{"paper_id":"98140ae9-7e1d-4d05-b902-18e0615eebb2","body_text":"76\nThis is an Open Access article distributed under the terms of the Creative Commons Attribu-\ntion Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits \nunrestricted non-commercial use, distribution, and reproduction in any medium, provided the \noriginal work is properly cited.\n© 2022 THE KOREAN SOCIETY FOR REPRODUCTIVE MEDICINEwww.eCERM.org\nIntroduction \nEndometriosis typically presents as three types: superficial perito-\nneal lesions, deep infiltrating endometriosis, and ovarian endometri-\noma [1]. Of these types, ovarian endometrioma can be easily identi-\nfied by ultrasonography; it is lined with endometrial tissue and con-\ntains a chocolate-colored fluid that arises from the accumulation of \nmenstrual debris. Ovarian endometrioma accounts for 17% to 44% \nof all cases of endometriosis [2]. Lee et al. [3] analyzed 1,374 cases \nEfficacy of ablation and sclerotherapy for the \nmanagement of ovarian endometrioma:  \nA narrative review\nByung Chul Jee\n1,2\n1\nDepartment of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam; \n2\nDepartment of Obstetrics and Gynecology, \nSeoul National University College of Medicine, Seoul, Republic of Korea\nREVIEW ARTICLE\nhttps://doi.org/10.5653/cerm.2021.05183\npISSN 2233-8233 · eISSN 2233-8241\nClin Exp Reprod Med 2022;49(2):76-86\nOvarian cystectomy is the preferred technique for the surgical management of ovarian endometrioma. However, other techniques such as \nablation or sclerotherapy are also commonly used. The aim of this review is to summarize information regarding the efficacy of ablation and \nsclerotherapy compared to cystectomy in terms of ovarian reserve, the recurrence rate, and the pregnancy rate. Several studies comparing \nablation versus cystectomy or sclerotherapy versus cystectomy in terms of the serum anti-Müllerian hormone (AMH) decrement, endometri-\noma recurrence, or the pregnancy rate were identified and summarized. Both ablation and cystectomy have a negative impact on ovarian re-\nserve, but ablation results in a smaller serum AMH decrement than cystectomy. Nonetheless, the recurrence rate is higher after ablation than \nafter cystectomy. More studies are needed to demonstrate whether the pregnancy rate is different according to whether patients undergo \nablation or cystectomy. The evidence remains inconclusive regarding whether sclerotherapy is better than cystectomy in terms of ovarian re-\nserve. The recurrence rates appear to be similar between sclerotherapy and cystectomy. There is not yet concrete evidence that sclerotherapy \nhelps to improve the pregnancy rate via in vitro fertilization in comparison to cystectomy or no sclerotherapy. \nKeywords: Ablation techniques; Anti-Müllerian hormone; Cystectomy; Endometriosis; In vitro fertilization; Ovarian reserve; pregnancy, \nSclero therap \nReceived: December 23, 2021 ∙ Revised: February 7, 2022 ∙ Accepted: February 23, 2022\nCorresponding author: Byung Chul Jee\nDepartment of Obstetrics and Gynecology, Seoul National University Bundang \nHospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Republic of \nKorea\nTel: +82-31-787-7254  Fax: +82-31-787-4054  E-mail: blasto@snubh.org\n(1,350 women) confirmed as endometriosis by pathological reports \nduring surgery performed at a single center for 9 years. The predom-\ninant location of endometriosis was in the ovaries (96.4%), followed \nby soft tissues (2.8%), the gastrointestinal tract (0.3%), and the uri-\nnary tract (0.2%). In ovarian endometrioma, unilateral lesions ac -\ncounted for about two-thirds of cases, and bilateral lesions for about \none-third. \nIn symptomatic women with ovarian endometriomas, a surgical \napproach is usually recommended. There are three main surgical \ntechniques: cystectomy, ablation, and sclerotherapy. The degree of \nsymptom relief and recurrence rate should be considered when as-\nsessing the therapeutic effects of various techniques. In addition, \nand more importantly, the preservation of ovarian reserve and the \nsubsequent pregnancy rate should be considered, especially in \nwomen who desire pregnancy in the future.  \nThe aim of this review is to summarize information regarding the \nefficacy of ablation and sclerotherapy compared to cystectomy in \n\n\nterms of preservation of ovarian reserve, the recurrence rate, and the \npregnancy rate. \nOvarian cystectomy \nOvarian cystectomy is the preferred technique in terms of recur-\nrence and the spontaneous pregnancy rate after surgery [4,5]. How-\never, cystectomy often causes ovarian damage and diminished ovar-\nian reserve. At 9 to 12 months after ovarian cystectomy, 39.5% and \n57% reductions in serum anti-Müllerian hormone (AMH) levels were \nobserved in patients with unilateral and bilateral endometriomas, \nrespectively [6]. Since ovarian endometrioma consists of a pseudo-\ncapsule, cystectomy leads to the removal of the lining of endometrial \ntissues as well as the normal ovarian tissues [7]. Furthermore, the re-\nmaining normal ovarian tissues are usually coagulated for bleeding \ncontrol, thereby further diminishing ovarian reserve. A greater de-\ncline in ovarian reserve could occur in older women and those with \nlarger ovarian endometriomas, bilateral lesions, and advanced-stage \ndisease [6,8-11]. Therefore, cystectomy has to be chosen very care-\nfully in women who desire future pregnancy or who are infertile. \nCystectomy is a very difficult option to choose in women who al -\nready have a diminished ovarian reserve before surgery, and even in \nwomen with recurrent endometrioma after surgery. As a way to pre-\nserve ovarian reserve when cystectomy is performed, hemostasis by \novarian suturing or a hemostatic agent has been introduced. \nTable 1 lists 11 comparative studies on serum AMH decrement (3 \nmonths or more postoperatively) after cystectomy of ovarian endo-\nmetrioma with bipolar coagulation versus suturing (five studies), as \nwell as bipolar coagulation versus a hemostatic agent (six studies). \nAlthough Baracat et al. [12] summarized comparative studies on se-\nrum AMH decrement after ovarian cystectomy, the meta-analysis in-\ncluded several studies that enrolled both endometrioma and \nnon-endometrioma groups. Therefore, in this review, three studies \nthat enrolled mixed groups were not included in Table 1 [13-15]. \nHowever, the study by Kang et al. [16] was included, because the se-\nrum AMH decrement in the endometrioma group could be extract-\ned separately. The serum AMH decrement was calculated as follows: \n[(postoperative AMH level–preoperative AMH level)/preoperative \nAMH level)] × 100 (%). \nAmong the five studies comparing bipolar coagulation versus su-\nturing, the serum AMH decrements were similar in three studies [17-\n19]. However, two studies reported significantly smaller serum AMH \ndecrements in the suturing group [20,21]. Among the six studies \ncomparing bipolar coagulation versus hemostatic agent, the serum \nAMH decrements were similar in three studies [22,23,24]. However, \nthree studies reported significantly smaller serum AMH decrements \nin the hemostatic agent group [16,25,26]. \nInterestingly, Araujo et al. [24] compared serum AMH decrements \nafter all three methods (bipolar coagulation versus suturing versus a \nhemostatic agent), but the serum AMH decrements were similar in \nall groups. These 11 studies showed varying results for the results of \nthe serum AMH decrement; therefore, no conclusions can be drawn. \nTable 1. Comparative studies on serum AMH decrement (3 months or more postoperative) after cystectomy for ovarian endometrioma \nwith bipolar coagulation versus suturing and bipolar coagulation versus a hemostatic agent\nStudy Study type/No. of women \nin each arm\nAMH measurement time \nafter cystectomy (mo)\nBipolar \ncoagulation (%) Suturing (%) Hemostatic (%) p-value\nFerrero et al. (2012) [17] Randomized/50 vs. 50 3 –19 –13 NS\n6 –23 –18 NS\n12 –23 –18 NS\nTakashima et al. (2013) [18] Retrospective/21 vs. 23 3 –3 –17 NS\nTanprasertkul et al. (2014) [19] Randomized/25 vs. 25 3 –28 –21.6 NS\n6 –27 –31.2 NS\nAsgari et al. (2016) [20] Randomized/57 vs. 52 3 –53.4 –15.9 < 0.001\nZhang et al. (2016) [21] Randomized/69 vs. 69 3 –58 –28 < 0.05\n6 –55 –28 < 0.05\n12 –53 –26 < 0.05\nSonmezer et al. (2013) [22] Randomized/15 vs. 15 3 –23 –19 NS\nSong et al. (2015) [25] Prospective/62 vs. 63 3 –42.2 –24.6 0.001\nKang et al. (2015) [16] Prospective/23 vs. 43 3 –41.1 –15.6 < 0.05\nChoi et al. (2018) [26] Randomized 40 vs. 40 3 –41.9 –18.1 0.007\nChung et al. (2019) [23] Randomized/47 vs. 47 3 –26.7 –12.7 NS\nAraujo et al. (2021) [24] Randomized/27 vs. 26 vs. 24 6 –6.7 –11 –13 NS\nAMH, anti-Müllerian hormone; NS, not significant.