{"paper_id":"a7739640-d039-4428-ad38-e1b0338abac7","body_text":"Clin. Exp. Obstet. Gynecol. 2024; 51(10): 226\nhttps://doi.org/10.31083/j.ceog5110226\nCopyright: © 2024 The Author(s). Published by IMR Press.\nThis is an open access article under the CC BY 4.0 license .\nPublisher’s Note: IMR Press stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nOriginal Research\nFactors Influencing Postoperative Recurrence and Live Birth\nAchievement after Laparoscopic Surgery for Ovarian Endometrioma:\nA Retrospective Study in a Regional Core Hospital\nRyosuke Arakaki1\n , Wataru Isono1,2,*, Hiroaki Fukuda 1, Junya Tanaka1, Arisa Minamino 1,\nShiko Hayashi1\n1Department of Obstetrics and Gynaecology, Kinan Hospital, 646-8588 Wakayama, Japan\n2Department of Obstetrics and Gynecology, Wakayama Medical University, 641-0012 Wakayama, Japan\n*Correspondence: tetuken2010@gmail.com (Wataru Isono)\nAcademic Editor: Michael H. Dahan\nSubmitted: 22 May 2024 Revised: 10 July 2024 Accepted: 31 July 2024 Published: 10 October 2024\nAbstract\nBackground: Ovarian endometrioma (OMA) is a common gynecological condition affecting women of reproductive age, often requir-\ning laparoscopic surgery for removal. However, the management of OMA, including postoperative hormone therapy, is complex and\nmust be tailored to the individual’s conditions. Therefore, to provide meaningful insights, we aimed to analyze 10 years of accumulated\ndata from patients who underwent laparoscopic surgery for OMA, with a primary focus mainly on postoperative OMA recurrence and\nlive birth outcomes. Methods: We reviewed the medical records of 158 patients who underwent laparoscopic surgery for OMA, includ-\ning total laparoscopic cystectomy (TLC) (79 patients), total laparoscopic adnexectomy (TLA) (62 patients), or both unilateral TLA and\ncontralateral TLC (17 patients), between January 2014 and December 2023. Among the OMA patients, we identified 7 cases of postop-\nerative OMA recurrence out of 158 patients, and 23 live births among 79 TLC patients. We performed a multivariate logistic regression\nanalysis to assess the impact of each representative factor on postoperative OMA recurrence and live birth achievement. Results: The\nmultivariate analyses of the 158 patients revealed that advance age and massive blood loss were significantly associated with an increased\nrisk of postoperative OMA recurrence, while postoperative hormone treatment was associated with a decreased risk of recurrence. In\nthe analysis of live birth achievement among the 79 TLC patients, advanced age, postoperative hormone treatment and cancer antigen\n125 (CA125) positivity were significantly associated with a reduced likelihood of achieving live birth. Conclusions: Our data highlight\nthe unfavorable effects of advanced age, massive blood loss and CA125 positivity on the outcomes of laparoscopic surgery for OMA.\nAdditionally, postoperative hormone treatment was found to decrease postoperative OMA recurrence. These findings may offer more\naccurate information to guidance in selecting treatment options for patients with OMA.\nKeywords: ovarian endometrioma; postoperative ovarian endometrioma recurrence; live birth achievement; retrospective study; ad-\nvanced age; massive blood loss; CA125 positivity; postoperative hormone treatment; total laparoscopic cystectomy; total laparoscopic\nadnexectomy\n1. Introduction\nEndometriosis is one of the most common gyneco-\nlogical diseases, affecting approximately 5% of women of\nreproductive age. It most frequently involves the ovaries,\nleading to the formation of a cystic mass known as an ovar-\nian endometrioma (OMA) [ 1,2]. OMA can be relatively\neasily to diagnosed using transvaginal ultrasound (TVUS)\nand magnetic resonance imaging (MRI), but its treatments\nis complex. Among them, laparoscopic surgeries are com-\nmonly performed to improve pain symptoms and