nnonsurgical group than in the surgical group (Log-rank \ntest, p = 0.002) (Fig. 2). As all patients in the study eventu-\nally conceived, no censoring was applied in the Kaplan–\nMeier analysis.\nA multivariate linear regression analysis was per -\nformed to identify factors influencing the time to con -\nception in women with endometriomas (Table  4; Fig.  3). \nThe analysis indicated that undergoing surgical treat -\nment for endometrioma significantly prolonged the time \nto conception by approximately 14 months (β = 14.027, \np = 0.002). Age, gravida, parity, pre-pregnancy BMI, cyst \nsize, and ART usage did not show statistically significant \nassociations with the time to conception. The overall \nregression model was statistically significant (F = 2.946, \np = 0.006) and explained 5.7% (adjusted R² = 0.057) of the \nvariance in time to conception. A forest plot (Fig.  3) was \ncreated to visually represent the regression coefficients \nand 95% confidence intervals for the variables included in \nthe multivariate linear regression analysis.\nDiscussion\nThe aim of the present study was to evaluate whether \nsurgical treatment affects the time to conception, mode \nof conception, pregnancy outcomes, and mode and time \nof delivery in patients with endometriomas. The primary \nFig. 1 Flowchart of the patient selection\n \n\nPage 5 of 10\nÖzkan et al. BMC Pregnancy and Childbirth           (2025) 25:824 \nfinding of the study was that the time to conception was \nlonger in the group of patients who underwent surgery \nfor endometriomas than that in the patients who did not \nundergo surgery. In contrast, no significant differences \nwere observed between the surgical and nonsurgical \ngroups with respect to mode of conception, pregnancy \noutcomes, mode of delivery, or timing of delivery. This \nsuggests that while surgical treatment may prolong the \ntime to conception, it does not impact overall preg -\nnancy outcomes after conception. To our knowledge, few \nstudies have investigated time to conception in patients \nwith endometriomas [ 17, 18], and these studies have \ndirectly compared surgical and nonsurgical manage -\nment approaches. These findings highlight the need for \nTable 1 Demographic, laboratory, and other characteristics of \nthe patients\nAge (years), median (IQR 25-75) 26 (23-29)\nGravida, median (IQR 25-75) 1 (0-2)\nParity, median (IQR 25-75) 0 (0-1)\nHistory of NVD, median (IQR 25-75) 0 (0-1)\nHistory of CS, median (IQR 25-75) 0 (0-0)\nPre-pregnancy BMI (kg/m2), median (IQR 25-75) 24 (22-27)\nCA-125, median (IQR 25-75) 39.0 (18.8-82.6)\nUltrasound Findings, n (%)\n Group1 (<4cm) 62 (27.4)\n Group2 (> 4 cm) 164 (72.6)\nEndometrioma Surgery, n (%)\n Non-surgical 146 (64.6)\n Surgical 80 (35.4)\nTime to conception (month), median (IQR 25-75) 24 (8-48)\nMode of conception n (%)\n Spontaneous 171 (75.7)\n Intrauterin inseminastion 16 (7.1)\n In vitro fertilization 39 (17.2)\nPregnancy complications n (%)\n Absent 115 (50.9)\n Present 49 (21.7)\n Abortion 62 (27.4)\nPregnancy outcome n (%)\n Live birth 164 (72.6)\n Abortion 62 (27.4)\nTime of delivery n (%)\n Term birth 139 (61.5)\n Preterm birth 25 (11.1)\n Abortion 62 (27.4)\nMode of delivery, n (%)\n NVD 68 (30.1)\n CS 96 (42.5)\n Abortion 62 (27.4)\nIQR Interquartilerange, NVD Normal vaginal delivery, CS Cesarean Section, BMI \nBody mass index, C A-125 Cancer antigen 125\nTable 2 Comparison of demographic characteristics between \nsurgical and Non-Surgical groups\nNon-surgical \ngroup\nSurgical \ngroup\np\nAge (years)\nMedian (IQR 25–75)\n26 (23–30) 26 (22–28) 0.146\nGravida\nMedian (IQR 25–75)\n1 (0–1) 1 (0–2) 0.040\nParity\nMedian (IQR 25–75)\n0 (0–1) 1 (0–2) 0.003\nHistory of NVD\nMedian (IQR 25–75)\n0 (0–1) 0 (0–1) 0.314\nHistory of CS\nMedian (IQR 25–75)\n0 (0–0) 0 (0–1) 0.005\nPre-pregnancy BMI Median \n(IQR 25–75)\n24 (22–26) 25 (22–28) 0.335\nIQR Interquartilerange, NVD Normal vaginal delivery, CS Cesarean Section, BMI \nBody mass index\nTable 3 Comparison of ultrasound findings, pregnancy \noutcomes, and laboratory results between surgical and non-\nsurgical groups\nNon-\nsurgical \ngroup\nSurgical \ngroup\np OR (95% \nConfi-\ndence \nInterval)\nUltrasound Findings, \nn (%)\n0.001 3.87 \n(1.84-\n8.15) Group1 (<4cm) 52 (35.6) 10 (12.5)\n Group2 (> 4 cm) 94 (64.4) 70 (87.5)\nMode of conception, \nn (%)\n0.073 1.76 \n(0.95-\n3.27) Spontaneous 116 (79.5) 55 (68.8)\n ART 30 25\n Intrauterin \ninseminastion\n11 (7.5) 5 (6.2)\n In vitro fertilization 19 (13) 20 (25)\nPregnancy outcome, \nn (%)\n0.220 0.61 \n(0.32-\n1.15) Live birth 101 (69.2) 63 (78.8)\n Abortion 45 (30.8) 17 (21.2)\nTime of delivery (Live \nbirths only), n (%)\n0.107 0.45 \n(0.17-\n1.21) Term birth 82 (81.2) 57 (90.5)\n Preterm birth 19 (18.8) 6 (9.5)\nPregnancy complica-\ntions (Live births only), \nn (%)\n0.322 0.70 \n(0.35-\n1.42)\n Absent 68 (67.3) 47 (74.6)\n Present 33 (32.7) 16 (25.4)\nMode of Delivery (Live \nbirths only), n (%)\n0.715 1.13 \n(0.59-\n2.14) NVD 43 (42.6) 25 (39.7)\n CS 58 (57.4) 38 (60.3)\nTime to conception \n(month), median (IQR \n25-75)\n18 (6-36) 24 (12-57) 0.030 -\nCA-125 (U/ml), median \n(IQR 25-75)\n39 \n(18-83)\n39.5 \n(20-74.8)\n0.973 -\nOR Odds ratio, IQR Interquartilerange, NVD Normal vaginal delivery, CS Ceserian \nsection, C A-125 Cancer antigen 125\n\nPage 6 of 10\nÖzkan et al. BMC Pregnancy and Childbirth           (2025) 25:824 \nindividualised decision-making regarding surgery in \nendometrioma patients planning pregnancy.\nHemmings et al. (1998) compared different surgi -\ncal techniques in the treatment of endometrioma and \nreported that the time to first pregnancy was shorter in \npatients who underwent laparoscopic fenestration and \ncoagulation compared to that in patients who under -\nwent cystectomy [17]. However, all patients in their study \nunderwent surgical treatment. Further, data regarding \ninfertility history of the patients included the study were \ninsufficient. Surgical techniques and clinical decision-\nmaking have also advanced significantly since 1998; \nhence, the capacity of the study to reflect current clinical \npractice is limited. Similar to this study, Roman et al. [18] \nconducted a retrospective review of patients undergo -\ning ablation using plasma energy surgery in a study of 55 \npatients and did not use a control group. In their study, \n42% patients had a history of infertility. They empha -\nsized that 33 patients wanted pregnancy and 22 patients \nbecame pregnant, and reported that the mean time from \nsurgery to first pregnancy was 7.6 months in patients \nwho conceived. Our study aims to bridge a different gap \nin clinical literature by directly comparing time to con -\nception and pregnancy outcomes between patients who \nunderwent surgical or conservative treatment in newly \nTable 4 Multivariate linear regression analysis of factors affecting \ntime to conception\nVariable Coeffi-\ncient (β)\nStan-\ndard \nError\nt-value p-\nvalue\nConstant 40.352 15.449 2.612 0.010\nAge (years)  −0.609 0.397  −1.534 0.127\nGravida (n)  −3.393 2.745  −1.236 0.218\nParity (n)  −1.089 3.647  −0.299 0.766\nPre-pregnancy BMI (kg/\nm²)\n0.255 0.504 0.505 0.614\nCyst size (cm, by \nultrasound)\n −0.291 0.998  −0.291 0.771\nART usage  −3.870 4.675  −0.828 0.409\nSurgical treatment 14.027 4.376 3.206 0.002\nFig. 2 Changing probability of conception over time in surgical and non-surgical groups\n \n\nPage 7 of 10\nÖzkan et al. BMC Pregnancy and Childbirth           (2025) 25:824 \ndiagnosed patients with no history of infertility and \nplanning pregnancy. Recent studies have shown that \nlaparoscopic cystectomy may increase the likelihood of \nspontaneous conception compared to laparotomy and \nthat cystectomy is associated with lower endometrioma \nrecurrence compared to other laparoscopic techniques. \nThis may be considered as a reason for an increase in the \nlikelihood of spontaneous conception [13, 22– 24].