\nwww.eCERM.org 77\nBC Jee     Surgical management of ovarian endometrioma\n\nThus, it remains unclear whether suturing or the use of hemostatic \nagents as a method of hemostasis results in smaller serum AMH dec-\nrements compared to bipolar coagulation. \nIn a systematic review and meta-analysis, 3-month postoperative \nAMH levels were significantly lower in patients who received bipolar \ncoagulation group than in those for whom a non-thermal hemosta-\nsis method was used (mean difference, – 0.79 ng/mL; 95% confi -\ndence interval [CI], –1.19 to –0.39) [27]. In that report, only three \nstudies were included; in one study, 3-month postoperative AMH \nlevels were compared between bipolar coagulation versus a hemo-\nstatic agent [22], while two studies compared 3-month postopera-\ntive AMH levels between bipolar coagulation and suturing [19,21].  \nAblation versus cystectomy \nAblation is a method of incising an ovarian endometrioma to re-\nmove the internal fluid and ablate the lining of endometrial tissue. \nAblation can be performed using bipolar coagulation, laser vaporiza-\ntion, or plasma energy [28]. Since the cyst wall is not removed, it is \ngenerally considered a better option than cystectomy in terms of \novarian reserve [11]. Table 2 lists 11 comparative studies on serum \nAMH decrement, recurrence of endometrioma, or the pregnancy \nrate after ablation versus cystectomy of ovarian endometrioma \n[8,10,29-37]. In most studies, bipolar coagulation was used as a \nmethod for ablation, but laser vaporization was used in four studies \n[10,29-31]. Plasma energy was used in only one study [32]. It is diffi-\ncult to draw a definitive conclusion from these 11 studies on which \nablation technique would be better. The reader should refer to each \narticle for details on how to use a specific ablation technique. \n1. Serum AMH decrement \nA randomized study by Giampaolino et al. [8] indicated that both \nablation and cystectomy had a negative impact on ovarian reserve. \nHowever, they found that endometrioma size was associated with \nthe magnitude of AMH decrement after ablation or cystectomy. In \n24 women with endometriomas measuring < 5 cm, the degree of \nAMH decrement at 3 months was similar between ablation and cys-\ntectomy (–18.2% vs. –17.6%), but in 22 women with endometriomas \n≥ 5 cm in size, a smaller decline of serum AMH level was noted in the \nablation group (–14.8% vs. –24.1%, p < 0.05). Therefore, in cases with \nendometriomas ≥ 5 cm in size, ablation might be better than cystec-\ntomy for preserving serum AMH levels. \nAnother randomized study by Candiani et al. [30] indicated that \nablation was better than cystectomy in terms of preserving serum \nAMH levels. In the ablation group, the mean preoperative and \n3-month postoperative serum AMH levels were 2.3 and 1.9 ng/mL, \nrespectively (p > 0.05), while in the cystectomy group, the corre -\nsponding levels were 2.6 and 1.8 ng/mL, respectively (p < 0.05). A \nprospective study by Saito et al. [10] showed that ablation was better \nthan cystectomy in terms of ovarian reserve, especially in bilateral le-\nsions. In women with bilateral lesions, the 1-, 6-, and 12-month post-\noperative AMH decrements were significantly smaller in the ablation \ngroup than in the cystectomy group. However, in women with uni-\nlateral lesions, the AMH decrements were similar between the abla-\ntion and cystectomy groups. \nA randomized study by Shaltout et al. [33] demonstrated that the \n6-month postoperative AMH decrement was significantly smaller in \nthe ablation group than in the cystectomy group. Interestingly, they \nfound that the insertion of oxidized regenerated cellulose (Surgicel; \nEthicon, Somerville, NJ, USA) inside the cavity of the cyst significantly \nminimized the AMH decrement in the ablation group, but not in the \ncystectomy group. A retrospective study by Chen et al. [34] indicated \nthat both ablation and cystectomy had a negative impact on ovarian \nreserve, but they found that ablation was better than cystectomy in \nterms of ovarian reserve. In the ablation group, the mean preopera-\ntive and 6-month postoperative serum AMH levels were 4.47 and \n3.95 ng/mL, respectively (p < 0.05), while the corresponding levels in \nthe cystectomy group were 4.25 and 3.40 ng/mL, respectively \n(p < 0.05). The mean change in AMH levels was significantly smaller \nin the ablation group (mean, –0.52 ng/mL vs. –0.85 ng/mL, p < 0.05). \nIn summary, five studies indicated that both ablation and cystec-\ntomy had negative impacts on ovarian reserve; however, smaller \ndecrements in the serum AMH level after ablation were uniformly re-\nported [8,10,30,33,34]. Ablation appears