fertil-\nity [ 3–6]. However, postoperative management is often\nneeded for patients who do not wish to conceive immedi-\nately after surgery, as there is a relatively high risk of post-\noperative recurrence [2,7,8]. In one previous review, the re-\ncurrence rate has been reported to exceed 20% five years af-\nter treatment [ 5]. Postoperative management includes hor-\nmonal treatments, including dienogest, oral contraceptive\npills (OCPs), and gonadotropin-releasing hormone (GnRH)\nanalogues. Comprehensive management, including careful\npostsurgical follow-up, is essential, with the choice of treat-\nment tailored to the individual patient’s situation and risk\nfactors, such as age, parity, OMA cyst size, and American\nSociety for Reproductive Medicine score (ASRM score).\nIn particular, for patients with infertility, the timing of\nlaparoscopic surgeries and postoperative management be-\ncome more complex, as hormonal treatments can hinder\npregnancy during the postoperative period [ 4–6]. For this\nreason, we have prioritize postoperative recurrence and live\nbirth outcomes in our treatment to selection, aiming to im-\nprove quality of life for our patients. We have leveraged our\nhospital’s unique advantage as the sole perinatal medical\ncenter in a rural area to achieve this goal. Therefore, in this\nstudy, we analyzed 10 years of accumulated data from pa-\ntients who underwent laparoscopic surgery for OMA. Our\n\naim was to identify significant factors associated with both\nfavorable outcomes, such as live birth achievement, and un-\nfavorable outcomes, such as recurrence.\n2. Materials and Methods\n2.1 Data Collection\nThis retrospective case series study was reviewed and\napproved by the Human Ethical Committee of Kinan Hos-\npital (Approval Number: 283, Clinical Outcomes of Endo-\nscopic Surgery: Retrospective Analyses, 2024/4/23). The\nstudy was conducted from January 2014 to December 2023.\nInformed consent was obtained from each patient prior\nto their inclusion in the study. The deidentified medical\nrecords of 158 female patients aged 50 years or younger,\nwho underwent laparoscopic surgery for the treatment of\nOMA confirmed by TVUS and/or MRI prior to surgery,\nwere reviewed retrospectively. Among these 158 patients,\nthe surgical approaches used were total laparoscopic cystec-\ntomy (TLC) (79 patients), total laparoscopic adnexectomy\n(TLA) (62 patients), and a combination of unilateral TLA\nand contralateral TLC (17 patients). Bilateral OMA was\ndetected in 28 patients in the TLC group, 10 patients in the\nTLA group, and 17 patients in the combined TLA and TLC\ngroups. Concomitant laparoscopic myomectomy (LM) was\nperformed in 8 patients. A total of 5 patients were excluded\nfrom the study due to recurrent OMA (3 patients) and post-\noperative detection of breast cancer (2 patients). Since the\nanalysis was restricted to patients of reproductive age (those\nyounger than 50 years) and excluded those who underwent\nboth abdominal and laparoscopic hysterectomy, the number\nof patients excluded from the study was small.\nWe extracted data on representative patient charac-\nteristics, such as age, delivery history, physical data, and\npresenting symptoms, from medical records. The follow-\nup period was calculated by subtracting the operation date\nof surgery from the last outpatient visit, postoperative hor-\nmone treatment included dienogest (61 patients), OCPs (37\npatients), GnRH analogues (5 patients), and levonorgestrel-\nreleasing intrauterine devices (2 patients). In 15 patients,\nmultiple hormone treatment methods were used in combi-\nnation.\n2.2 Analysis Method\nFirst, all 158 patients were divided into two groups\naccording to the presence or absence of postoperative OMA\nrecurrence. The 15 indicators listed in Table 1 were then\ncompared via Student’s t-test and Pearson’s Chi-square test.