\nIn contrast, studies evaluating patients with endo -\nmetriomas undergoing in vitro fertilization (IVF) have \nreported conflicting results regarding oocyte quality, \nanti-Müllerian hormone (AMH) levels, fertilization rates, \nand pregnancy outcomes after cystectomy [ 5, 25– 27]. \nSome studies have shown that AFC remains unchanged \nafter endometrioma surgery. No significant difference \nwas observed between AFC measured before and after \nsurgery [28, 29]. Conversely, a large-scale study reported \nthat cystectomy may reduce ovarian reserve (as indicated \nby AFC and AMH levels) and pregnancy rates in the long \nterm [30]. These conflicting results may be attributed to \ndifferences in surgeon experience and surgical techniques \nused. Furthermore, these results could be attributed to \ndifferences in the age, infertility history, and baseline \nAMH and AFC values of the selected patients. Only \npatients who underwent laparoscopic cystectomy were \nincluded in this study and patients who underwent lapa -\nrotomy or alternative techniques such as aspiration and \ncoagulation were excluded. The surgical group comprised \npatients with a relatively high pregnancy potential. \nThe patients were young, had no history of infertility, \nactively desired pregnancy, and had a normal AFC count \non routine pre-pregnancy examination. Despite these \ncharacteristics, the time to conception was found to be \nshorter in the nonsurgical group ( p = 0.030). Kaplan–\nMeier analysis and the Log-rank test results showed that \nthe nonsurgical group had a higher conception rate per \nmonthly interval than the surgical group ( p = 0.002). Fur-\nthermore, multivariate linear regression analysis showed \nthat endometrioma surgery was independently linked to \na notably longer time to conception (β = 14.0, p = 0.002). \nThis finding suggests that patients with endometriomas \nwho undergo conservative treatment may have a higher \npotential to conceive in the long term. This advantage \nobserved in the nonsurgical group may be attributed to \nthe preservation of ovarian reserve and the prevention of \npotential adverse effects associated with surgery.\nOne of the possible mechanisms underlying the lon -\nger time to conception in the surgical group may involve \ndirect surgical trauma to the ovarian cortex and a reduc -\ntion in ovarian reserve due to the loss of healthy follicu -\nlar tissue during cystectomy. Additionally, postoperative \ninflammation and the development of intra-abdominal \nadhesions may disrupt the tubo-ovarian association, \npotentially affecting fertility. Further, adhesions caused \nby endometrioma can impair the anatomical relation -\nship between the fallopian tube and ovary, resulting in \nFig. 3 Forest plot of multivariate linear regression analysis: factors influencing time to conception\n \n\nPage 8 of 10\nÖzkan et al. BMC Pregnancy and Childbirth           (2025) 25:824 \ninfertility. Some studies have reported an increase in \npregnancy rates following adhesiolysis for treating endo -\nmetrioma [ 31]. Although reaching a consensus on this \nissue is difficult, our findings suggest that conservative \nmanagement of patients recently-diagnosed with endo -\nmetriomas who do not have a history of infertility and are \nplanning pregnancy may result in more favorable results \nin selected patient groups.\nLive birth rates in patients who underwent surgery \nhave been compared to those in patients who did not. \nA meta-analysis by Wu et al. including 13 studies found \nno significant difference in live birth and pregnancy rates \nbetween patients treated surgically and those treated \nconservatively (OR: 0.83, 95% CI: 0.56–1.22) [ 8]. Simi -\nlarly, large meta-analyses by Hamdan et al. and Nickkho-\nAmiry et al. found no significant difference in live birth \nand pregnancy rates between surgical and nonsurgical \npatients (OR: 0.90, 95% CI: 0.63–1.28; OR: 0.75, 95% CI: \n0.54–1.06, respectively) [ 32, 33]. Hosseinimousa et al. \nalso showed that laparoscopic cystectomy did not affect \nlive birth rates (OR: 1.08, (95% CI 0.51–22.77)) [ 34]. Shi \net al. argued that the adverse effects of endometriosis on \npregnancy outcomes may be mitigated following laparo -\nscopic surgery, and showed an increase in clinical preg -\nnancy rates in the surgically treated group [ 35]. However, \nin the study by Shi et al., the surgical group had a lower \nBMI and consisted of younger patients, which may have \ncontributed to the observed differences. In this study, age \nand BMI were similar between the groups, and no signifi-\ncant difference was found in live birth rates between the \nsurgical and nonsurgical groups (OR: 0.61, 95% CI: 0.32–\n1.15; p = 0.220).