{"paper_id":"d1aa0a6e-464f-4916-bd24-879083e14434","body_text":"Javedani Masroor et al. \nMiddle East Fertility Society Journal           (2025) 30:19  \nhttps://doi.org/10.1186/s43043-025-00232-x\nRESEARCH Open Access\n© The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which \npermits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the \noriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. 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 \nto the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory \nregulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this \nlicence, visit http://creativecommons.org/licenses/by/4.0/.\nMiddle East Fertility\nSociety Journal\nEvaluation of endometrioma size effect \non IVF outcomes in young infertile women \ncandidates for IVF cycle\nMojgan Javedani Masroor1, Shima Ghezalbash1, Zahra Zandie1, Elahe Ghaderi1 and Saeedeh Shirdel2* \nAbstract \nBackground Endometriomas are ovarian cysts associated with endometriosis, potentially impacting ovarian reserve \nand in vitro fertilization (IVF) outcomes. The effect of endometrioma size on IVF success remains controversial. This \nstudy aimed to evaluate the influence of endometrioma size on ovarian reserve parameters, oocyte and embryo qual-\nity, and pregnancy outcomes in infertile women undergoing IVF.\nMethod This cross-sectional study included 57 infertile women with unilateral endometriomas undergoing IVF \nat Akbarabadi Hospital, Iran. Participants were divided into two groups based on endometrioma size: < 3 cm (n = 26) \nand ≥ 3 cm (n = 31). Ovarian reserve markers (AMH, AFC, FSH), oocyte and embryo quality, clinical pregnancy rate, \nand live birth rate were compared between groups. Statistical analyses were performed using SPSS 27.\nResult There were no significant differences between the two groups in age, BMI, duration of infertility, AMH, AFC, \nor FSH levels. Oocyte quality, embryo quality, and clinical pregnancy rates were also comparable (P > 0.05). However, \na significantly lower live birth rate was observed in the ≥ 3 cm endometrioma group compared to the < 3 cm group \n(28.6% vs. 70.0%, P = 0.004).\nConclusion Endometrioma size does not significantly affect ovarian reserve, oocyte retrieval, or early embryo \ndevelopment. However, larger endometriomas (≥ 3 cm) may be associated with a lower live birth rate, possibly due \nto inflammatory or mechanical effects. Further multicenter studies with larger sample sizes are needed to confirm \nthese findings and optimize IVF strategies for women with endometriomas.\nKeywords Endometrioma, IVF, Oocytes, Ovarian stimulation\nIntroduction\nThe general prevalence of endometriosis is about 10 to \n20%, with stage-specific prevalence ranging from 2% for \nstage 4 to 20% for stage 1 [1, 2]. The prevalence rate of \nendometriosis among women experiencing infertility is \nabout 30 to 50% [2–4]. Depending on the endometriosis \nsite, it can be categorized into various subtypes, includ -\ning endometrioma, deep infiltrating endometriosis (DIE), \nand superficial endometriosis [5–7]. Around 17 to 44% \nof women with a diagnosis of endometriosis will develop \nan endometrioma, lesions that contain thick, dark brown \nfluid and are called chocolate cysts [4, 8].\nRecent meta-analyses have indicated that both serum \nanti-Müllerian hormone (AMH) levels and antral fol -\nlicle count (AFC) are significantly lower in patients with \nendometriomas when compared to other benign ovarian \ncysts or non-cystic ovaries [9, 10]. The ovulation rate in \novaries impacted by an endometrioma is lower than in \nthe opposite unaffected ovary. The average ovulation rate \nin affected ovaries is 34.4 ± 6.6%, less than the anticipated \n*Correspondence:\nSaeedeh Shirdel\nsaeedehshirdel10@gmail.com\n1 Shahid Akbar Abadi Clinical Research Development Unit, School \nof Medicine, Iran University of Medical Sciences, Tehran, Iran\n2 Vali-E-Asr Reproductive Health Research Center, Family Health Research \nInstitute, Tehran University of Medical Sciences, Tehran, Iran\n\nPage 2 of 7Javedani Masroor et al. Middle East Fertility Society Journal           (2025) 30:19 \nrate of 50% in unaffected ovaries [11]. Assessing the \nreproductive outcomes of women with endometriomas \nwho have not previously had adnexal surgery revealed a \ndecreased response to ovarian stimulation, indicated by \nan increased cycle cancellation rate, a reduced number \nof retrieved m2 oocytes, but high-quality embryos, clini -\ncal pregnancy rate, implantation rate (IR) and live birth \nrate(LBR) were similar in women with and without endo-\nmetrioma. The number of embryos varied in different \nstudies [12–14]. The surgical procedure for an endome -\ntrioma is still controversial. Although specific research \nindicates that surgically excising large endometriomas \nmight enhance oocyte quality by lowering inflammation \nand clearing the ovarian environment, the surgery can \nalso diminish ovarian reserve; clinicians should consider \nits risk-benefit balance [14–16].