\nSimilarly, the 79 patients who underwent TLC were divided\ninto two groups based on whether a live birth was achieved.\nThe 12 indicators listed in Table 2 were then compared.\nNext, to identify risk factors for postoperative OMA\nrecurrence, we performed a multivariate logistic regression\nanalysis. Patients were divided into two groups according\nto the presence or absence of the following factors: (1) ad-\nvanced age, defined as ≥35 years; (2) high American So-\nciety for Reproductive Medicine score (ASRM score), de-\nfined as a score ≥80; (3) large cyst, defined as a cyst mea-\nsuring ≥80 mm; (4) elevated body mass index (BMI), de-\nfined as BMI ≥22 kg/m2; (5) nulliparity, defined as no pre-\nvious deliveries; (6) postoperative hormone treatment; (7)\nbilateral cysts; (8) TLA; (9) cancer antigen 125 (CA125)\npositivity, defined as a serum CA125 level ≥35 U/mL; (10)\nlong operation time, defined as an operation time ≥150\nminutes; and (11) massive blood loss, defined as a blood\nloss amount ≥200 mL (see Table 3). Similarly, to iden-\ntify the factors influencing live birth achievement, we ana-\nlyzed the aforementioned 10 factors after excluding TLA\n(Table 4). The criteria for “large cyst”, “long operation\ntime”, and “massive blood loss” were determined based on\nof the average (Avg) and standard deviation (SD) (mini-\nmum (Min) and maximum (Max)) of the aforementioned\n158 and 79 patients.\nStatistical analyses were performed using Microsoft\nExcel 365 (Microsoft Corporation, Redmond, W A, USA)\nand JMP version 17 for MAC (SAS Institute, Inc., Tokyo,\nJapan) to determine the correlations between patient char-\nacteristics and the outcomes of laparoscopic surgery. The\nodds ratios (ORs) and 95% confidence intervals (95% CIs)\nwere estimated to determine the strength of the correlations.\np < 0.05 indicated statistical significance.\n3. Results\n3.1 Patient Characteristics\nThe results obtained (Avg ± SD [Min–Max]) of the\nfollow-up time, age, BMI, cyst size, and ASRM were\n1304.6 ± 1094.3 (25–3731) days, 36.7 ± 7.2 (21–50) years,\n21.6 ± 3.8 (14.5–35.1) kg/m 2, 62.1 ± 22.2 (14–146) mm,\nand 54.0 ± 32.1 (17–144), respectively (Table 1). Almost\nall patients (144/158 patients) experienced menstruation-\nrelated symptoms, including pain (122 patients) or hyper-\nmenorrhea (120 patients). However, data on infertility were\nnot available. In these cases, presenting symptoms were ex-\ncluded from the analyses. When comparing the postopera-\ntive OMA recurrence group with the control group, a sig-\nnificant difference was found only in the follow-up time,\nprobably due to the small number of patients with postop-\nerative OMA recurrence. On the other hand, as shown in\nTable 2, the analysis of live birth achievement revealed sig-\nnificantly lower values for age, cyst size, and postoperative\nhormone treatment.\n3.2 Risk Factors for Postoperative OMA Recurrence\nPostoperative OMA recurrence was detected in 7 of\n158 patients, with all diagnoses confirmed via MRI. The re-\ncurrence rate observed in this study was relatively low. This\nwas probably due to the presence of patients who were re-\nferred to our hospital specifically for TLC or TLA. In these\npatients, the follow-up period was inevitably short. Ad-\nditionally, only approximately 40% of patients underwent\nTLA (n = 62/158), and OMA recurrence was detected in 1\npatient.\n2\n\n\nTable 1. Characteristics of patients who experienced postoperative OMA recurrence.