\nAn increased risk of pregnancy and fetal complica -\ntions in patients with endometriosis has been highlighted \nby several studies. Adverse pregnancy outcomes such \nas preterm labor, preeclampsia, fetal growth restriction, \nplacenta previa, placental abruption, postpartum hem -\norrhage and stillbirth have been reported [ 36– 39]. In \nthe present study, both groups comprised patients with \nendometriomas. We compared pregnancy complications \nbetween the surgical and nonsurgical groups because the \nnumber of cases with complications was not adequate \nfor statistical comparison. As such, the study may not \nhave sufficient statistical power to detect significant dif -\nferences in rare pregnancy outcomes. No significant dif -\nferences were observed between the two groups in terms \nof overall complications (OR: 0.70, 95% CI: 0.35–1.42; \np = 0.322).\nIn patients planning pregnancy, the size of endo -\nmetrioma cysts is one of the key parameters influenc -\ning the decision for surgical intervention. However, \nlarger cysts pose a greater risk of damage to ovarian tis -\nsue during surgery, which may result in a reduction in \novarian reserve [ 14, 40]. According to the 2022 ESHRE \nguidelines, cyst size alone is not a sufficient indication for \nsurgery; the decision should also take into account other \nsymptoms [5]. rASRM reports that laparoscopy increases \nlive birth rates in patients with stage 1–2 disease; how -\never, routine surgery is not recommended as its benefits \nare uncertain [ 5, 32]. In this study, the surgical group \npredominantly comprised patients having cysts of ≥ 4 cm \n(p < 0.001). This suggests that cyst size affects the decision \nfor surgery. However, further analysis revealed that the \nnumber of patients with cysts > 4 cm was similar between \nthe surgical and nonsurgical groups. Notably, the num -\nber was higher in the nonsurgical group (70 (42.7%) vs. \n94 (57.3%), respectively). This suggests that cyst size may \nhave influenced the decision for surgery; however, it was \nnot the only determinant and that other clinical factors \ncontributed to the treatment approach in the patients \nincluded in the study.\nThe timing and mode of delivery differ between preg -\nnant patients diagnosed with endometriomas and healthy \npregnant women. Women with endometriomas have \nhigher rates of cesarean section and an increased risk of \npreterm birth [ 34, 41]. In the present study, all patients \nwere diagnosed with endometriomas. Further, 30% \npatients had a vaginal delivery, 42.5% underwent cesar -\nean section, and 27.4% experienced pregnancy loss before \nviability. There was no significant difference between the \nsurgical and nonsurgical groups in terms of mode of \ndelivery (OR: 1.13, 95% CI 0.59–2.14; p = 0.715). Regard-\ning the time of delivery, the majority of the patients in \nboth groups delivered at term. There was no statistically \nsignificant difference between the groups in terms time \nof delivery (OR: 0.45, 95% CI 0.17–1.21; p = 0.107).\nThis study had a retrospective design and was con -\nducted using data from a single center. This may limit \nthe generalizability of the findings to different popula -\ntions. Although our study was limited to a single tertiary \ncare center, our findings are consistent with previous \nlarge-scale meta-analyses, suggesting that the results can \nbe generalized to similar populations in other settings. \nAMH levels were not available for all patients, and there -\nfore, were not included in the analysis, which is another \nlimitation of our study. Although baseline AMH levels \nwere not available for the study population, all patients \nincluded in the study had an AFC above 5 at their first \npreconception assessment, minimizing the possibility of \nsevere baseline ovarian reserve deficiency. Furthermore, \nbecause our study included both surgical and nonsurgi -\ncal patients, a standardized classification of endome -\ntriosis severity (such as the rASRM score) could not be \nuniformly applied, which may limit our ability to account \nfor disease severity as a confounding factor. Furthermore, \nalthough endometrioma was diagnosed using ultrasound \nand MRI findings in the nonsurgical group, the lack of \npathologic confirmation represents another limitation of \n\nPage 9 of 10\nÖzkan et al. BMC Pregnancy and Childbirth           (2025) 25:824 \nthe study. Moreover, subgroup analyses based on mode \nof conception (spontaneous vs. ART) were not included. \nFuture studies focusing on this issue may provide valu -\nable insights into treatment choice.