\nAlthough numerous studies examined the effect of \nendometriomas and their surgical treatment on repro -\nductive characteristics and in vitro fertilization (IVF) out-\ncomes, there is a scarcity of research with mixed results \nregarding the impact of endometrioma size on these fac -\ntors. According to some studies, larger endometriomas \n(≥ 3–5 cm) at the time of IVF significantly decrease the \nnumber of oocytes retrieved and ovarian reserve com -\npared with the contralateral healthy ovaries [17–19]. \nHowever, in other studies, the larger size did not increase \nadverse IVF outcomes, including embryo quality [20].\nConsidering the conflicting and lack of evidence on the \nimpact of endometrioma size on IVF outcomes, our study \naims to investigate further the effect of endometrioma \nsize on IVF outcomes, which can assist in optimizing \nfuture treatment strategies and improving reproductive \noutcomes in patients.\nMethod\nStudy setting and design\nThis cross-sectional study was conducted at the infertil -\nity clinic of Akbarabadi Hospital, Tehran, from March \n2022 to March 2024. The study aimed to evaluate endo -\nmetrioma size on various IVF outcomes among infertile \nwomen.\nEligibility criteria\nThe inclusion criteria were women aged between 20 \nand 37 years undergoing IVF for infertility, the presence \nof unilateral endometrioma diagnosed via transvaginal \nultrasonography (TVUS), no history of IVF failure, and \nno previous ovarian or pelvic surgery. The exclusion cri -\nteria were severe male factor infertility, hydrosalpinx, \nprimary ovarian insufficiency (POI), hyperprolactinemia, \nuterine abnormality, history of recurrent miscarriage, \npolycystic ovarian syndrome, and history of autoimmune \ndisease or malignancy. Participants were aged 20–37 \nyears to minimize age-related confounding on ovarian \nreserve and IVF outcomes, as reproductive potential \ndeclines significantly beyond this threshold [21].\nEthical consideration\nThe study was approved by the Iran University of Medical \nScience ethics committee (approval number:IR.IUMS.\nFMD.REC.1401.124). Written informed consent was \nobtained from all participants, ensuring confidentiality.\nSample size and calculation\nThe sample size was calculated using the information \nobtained from the Ferrero 2017 study and the G POWER \nsoftware [19]. Considering the first type error of 0.05 and \nthe second type error of 0.2, as well as the average of 3.5 \n(± 1.7) MΙ eggs for the small endometrioma group and 2 \nfor the large endometrioma group, we determined that at \nleast 21 participants were needed for each group.\nData collection\nThis cross-sectional study with longitudinal follow-\nup prospectively collected IVF outcome data (March \n2022–2024) while utilizing medical records for baseline \ncharacteristics. Gynecologists actively recorded IVF out -\ncomes during patient follow-up visits, ensuring real-time \ndata collection for critical endpoints like oocyte quality, \nembryo transfer results, and live birth rates. Baseline data \n(endometrioma size, AMH levels, AFC) were extracted \nfrom medical records but verified by clinicians.\nParticipants were divided into two groups according \nto their endometrioma size (diameter) measurement \nby TVUS (centimeter). One group had endometriomas \nsmaller than 3 cm in diameter, and the other had 3 cm or \ngreater endometriomas. The 3  cm cutoff was chosen to \nbalance clinical significance and alignment with existing \nliterature [17, 22]. Endometrioma size was determined \nby averaging the transverse and longitudinal diameters \nmeasured via TVUS. This approach accounts for poten -\ntial irregular cyst morphology and reduces measurement \nbias compared to single-diameter reporting. Data were \ncollected through patients’ medical records. Variable \ngathered included:\nDemographic data: age (years), body mass index (BMI), \n(kg/m2), and the duration of infertility (years).\nThe reproductive parameters before IVF: anti-Mülle -\nrian hormone (AMH) level (ng/ml), antral follicle count \n(AFC), and follicle-stimulating hormone (FSH) level \n(IU/L).