\nTotal (Avg. ± SD, Min–Max, Number) Postoperative OMA recurrence cases (Avg. ± SD, Min–Max, Number) Control (Avg. ± SD, Min–Max, Number) p-value\nFollow-up period (days) 1304.6 ± 1094.3, 25–3731, n = 158 2831.3 ± 991.7, 1585–3731, n = 7 1233.8 ± 1048.9, 25–3674, n = 151 <0.01\nAge (years) 36.7 ± 7.2, 21–50, n = 158 38.1 ± 5, 33–45, n = 7 36.6 ± 7.3, 21–50, n = 151 0.58\nBMI (kg/m2) 21.6 ± 3.8, 14.5–35.1, n = 154 20.6 ± 2.4, 17.9–24.5, n = 7 21.7 ± 3.8, 14.5–35.1, n = 147 0.45\nCyst size (mm) 62.1 ± 22.2, 14–146, n = 158 61.9 ± 27.3, 20–109, n = 7 62.1 ± 22.1, 14–146, n = 151 0.97\nASRM score 54.0 ± 32.1, 17–144, n = 158 64.1 ± 23.6, 33–92, n = 7 53.5 ± 32.4, 17–144, n = 151 0.39\nOperation time (minutes) 115.5 ± 41.8, 43–262, n = 158 140.1 ± 44.1, 84–208, n = 7 114.4 ± 41.5, 43–262, n = 151 0.11\nBlood loss amount (mL) 49.7 ± 91.5, 0–507, n = 158 80.4 ± 123.5, 0–306, n = 7 48.3 ± 90, 0–507, n = 151 0.36\nNulliparity n = 94/158 n = 4/7 n = 90/151 1.00\nPostoperative hormone treatment n = 89/158 n = 2/7 n = 87/151 0.51\nBilateral cysts n = 55/158 n = 3/7 n = 52/151 0.98\nCA125 positivity n = 101/158 n = 5/7 n = 96/151 0.98\nTLC n = 79/158 n = 5/7 n = 74/151 0.72\nTLA n = 62/158 n = 1/7 n = 61/151 0.59\nUnilateral TLA and contralateral TLC n = 17/158 n = 1/7 n = 16/151 0.99\nConcomitant LM n = 8/158 n = 1/7 n = 7/151 0.73\n158 patients were divided into two groups according to the presence or absence of postoperative OMA recurrence, and 15 representative indices were compared.\nAvg, average; ASMR score, American Society for Reproductive Medicine score; BMI, body mass index; CA125, cancer antigen 125; LM, laparoscopic myomectomy; Max, maximum; Min; minimum;\nOMA, ovarian endometrioma; SD, standard deviation; TLA, total laparoscopic adnexectomy; TLC, total laparoscopic cystectomy.\nTable 2. Characteristics of patients who achieved a live birth.\nTotal (Avg. ± SD, Min–Max, Number) Live birth achievement cases (Avg. ± SD, Min–Max, Number) Control (Avg. ± SD, Min–Max, Number) p-value\nFollow-up period (days) 1301.2 ± 1081.6, 25–3731, n = 79 1652 ± 1134.2, 208–3674, n = 23 1157.1 ± 1035.4, 25–3731, n = 56 0.06\nAge (years) 31.5 ± 5.2, 21–45, n = 79 29.6 ± 4, 22–35, n = 23 32.3 ± 5.5, 21–45, n = 56 0.03\nBMI (kg/m2) 21.9 ± 3.8, 15.7–33.3, n = 79 23.0 ± 4.8, 15.7–33.3, n = 23 21.5 ± 3.3, 16.6–32.0, n = 56 0.11\nCyst size (mm) 61.7 ± 20.6, 14–146, n = 79 48.7 ± 17.1, 20–90, n = 23 67.1 ± 19.6, 14–146, n = 56 <0.01\nASRM score 51.2 ± 28.9, 17–128, n = 79 45.5 ± 24.2, 17–108, n = 23 53.6 ± 30.6, 20–128, n = 56 0.26\nOperation time (minutes) 124.2 ± 41, 58–221, n = 79 118.3 ± 41.9, 58–208, n = 23 126.7 ± 40.8, 62–221, n = 56 0.41\nBlood loss amount (mL) 59.6 ± 105.9, 0–507, n = 79 41.1 ± 96.8, 0–350, n = 23 67.2 ± 109.4, 0–507, n = 56 0.32\nNulliparity n = 63/79 n = 21/23 n = 42/56 0.44\nPostoperative hormone treatment n = 46/79 n = 6/23 n = 40/56 <0.01\nBilateral cysts n = 28/79 n = 5/23 n = 23/56 0.45\nCA125 positivity n = 21/79 n = 6/23 n = 15/56 1.00\nConcomitant LM n = 2/79 n = 1/23 n = 1/56 0.93\n79 patients were divided into two groups according to whether a live birth was achieved, and 12 representative indices were compared.\nAvg, average; ASMR score, American Society for Reproductive Medicine score; BMI, body mass index; CA125, Cancer Antigen 125; LM, laparoscopic myomectomy; Max, maximum; Min; minimum;\nSD, standard deviation.\n3\n\nTable 3. Risk factors for postoperative OMA recurrence.\nFactors OR (95% CI, Number) p-value\nAdvanced age ≥35 years old 4.1 (0.5–34.6, n = 6/96) <0.01\nHigh ASRM score ≥80 2.6 (0.6–12.1, n = 3/37) 0.57\nLarge cyst ≥80 mm 0.9 (0.1–7.7, n = 1/25) 0.47\nAbove standard BMI ≥22 kg/m2 0.8 (0.2–4.3, n = 2/52) 0.80\nNulliparity 0.9 (0.2–4.2, n = 4/94) 0.77\nPostoperative hormone treatment 0.3 (0.1–1.6, n = 2/89) 0.03\nBilateral cysts 1.4 (0.3–6.6, n = 3/55) 0.27\nTLA 0.2 (0.0–2.1, n = 1/62) <0.01\nCA125 positivity 1.4 (0.3–7.6, n = 5/101) 0.48\nLong operation time ≥150 minutes 1.8 (0.3–9.5, n = 2/30) 0.78\nMassive blood loss ≥200 mL 3.9 (0.7–22.1, n = 2/16) 0.03\nMultivariate analysis was performed on 158 patients to examine the\neffects of 11 representative factors based on data collected from med-\nical records. Table shows the number of patients with each factor,\nthe ORs and 95% CIs for postoperative OMA recurrence, and the\np-values.