to be advantageous in \nterms of the preservation of ovarian reserve, especially in women \nwith endometriomas ≥ 5 cm in size or bilateral lesions [8,10]. \n2. Recurrence rate \nSeven studies compared the recurrence rate of endometrioma be-\ntween ablation versus cystectomy [10,29,31,33-36]. Interestingly, five \nstudies reported a higher recurrence rate in the ablation group than \nin the cystectomy group, but without a statistically significant differ-\nence [31,33-36]. In a randomized study, Carmona et al. [29] reported \na significantly higher recurrence rate at the 1-year follow-up in the \nablation group than the cystectomy group (31% vs. 11%, p < 0.05). \nHowever, the overall recurrence rate at the 5-year follow-up became \nsimilar between the two groups (37% vs. 22%, p > 0.05). In a pro-\nspective study, Saito et al. [10] reported no recurrence in any patients \nin the study population. \nIn a randomized study, Shaltout et al. [33] reported that the inser-\ntion of oxidized regenerated cellulose (Surgicel) inside the cavity of \nthe cyst significantly lowered the recurrence rate in both the ablation \ngroup (27.1% to 10.9%) and the cystectomy group (24.4% to 9.1%). \nAn earlier Cochrane review (published in 2008) included the afore-\nhttps://doi.org/10.5653/cerm.2021.0518378\nClin Exp Reprod Med 2022;49(2):76-86\n\nTable 2. Comparative studies on serum AMH decrement, recurrence of endometrioma, and the pregnancy rate after ablation versus cystectomy for ovarian endometrioma\nStudy Methods for ablation \n(No. of women in each arm) AMH Recurrence of endometrioma Pregnancy rate\nBeretta et al. (1998) [35]/randomized Bipolar coagulation NA 2 yr: 2 yr: \nAblation (n = 32) vs. cystectomy (n = 32) 18.8% vs. 6.2% (NS) 23.5% vs. 66.7% (p < 0.05)\nAlborzi et al. (2004) [36]/randomized Bipolar coagulation\nAblation (n = 48) vs. cystectomy (n = 52)\nNA 1 yr: \n18.8% vs. 5.8% (NS)\n1 yr: \n23.3% vs. 59.4% (p < 0.05)\n2 yr: \n31.3% vs. 17.3% (NS)\nAlborzi et al. (2007) [37]/randomized Bipolar coagulation NA NA After superovulation: 30% vs. 35.7% (NS)\nAblation (n = 40) vs. cystectomy (n = 70)\nCarmona et al. (2011) [29]/randomized Laser vaporization\nAblation (n = 38) vs. cystectomy (n = 36)\nNA 1 yr: \n31% vs. 11% (p < 0.05)\nNA\n5 yr: \n37% vs. 22% (NS)\nGiampaolino et al. (2015) [8]/randomized Bipolar coagulation 3 mo: NA NA\n(endometrioma size < 5 cm)\nAblation (n = 11) vs. cystectomy (n = 13) –18.2% vs. –17.6% (NS)\n(endometrioma size ≥ 5 cm)\nAblation (n = 11) vs. cystectomy (n = 11) –14.8% vs. –24.1% (p < 0.05)\nMircea et al. (2016) [32]/comparative Plasma energy NA NA\nAblation (n = 64) vs. cystectomy (n = 40) 2 yr: 61.3% vs. 69.3% (NS)\n3 yr: 84.4% vs. 78.3% (NS)\nCandiani et al. (2018) [30]/randomized Laser vaporization Preoperative vs. 3 mo (ng/mL): NA NA\nAblation (n = 30) 2.3 vs. 1.9 (NS)\nCystectomy (n = 30) 2.6 vs. 1.8 (p < 0.05)\nSaito et al. (2018) [10]/prospective Laser vaporization 1 mo/6 mo /12 mo: 12 mo NA\nBilateral ablation (n = 16) –69%/–59%/–53% 0\nBilateral cystectomy (n = 10) –84%/–74%/–73% 0\n(p= 0.04/p = 0.02/p = 0.02)\nUnilateral ablation (n = 12) –55%/–49%/–43% 0\nUnilateral cystectomy (n = 24) –61%/–55%/–48% 0\n(p> 0.05/p> 0.05/p> 0.05)\nShaltout et al. (2019) [33]/randomized Bipolar coagulation 6 mo: 2 yr: NA\nAblation (n = 48) vs. cystectomy (n = 45) –33.5% vs. –54.1% (p < 0.05) 27.1% vs. 24.4% (NS)\n(with Surgicel®)\nAblation (n = 46) vs. cystectomy (n = 44) –17.3% vs. –45.4% (p < 0.05) 10.9% vs. 9.1% (NS)\nCandiani et al. (2020) [31]/retrospective Laser vaporization NA 29 mo: NA\nAblation (n = 61) vs. cystectomy (n = 64) 4.9% vs. 6.3% (NS)\nChen et al. (2021) [34]/retrospective Bipolar coagulation Preoperative/6 mo (ng/mL): 2 yr: \nAblation (n = 30) 4.47/3.95\na)\n (difference, –0.52) 16.67% 73% during 32 mo\nCystectomy (n = 46) 4.25/3.40\na)\n (difference, –0.85; p < 0.05) 4.35% (NS) 71% during 30 mo (NS)\nAMH, anti-Müllerian hormone; NA, not available; NS, not significant.\na)\np<0.05 when compared with the preoperative serum AMH level.