\nDespite these limitations, the primary strength of this \nstudy lies in its focus on a cohort consisting predomi -\nnantly of patients who conceived spontaneously. Most \nstudies in the literature investigating endometrioma and \npregnancy outcomes have been designed in populations \nundergoing IVF or intracytoplasmic sperm injection \n(ICSI). In contrast, 75.8% of the patients in this study \nconceived spontaneously.\nConclusions\nThis study aims to elucidate an area that has not been \nadequately addressed in the literature by comparing time \nto conception and pregnancy outcomes between patients \nwith endometriomas with and without surgery. Our find-\nings suggest that surgery prolongs the time to conception \nin patients with endometriomas; however, surgery does \nnot influence the mode of conception, intrapartum preg -\nnancy outcomes, mode of delivery, or timing of delivery. \nIn the light of our findings, conservative approach can be \nconsidered as one of the first treatment choice in newly \ndiagnosed patients with endometriomas who have no \nhistory of infertility and planning pregnancy. The earlier \ntime to conception observed in the nonsurgical group \nsuggests the importance of a more careful and individu -\nalized approach to the surgical decision. Clinical deci -\nsion-making should take into account individual patient \ncharacteristics such as ovarian reserve, severity of disease \nand symptoms, and pregnancy plan to guide the need for \nsurgical intervention in women with endometriomas. \nFurther prospective studies, especially randomized con -\ntrolled trials, are needed to validate the findings of this \nretrospective study.\nAbbreviations\nAFC  Antral follicle count\nESHRE  European Society of Human Reproduction and Embryology\nIVF  In vitro fertilization\nICSI  Intracytoplasmic sperm injection\nMRI  Magnetic Resonance Imaging\nrASRM  Revised American Society for Reproductive Medicine\nBMI  Body Mass Index\nAcknowledgements\nWe thank all the participating patients for their generous contributions to this \nstudy.\nAuthors' contributions\nHDO, MAO, NÇK and YYU contributed to the concept and design of the study. \nMAO, NCK performed the statistical analyses. HDO and MO drafted the first \nversion of the manuscript. MAO, HDO, AGY, NCK were involved in analyzing \nand interpreting the data. HDO, MAO contributed to interpreting the data, \nand gave critical feedback throughout the preparation of manuscript. YYU \ncritically reviewed the manuscript, and all authors gave approval for the final \nversion of the manuscript.\nFunding\nNo Funding.\nData availability\nThe data that support the findings of this study are not openly available due \nto reasons of sensitivity. If requested, data can be shared by the corresponding \nauthor with patient names and ID’s anonymized.\nDeclarations\nEthics approval and consent to participate\nEthical approval for the study was obtained from the Etlik Zübeyde Hanım \nTraining and Research Hospital Ethics Committee (decision number 2024/12, \ndated 09.10.2024). The requirement for informed consent to participate was \nwaived by the same Ethics Committee due to the retrospective nature of \nthe study. 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Endome-\ntriosis and obstetrics complications: a systematic review and meta-analysis. \nFertil Steril. 2017;108 4:667–6725.\nPublisher’s note\nSpringer Nature remains neutral with regard to jurisdictional claims in \npublished maps and institutional affiliations.","source_license":"CC0","license_restricted":false}