\nASMR score, American Society for Reproductive Medicine score;\nBMI, body mass index; CA125, cancer antigen 125; CI, confidence\ninterval; OMA, ovarian endometrioma; OR, odds ratio; TLA, total\nlaparoscopic adnexectomy.\nTo identify significant factors affecting the likelihood\nof postoperative OMA recurrence while controlling for con-\nfounding factors, a multivariate analysis of 11 represen-\ntative factors was performed (Table 3). This analysis re-\nvealed that advanced age (OR: 4.1, p < 0.01) and mas-\nsive blood loss (OR: 3.9, p < 0.05) were significant fac-\ntors that increased the likelihood of postoperative OMA re-\ncurrence. Conversely, postoperative OMA recurrence was\nsignificantly and negatively associated with postoperative\nhormone treatment (OR: 0.3, p < 0.05) and TLA (OR: 0.2,\np < 0.01).\n3.3 Factors Influencing Live Birth\nIn total, 24 out of 158 patients achieved a live birth,\nincluding 23 out of 79 patients who underwent TLC. Next,\ndata from 79 patients who underwent TLC and were aged\nbetween 21 and 45 years old were analyzed via multivari-\nate analysis of 10 representative factors to identify signifi-\ncant factors affecting the likelihood of achieving a live birth\n(Table 4). The present analysis revealed that three factors,\nnamely, advanced age (OR: 0.4, p < 0.05), postoperative\nhormone treatment (OR: 0.1, p < 0.01), and CA125 posi-\ntivity (OR: 0.3, p < 0.05), had significant negative effects\non live birth achievement.\n4. Discussion\nLaparoscopic surgery has become a commonly per-\nformed procedure for the treatment of OMA due to its rel-\natively short recovery time, brief hospital stay, and min-\nimal surgical wound [ 3]. However, managing OMA after\nsurgery is complex due of its relatively high recurrence rate.\nTable 4. Factors influencing live birth achievement.\nFactors OR (95% CI, Number) p-value\nAdvanced age ≥35 years old 0.4 (0.1–1.4, n = 4/23) 0.02\nHigh ASRM score ≥80 0.8 (0.2–2.7, n = 4/16) 0.72\nLarge cyst ≥80 mm 0.2 (0.0–1.5, n = 1/12) 0.19\nAbove standard BMI ≥22 kg/m2 1.7 (0.6–4.4, n = 11/31) 0.08\nNulliparity 3.5 (0.7–16.8, n = 21/63) 0.09\nPostoperative hormone treatment 0.1 (0.0–0.4, n = 6/46) <0.01\nBilateral cysts 0.4 (0.1–1.2, n = 5/28) 0.28\nCA125 positivity 0.3 (0.1–0.7, n = 9/49) 0.02\nLong operation time ≥150 minutes 1.0 (0.3–2.9, n = 6/21) 0.75\nMassive blood loss ≥200 mL 0.6 (0.1–2.9, n = 2/10) 0.80\nMultivariate analysis was performed on the data of 79 patients to\nexamine the effects of 11 representative factors for which data were\ncollected from medical records. Table shows the number of patients\nwith each factor, the ORs and 95% CIs for live birth achievement,\nand the p-values.\nASMR score, American Society for Reproductive Medicine score;\nBMI, body mass index; CA125, cancer antigen 125; CI, confidence\ninterval; OR, odds ratio.\nTherefore, postoperative follow-up, including postopera-\ntive hormone treatment, is crucial [2,9]. In particular, when\nperforming TLC to preserve fertility, complete removal of\nthe endometriotic lesion is often not feasible. In this anal-\nysis, TLA was found to have a significant negative impact\non postoperative OMA recurrence. To improve OMA treat-\nment and inform the selection of appropriate management\nstrategies, whether expectant, medical, or surgical manage-\nment [10], comprehensive analyses of patient data, includ-\ning surgical outcomes and follow-up durations, are becom-\ning increasingly important. Therefore, in this study, since\nmore than 70% of patients (n = 115/158) were followed up\nafter surgery for over 1 year, we collected data on both good\nand unfavorable outcomes, specifically, live birth achieve-\nment and recurrence.