\nwww.eCERM.org 79\nBC Jee     Surgical management of ovarian endometrioma\n\nmentioned two studies [35,36] and concluded that cystectomy \nshowed a significantly lower recurrence rate (odds ratio [OR], 0.41; \n95% CI, 0.18–0.93) [4]. In that review, symptom recurrence was also \nsignificantly lower in the cystectomy group (dysmenorrhea: relative \nrisk [RR], 0.15; 95% CI, 0.06–0.38; dyspareunia: RR, 0.08; 95% CI, 0.01–\n0.51; non-menstrual pelvic pain: RR, 0.10; 95% CI, 0.02–0.56). These \nseven studies clearly show that the recurrence rate tends to be high-\ner after ablation than after cystectomy. \n3. Pregnancy rate \nFive studies reported the pregnancy rate after ablation versus cys-\ntectomy [32,34-37]. In a randomized study by Beretta et al. [35], the \n2-year cumulative pregnancy rate was significantly lower in the abla-\ntion group than in the cystectomy group (23.5% vs. 66.7%, p < 0.05). \nIn a randomized study by Alborzi et al. [36], the 1-year cumulative \npregnancy rate was also significantly lower in the ablation group \nthan in the cystectomy group (23.3% vs. 59.4%, p < 0.05). \nHowever, in a subsequent randomized study by Alborzi et al. [37], \nthe pregnancy rate after superovulation was similar between the ab-\nlation and cystectomy groups (30% vs. 35.7%). A multicenter \ncase-control study by Mircea et al. [32] showed that the probability \nof spontaneous pregnancy at 24 and 36 months was similar be -\ntween the ablation and cystectomy groups (61.3% and 84.4% vs. \n69.3% and 78.3%, respectively). In a recent retrospective study, Chen \net al. [34] also reported a similar spontaneous pregnancy rate be-\ntween the ablation and cystectomy groups (73% during 32 months \nvs. 71% during 30 months). \nAn earlier Cochrane review (published in 2008) included the afore-\nmentioned three studies [35-37] and concluded that cystectomy \nshowed a significantly higher pregnancy rate (OR, 5.21; 95% CI, \n2.04–13.29) [4]. However, two subsequent studies reported a similar \npregnancy rate between the ablation and cystectomy groups \n[32,34]. Therefore, more research is needed to demonstrate whether \nthe pregnancy rate is different between ablation and cystectomy. \nSome clinicians used a “combination technique” or a “three-stage \nprocedure, ” but there are very few comparative studies on these \ntechniques. Therefore, they are briefly presented below. In the com-\nbination technique, a large part of the endometrioma wall is first re-\nmoved by cystectomy, and the remaining 10%–20% of the endome-\ntrioma wall close to the hilum is ablated [38]. In a randomized study, \nthe combination technique showed a similar recurrence rate to that \nachieved using cystectomy (2.0% vs. 5.9% at 6 months postopera-\ntively) [39]. The three-stage procedure refers to drainage of the cyst \nduring laparoscopy, followed by subsequent gonadotropin-releasing \nhormone agonist treatment, and then ablation of the remains during \na second laparoscopy [40]. In a small randomized study, the three-\nstage procedure showed a smaller serum AMH decrement at 6 \nmonths postoperatively (mean, 4.5 to 3.99 ng/mL; p > 0.05) com-\npared to cystectomy (mean, 3.9 to 2.9 ng/mL; p < 0.05) [41]. \nSclerotherapy versus cystectomy \nOvarian cystectomy and ablation are now usually performed via \nthe laparoscopic approach. In contrast, sclerotherapy is a type of \nnon-surgical management of ovarian endometrioma. Sclerotherapy \ninvolves performing direct percutaneous puncture of ovarian endo-\nmetrioma to remove the internal fluid, inserting a sclerosing agent \nsuch as ethanol into the cyst cavity, and removing it after a certain \nperiod of time (“washing” method). Noma and Yoshida [42] reported \na higher recurrence rate after ethanol washing for < 10 minutes than \nafter ≥ 10 minutes (62.5% vs. 9.1%, p < 0.05).  \nSome groups used retention of ethanol, wherein the ethanol is left \nin situ. In a retrospective study of recurrent endometrioma cases, the \nwashing method for 0–10 minutes showed a non-significantly high-\ner recurrence rate (during 1 year) than the retention method (32.1% \nvs. 13.3%, p > 0.05) [43]. Another retrospective study of recurrent en-\ndometrioma cases showed that the washing method (for 10 min-\nutes) led to a significantly lower cure rate (during 1 year) than the re-\ntention method (82% vs. 96%) [44]. \nHowever, a recent retrospective study of patients with recurrent or \nbilateral endometrioma found similar 1-year recurrence rates be-\ntween the washing (for 10 minutes) and retention methods (48.1% \nversus vs. 37.5%) [45]. In that report, live birth rates (spontaneous or \nartificial conception) were also similar (40% vs. 46.2%). In another re-\ncent retrospective study, the washing method (for 1–3 minutes) \nshowed a smaller AMH decrement at 6 months postoperatively than \nthe retention method (–2.7% vs. –23.6%, p < 0.05) [46]. In that re-\nport, the overall pregnancy rates (up to 9 