\nIn evaluating postoperative OMA recurrence as an\nunfavorable result, we found that three factors—advanced\nage, massive blood loss, and postoperative hormone\ntreatment—were significant. As expected, postopera-\ntive hormone treatment proved effective in decreasing en-\ndometriosis recurrence [ 2,9]. Among the aforementioned\n115 patients who were followed up for over 1 year, more\nthan 65% (n = 75/115) received postoperative hormone\ntreatment. This tendency might have contributed to the rel-\natively low recurrence rate observed in our study, consistent\nwith findings reported in previous reports [ 11]. The other\ntwo factors may indicate advanced endometriosis and in-\ncreased surgical difficulty. Advanced age also had a signif-\nicant negative impact on likelihood of achieving of a live\nbirth. In this study, we were unable to identify any cases\nwhere nulliparous women aged 36 years or older delivered\na baby after laparoscopic surgery. The negative impact of\nCA125 positivity may indicate the presence of undetectable\n4\n\n\nendometriosis, while the negative of postoperative hormone\ntreatment could be attributed to its to suppression of ovula-\ntion. In contrast to previous reports [ 2,12], we did not find\na significant effect of cyst size or the ASRM score. Addi-\ntionally, to validate our findings regarding significant fac-\ntors, additional data and analyses may be required. Unfor-\ntunately, this study had several limitations due to its retro-\nspective nature and the fact that it was conducted at a rural\ngeneral hospital. Specifically, the data were not always suf-\nficient, particularly regarding presenting symptoms. Ad-\nditionally, there was variability in follow-up periods, and\nthe number of variables for which data were extracted was\nlimited. To address these limitations, data analysis at hos-\npitals with advanced capabilities, such as university hospi-\ntals, may be necessary. The management methods, includ-\ning surgical techniques and postoperative infertility treat-\nments, were also limited by physician skill and institutional\ncapacity. In rural hospitals, introducing new techniques,\nsuch as laser vaporization [ 13], laparoscopic ovarian su-\nturing [14,15], and assisted reproductive technologies, can\nbe challenging. Therefore, further large-scale studies are\nneeded to obtain more accurate and comprehensive infor-\nmation.\n5. Conclusions\nWe identified the factors that negatively impact the\noutcomes of laparoscopic surgery for OMA, including ad-\nvanced age, massive blood loss, and CA125 positivity. Ad-\nditionally, postoperative hormone treatment was associated\nwith a reduction in postoperative OMA recurrence. These\nresults offer valuable insights to guide the selection of treat-\nment methods for OMA. However, due to limitations asso-\nciated with using retrospective data from medical records,\nfurther studies are needed.\nAbbreviations\nASRM score, American Society for Reproductive\nMedicine score; Avg, average; BMI, body mass index;\nCA125, cancer antigen 125; GnRH, gonadotropin-releasing\nhormone; LM, laparoscopic myomectomy; MRI, magnetic\nresonance imaging; CI, confidence interval; OCP , oral con-\ntraceptive pill; OMA, ovarian endometrioma; OR, odds ra-\ntio; SD, standard deviation; TLA, total laparoscopic ad-\nnexectomy; TLC, total laparoscopic cystectomy; TVUS,\ntransvaginal ultrasound.\nAvailability of Data and Materials\nThe datasets used and analysed during the current\nstudy are available from the corresponding author upon rea-\nsonable request.\nAuthor Contributions\nRA and WI collected and analysed the data and wrote\nthe manuscript. WI supervised the entire study. SH, RA,\nWI, HF, JT and AM performed medical care on the sub-\njects. SH determined the surgical method and supervised\nall medical procedures. All the authors have read and ap-\nproved the final manuscript. All authors contributed to ed-\nitorial changes in the manuscript. All authors have partici-\npated sufficiently in the work and agreed to be accountable\nfor all aspects of the work.