years) were similar (47.2% \nvs. 54.5%). Thus, it remains unclear whether the washing method \nhas a higher recurrence rate than the retention method in sclerother-\napy of ovarian endometrioma. More research is needed to demon-\nstrate whether the washing method results in a smaller serum AMH \ndecrement than the retention method. \nDirect puncture can be performed using a long aspiration needle \n(16–17 gauge) or a flexible catheter (i.e., catheter-directed sclero-\ntherapy). In a prospective study (14 women with primary or recur-\nrent endometrioma), catheter-directed sclerotherapy decreased en-\ndometrioma size (from 5.8 cm to 1.1 cm), and no recurrence of endo-\nmetrioma was noted during a mean follow-up of 1 year [47]. The \nmean preoperative and 6-month postoperative serum AMH levels \nwere similar (from 4.29 to 4.36 ng/mL, p > 0.05). Simple aspiration \nalone is usually not recommended because it has a very high recur-\nrence rate (83%–91.5%) [48,49]. However, Zhu et al. [49] reported \nthat repetitive aspiration tended to decrease the recurrence rate, \nhttps://doi.org/10.5653/cerm.2021.0518380\nClin Exp Reprod Med 2022;49(2):76-86\n\nwhich was 5.4% after the sixth aspiration. \nTable 3 lists eight studies [42,50-56] that compared sclerotherapy \nversus cystectomy for ovarian endometrioma or sclerotherapy versus \nno intervention in terms of the serum AMH decrement, recurrence of \nendometrioma, and the pregnancy rate. Five studies included wom-\nen undergoing in vitro fertilization and embryo transfer (IVF-ET), and \nthe primary endpoint of those studies was clinical pregnancy rate (or \nlive birth rate) [50-54]. In a study by Alborzi et al. [54], sclerotherapy \nwas performed at the time of ovum pickup, and thereafter patients \nwere followed for clinical pregnancy by IVF-ET or recurrence. \n1. Serum AMH decrement \nOnly two studies described the serum AMH decrement at 6 months \npostoperatively after sclerotherapy versus cystectomy [55,56]. In a \nstudy by Garcia-Tejedor et al. [55], preoperative serum AMH levels \nwere similar between sclerotherapy versus cystectomy (2.20 vs. 1.09 \nng/mL), and the 6-month postoperative serum AMH levels were also \nsimilar between the two groups (2.02 vs. 1.35 ng/mL). In a study by \nKoo et al. [56], a serum AMH decrement at 6 months postoperatively \nwas not observed in the sclerotherapy group (2.3 to 2.6 ng/mL, \np > 0.05), but a significant serum AMH decrement was found in the \ncystectomy group (3.0 to 1.6 ng/mL, p < 0.05). Thus, it remains incon-\nclusive whether sclerotherapy is better than cystectomy in terms of \novarian reserve. \n2. Recurrence rate \nFour studies described the recurrence rate of endometrioma after \nsclerotherapy versus cystectomy [42,54-56]. Three studies reported \na similar recurrence rate between sclerotherapy and cystectomy, \nbut only one study by Alborzi et al. [54] reported a significantly \nhigher recurrence rate in the sclerotherapy group than in the cys-\ntectomy group (34.1% vs. 14.0%, p < 0.05). The authors [ 54] ex-\nplained that the unusually higher recurrence rate in the sclerother-\napy group could be attributed to the longer follow-up period in \ntheir study. Nonetheless, the majority of currently available reports \nshow a similar recurrence rate when comparing sclerotherapy ver-\nsus cystectomy.  \n3. Pregnancy rate \nTwo studies described a similar spontaneous pregnancy rate be-\ntween sclerotherapy and cystectomy [42,55]. Five studies described \npregnancy rates via IVF-ET, but the participants in the two compara-\ntive arms were quite heterogeneous [50-54]. Yazbeck et al. [50] com-\npared IVF-ET outcomes between sclerotherapy and cystectomy \ngroups in a prospective study of patients with recurrent endometrio-\nma. The ongoing pregnancy rates after one IVF cycle (48.3% vs. \n19.2%, p = 0.04) and after three IVF cycles (55.2% vs. 26.9%, p = 0.03) \nwere significantly higher in the sclerotherapy group. \nAflatoonian et al. [51] compared IVF-ET outcomes between the \nsclerotherapy group for patients with recurrent endometrioma and \ncurrently recurring endometrioma (i.e., no intervention) in a random-\nized study, and the pregnancy rates after one IVF cycle were similar \n(27.8% vs. 15%, p > 0.05). In a retrospective study, Lee et al. [52] com-\npared IVF-ET outcomes between patients who underwent sclero-\ntherapy for recurrent endometrioma, currently recurring endometri-\noma group (after previous cystectomy), and current endometrioma \ngroups . The pregnancy rates after one IVF cycle were similar (44.4% \nvs. 37.1% vs. 41.1%). \nMiquel et al. [53] compared IVF-ET outcomes between a sclero-\ntherapy group and a current endometrioma group in a retrospective \nstudy, and the live birth rate after multiple IVF cycles was significant-\nly higher in the sclerotherapy group (31.3% vs. 14.5%, p < 0.05). In a \nprospective study, Alborzi et al. [54] compared IVF-ET outcomes be-\ntween the sclerotherapy group and the cystectomy group, and the \nlive birth rates after one IVF cycle were similar (29.5% vs. 38.6%). In \nthat study, sclerotherapy was performed at the time of oocyte pick-\nup; thus, the sclerotherapy group could be interpreted as currently \nhaving endometrioma, at least at the time of oocyte pickup. \nThe five studies regarding the pregnancy rate via IVF-ET in women \nwith endometrioma can be summarized as follows. (1) For recurrent \nendometrioma, sclerotherapy may be more beneficial than cystecto-\nmy (based on one study) [50]. (2) For recurrent endometrioma, \nsclerotherapy may not be more beneficial than no sclerotherapy \n(based on two studies) [51,52]. (3) For endometrioma, sclerotherapy \nmay be more beneficial than no sclerotherapy in terms of the cumu-\nlative live birth rate (based on one study) [53]. \nThus, there is no concrete evidence that sclerotherapy helps to im-\nprove the IVF pregnancy rate (when compared to cystectomy or no \nsclerotherapy). However, the spontaneous pregnancy rate was simi-\nlar between sclerotherapy and cystectomy. In women with recurrent \nendometrioma after surgery, cystectomy is a very difficult option to \nchoose because of a diminished ovarian reserve. As an alternative, \nsclerotherapy can be a good option for recurrent endometrioma, but \nthe sclerotherapy-related decrement of serum AMH and reproduc-\ntive outcomes should be further evaluated. \nSclerotherapy can induce abdominal pain (due to ethanol leakage \ninto the peritoneal cavity), intraperitoneal hemorrhage, peritonitis, \novarian abscess, and systemic absorption-related acute alcohol in-\ntoxication.  Table 4  lists the aforementioned comparative or \nnon-comparative studies and presents the complications of sclero-\ntherapy in detail. The overall crude complication rate was 5.2% \n(36/693). \nwww.eCERM.org 81\nBC Jee     Surgical management of ovarian endometrioma\n\nTable 3. Comparative studies of serum AMH decrement, recurrence of endometrioma, and the pregnancy rate after sclerotherapy versus cystectomy for ovarian endometrioma or \nversus no intervention\nStudy No. of women in each arm Methods for sclerotherapy AMH (ng/mL) Recurrence of endometrioma Pregnancy rate\nNoma et al. (2001) [42]/ \nretrospective\nSclerotherapy (n = 74) 100% Ethanol washing (30 min) NA 14.9% during 21 mo 52.1% (12/23) during 21 mo\nCystectomy (n = 30) 3.8% during 18.7 mo (NS) 38.4% (5/13) during 18.7 mo (NS)\nYazbeck et al. (2009) [50]/\nprospective\nSclerotherapy for recurrent OMA (n = 31)IVF soon after 100% ethanol washing (10 min) NA 12.9% during 26 mo OPR after 1 IVF/3 IVFs:\n48.3%/55.2%\nCystectomy for recurrent OMA (n = 26)IVF within unknown period after initial surgery NA 19.2%/26.9%\n(p = 0.04/p = 0.03)\nAflatoonian et al. (2013) \n[51]/randomized\nSclerotherapy for recurrent OMA (n = 20)IVF after 3 mo since 98% ethanol washing (10 min) NA 20% during 6 mo CPR after 1 IVF: 0.278\nOMA, recurrent (n = 20) IVF (no intervention) NA 15% (NS)\nLee et al. (2014) [52]/ \nretrospective\nSclerotherapy for recurrent OMA (n = 29)IVF within 1 yr since 20% ethanol washing  \n(time unknown)\nNA NA CPR after 1 IVF: 0.444\nOMA recurrent after cystectomy (n = 36)IVF within 5 yr after cystectomy 37.1% (NS)\nOMA (n = 36) IVF (no intervention) 41.1% (NS)\nGarcia-Tejedor et al. \n(2020) [55]/prospective\nSclerotherapy (n = 17) 100% ethanol washing (15 min) Preoperative/6 mo: During 20 mo During 20 mo\nCystectomy (n = 14) 2.20/2.02 (NS) 0.059 0.176\n1.09/1.35 (NS) 28.6% (NS) 0% (NS)\nMiquel et al. (2020) [53]/\nretrospective\nSclerotherapy (n = 37) IVF after 96% ethanol washing (10 min) NA NA LBR\nOMA (n = 37) IVF (no intervention) 31.3% (67 cycles)\n14.5% (69 cycles) (p < 0.05)\nKoo et al. (2021) [56]/ \nretrospective\nSclerotherapy (n = 20) 99% Ethanol washing (20 min) via a  \ncatheter-directed method\nPreoperative/6 mo:  0% during mean 23.7 mo NA\nCystectomy (n = 51) 2.3/2.6 (NS) 7.8% during mean 21.7 mo\n3.0/1.6 (p < 0.05)\na)\n(NS)\nAlborzi et al. (2021) [54]/\nprospective\nSclerotherapy (n = 44) At the time of OPU by 96% ethanol retention NA 2 yr–7 yr: 0.341 LBR after 1 IVF: 0.295\nCystectomy (n = 57) IVF after 1 yr since cystectomy 14.0% (p < 0.05) 38.6% (NS)\nAMH, anti-Müllerian hormone; NA, not available; NS, not significant; OMA, endometrioma; IVF , in vitro fertilization; OPR, ongoing pregnancy rate; CPR, clinical pregnancy rate; LBR, live birth rate; OPU, \novum pickup.