\nEthics Approval and Consent to Participate\nThis study was reviewed and approved by the Hu-\nman Ethical Committee of Kinan Hospital (approval num-\nber 283). Informed consent was obtained from all patients.\nAcknowledgment\nThis research was supported by Kina Hospital regard-\ning the provision of medical information.\nFunding\nThe authors disclose the receipt of financial support\nfrom the Wakayama Prefecture Obstetrician Secure Fund\nfor the preparation and publication of this article.\nConflict of Interest\nThe authors declare no conflict of interest.\nReferences\n[1] Viganò P , Parazzini F, Somigliana E, V ercellini P . Endometrio-\nsis: epidemiology and aetiological factors. Best Practice & Re-\nsearch. Clinical Obstetrics & Gynaecology. 2004; 18: 177–200.\n[2] Nezhat FR, Cathcart AM, Nezhat CH, Nezhat CR. Pathophysi-\nology and Clinical Implications of Ovarian Endometriomas. Ob-\nstetrics and Gynecology. 2024; 143: 759–766.\n[3] Hart RJ, Hickey M, Maouris P , Buckett W. Excisional\nsurgery versus ablative surgery for ovarian endometriomata. The\nCochrane Database of Systematic Reviews. 2008; CD004992.\n[4] Benschop L, Farquhar C, van der Poel N, Heineman MJ. Inter-\nventions for women with endometrioma prior to assisted repro-\nductive technology. The Cochrane Database of Systematic Re-\nviews. 2010; CD008571.\n[5] Brown J, Farquhar C. Endometriosis: an overview of Cochrane\nReviews. The Cochrane Database of Systematic Reviews. 2014;\n2014: CD009590.\n[6] Daniilidis A, Grigoriadis G, Kalaitzopoulos DR, Angioni S,\nKalkan Ü, Crestani A, et al . Surgical Management of Ovarian\nEndometrioma: Impact on Ovarian Reserve Parameters and Re-\nproductive Outcomes. Journal of Clinical Medicine. 2023; 12:\n5324.\n[7] Choi SH, Kim S, Lee SW, Won S, Shim SH, Lee N, et al . Re-\ncurrence, Reoperation, Pregnancy Rates, and Risk Factors for\nRecurrence after Ovarian Endometrioma Surgery: Long-Term\nFollow-Up of 756 Women. Y onsei Medical Journal. 2023; 64:\n204–212.\n[8] Ngernprom P , Klangsin S, Suwanrath C, Peeyananjarassri K.\nRisk factors for recurrent endometriosis after conservative\nsurgery in a quaternary care center in southern Thailand. PLoS\nONE. 2023; 18: e0289832.\n[9] Koga K, Takamura M, Fujii T, Osuga Y . Prevention of the re-\ncurrence of symptom and lesions after conservative surgery for\nendometriosis. Fertility and Sterility. 2015; 104: 793–801.\n5\n\n[10] Muzii L, Galati G, Mattei G, Chinè A, Perniola G, Di Donato V ,\net al. Expectant, Medical, and Surgical Management of Ovarian\nEndometriomas. Journal of Clinical Medicine. 2023; 12: 1858.\n[11] V ercellini P , DE Matteis S, Somigliana E, Buggio L, Frattaruolo\nMP , Fedele L. Long-term adjuvant therapy for the prevention\nof postoperative endometrioma recurrence: a systematic review\nand meta-analysis. Acta Obstetricia et Gynecologica Scandinav-\nica. 2013; 92: 8–16.\n[12] Zheng L, Han J. Analysis of Risk Factors for Bleeding and Re-\ncurrence of Ovarian Endometriomas after Laparoscopic Surgery\nand Its Impact on Pregnancy Outcomes. Clinical and Experi-\nmental Obstetrics & Gynecology. 2024; 51: 5.\n[13] Adamyan L, Kasyan V , Pivazyan L, Isaeva S, Avetisyan J. Laser\nvaporization compared with other surgical techniques in women\nwith ovarian endometrioma: a systematic review and meta-\nanalysis. Archives of Gynecology and Obstetrics. 2023; 308:\n413–425.\n[14] Kitajima M, Khan KN, Harada A, Taniguchi K, Inoue T, Ka-\nneuchi M, et al. Association between ovarian endometrioma and\novarian reserve. Frontiers in Bioscience-Elite. 2018; 10: 92–\n102.\n[15] Riemma G, De Franciscis P , La V erde M, Ravo M, Fumiento P ,\nFasulo DD, et al. Impact of the hemostatic approach after laparo-\nscopic endometrioma excision on ovarian reserve: Systematic\nreview and network meta-analysis of randomized controlled tri-\nals. International Journal of Gynaecology and Obstetrics. 2023;\n162: 222–232.\n6","source_license":"CC0","license_restricted":false}