\na)\np<0.05 when compared with the preoperative AMH level.\nhttps://doi.org/10.5653/cerm.2021.0518382\nClin Exp Reprod Med 2022;49(2):76-86\n\nConclusions \nThe findings of this review can be summarized as follows. First, \nwhen cystectomy of ovarian endometrioma is performed, it remains \nunclear whether suturing or the use of hemostatic agents as a meth-\nod of hemostasis results in a smaller serum AMH decrement than bi-\npolar coagulation. Second, both ablation and cystectomy have a \nnegative impact on ovarian reserve, but ablation results in a smaller \nserum AMH decrement than cystectomy. Thus, ablation can be rec-\nommended in terms of ovarian reserve. However, ablation tends to \nresult in a higher recurrence rate than cystectomy. In the past, abla-\ntion has been reported to be disadvantageous in terms of the preg-\nnancy rate in comparison to cystectomy; however, several recent re-\nports have presented similar pregnancy rates between the two \ngroups. Therefore, more studies are needed to demonstrate whether \nthe pregnancy rate is different between ablation and cystectomy. \nThird, when sclerotherapy of ovarian endometrioma is performed, \nit remains unclear whether the washing method has a higher recur-\nrence rate than the retention method. In addition, more research is \nneeded to show whether the washing method results in a smaller \nserum AMH decrement than the retention method. Last, it remains \ninconclusive whether sclerotherapy is better than cystectomy in \nterms of ovarian reserve. The recurrence rate appears to be similar af-\nter sclerotherapy and cystectomy. There is no concrete evidence that \nsclerotherapy helps to improve the IVF pregnancy rate when com-\npared to cystectomy or no sclerotherapy. In the author’s opinion, \nsclerotherapy should be applied carefully only to recurrent endome-\ntriomas when it would be difficult to perform cystectomy or ablation. \nConflict of interest \nByung Chul Jee has been the editor-in-chief of Clinical and Exper-\nimental Reproductive Medicine since 2018; however, he was not in-\nvolved in the peer reviewer selection, evaluation, or decision process \nof this article. No other potential conflict of interest relevant to this \narticle was reported. \nORCID \nByung Chul Jee https://orcid.org/0000-0003-2289-6090 \nReferences \n1. Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endome-\ntriosis, and adenomyotic nodules of the rectovaginal septum are \nthree different entities. Fertil Steril 1997;68:585–96. \n2. Busacca M, Vignali M. Ovarian endometriosis: from pathogenesis \nto surgical treatment. Curr Opin Obstet Gynecol 2003;15:321–6. \n3. Lee HJ, Park YM, Jee BC, Kim YB, Suh CS. 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Surgical resec-\ntion or aspiration with ethanol sclerotherapy of endometrioma \nbefore in vitro fertilization in infertilie women with endometrio-\nma. Obstet Gynecol Sci 2014;57:297–303. \n53. Miquel L, Preaubert L, Gnisci A, Resseguier N, Pivano A, Perrin J, et \nal. Endometrioma ethanol sclerotherapy could increase IVF live \nbirth rate in women with moderate-severe endometriosis. PLoS \nOne 2020;15:e0239846. \n54. Alborzi S, Askary E, Keramati P , Moradi Alamdarloo S, Poordast T, \nAshraf MA, et al. Assisted reproductive technique outcomes in \npatients with endometrioma undergoing sclerotherapy vs lapa-\nroscopic cystectomy: prospective cross-sectional study. Reprod \nMed Biol 2021;20:313–20. \n55. Garcia-Tejedor A, Martinez-Garcia JM, Candas B, Suarez E, Mana-\nlich L, Gomez M, et al. Ethanol sclerotherapy versus laparoscopic \nsurgery for endometrioma treatment: a prospective, multicenter, \ncohort pilot study. J Minim Invasive Gynecol 2020;27:1133–40. \n56. Koo JH, Lee I, Han K, Seo SK, Kim MD, Lee JK, et al. Comparison of \nthe therapeutic efficacy and ovarian reserve between catheter-di-\nrected sclerotherapy and surgical excision for ovarian endometri-\noma. Eur Radiol 2021;31:543–8. \nhttps://doi.org/10.5653/cerm.2021.0518386\nClin Exp Reprod Med 2022;49(2):76-86","source_license":"CC0","license_restricted":false}