\nIVF-related outcomes: quality of retrieved oocytes, \nnumber and quality of transferred embryos, clinical preg-\nnancy rate, and live birth rate (LBR).\n\nPage 3 of 7\nJavedani Masroor et al. Middle East Fertility Society Journal           (2025) 30:19 \n \nPatients were included in the gonadotropin-releasing \nhormone (GnRH) antagonist protocol for IVF. The gon -\nadotropin dose was modified based on the assessment of \nfollicular growth observed through TVUS. When at least \ntwo follicles reached a mean diameter of 18 mm, oocyte \nmaturation was induced with 4,000 to 10,000  IU dose \nof human chorionic gonadotropin (HCG), and oocyte \nretrieval, assisted by TVUS, was conducted about 36 h \nfollowing the hCG injection. Then, the number and qual-\nity of oocytes were checked according to the degree of \nnucleus maturity (MΙ/MΙΙ/GV).\nIt should be noted that the injected sperm of all patients \nhave normal parameters according to WHO criteria. The \nquality of the resulting embryos by the embryologist of \nthe center on the third day of fertilization was evaluated \nand divided into four groups: grading A (equal blasto -\nmeres without fragments or less than 10%), B (equal blas-\ntomeres with fragments between 10 and 30%), C (equal \nor unequal blastomeres with fragments 30–50%), and D \n(uneven blastomeres with fragment with more than 50% \nfragments). Then, fresh embryos were transferred after \n6  weeks The second transfer was done among patients \nwith failure in first time. The third transfer was done in \ncases of second transfer failure. An ultrasound examina -\ntion was performed to determine clinical pregnancy. The \nlive birth rate was also evaluated.\nStatistical analysis\nThe information was inputted into the SPSS software \nversion 27. The mean and standard deviation (SD) were \nemployed to describe continuous variables, while cate -\ngorical data were presented as frequency and percentage. \nRank variables were analyzed using the k2 test or Fisher’s \nexact test, whereas quantitative variables were assessed \nwith the t-test or Mann–Whitney test. The Kolmogorov–\nSmirnov test was utilized to evaluate the distribution of \nthe data.\nQuantitative parametric data were evaluated using \nan independent t-test, while non-parametric data were \nassessed with the Mann–Whitney test. Qualitative \ndata were examined through the χ2 (chi-square) test. A \nP-value of less than 0.05 was determined to be statisti -\ncally significant. Multivariate regression analysis was \nconducted to adjust potential confounding variables like \nmaternal age.\nResult\nIn this study, 57 infertile women with unilateral endo -\nmetrioma who underwent IVF were evaluated. Partici -\npants were allocated into two groups: 26(45.6%) patients \nin the group with endometriomas smaller than 3  cm \nand 31(54.4%) patients with endometriomas equal to or \ngreater than 3 cm in diameter.\nWhen comparing the maternal demographic variables, \nincluding age, BMI, and the duration of infertility, there \nwere no significant differences between the two groups \n(P > 0.05). FSH levels were consistent between the two \ngroups: 8.99 ± 0.45 IU in the group with endometrioma \n< 3 cm and 8.0187 ± 0.50 in the other group (P = 0.53). \nThere was no significant difference concerning AMH lev-\nels between the smaller endometrioma group, 1.38 ± 0.83 \nng/dl, and the larger endometrioma group, 1.44 ± 0.85 \nng/dl (P = 0.79). Also, the mean number of antral folli -\ncles on the right and left sides in the two endometrioma \nsize groups had no statistically significant difference (P = \n0.477). All the above-mentioned data are summarized in \nTable 1.\nRegarding oocyte quality, there were no significant dif -\nferences between the two groups. The number of patients \nwith high-quality oocytes (MΙΙ) was 112(58.6%) in the \nendometrioma group < 3 cm and 97 (51.9%) in the endo -\nmetrioma group ≥ 3 cm, which is not statistically signifi -\ncant (P = 0.63) (Table 2).\nThere was no significant difference in the number \nand quality of embryos between the two groups, with \nTable 1 Comparison of the characteristics of patients before starting IVF cycle in two group\nP < 0.05 is considered statistically significant\nn sample size\nData are presented as mean±standard deviation (SD)\nVariable Endometrioma < 3 cm (n = 26) Endometrioma ≥ 3 cm (n = \n31)\nTotal (n = 5 7) P-value\nAge (years) 29.38 ± 3.93 29.03 ± 4.17 29/19 ± 4/03 0.74\nBMI (kg/m2) 21.96 ± 1.90 22.67 ± 1.81 22/350/41/87 0.15\nInfertility duration (years) 2.65 ± 0.65 2.64 ± 0.75 2/65 ± 0/72 0.96\nFSH (IU/L) 8.09 ± 0.45 8.01 ± 0.50 8/05 ± 0/48 0.53\nAMH (ng/ml) 1.38 ± 0.83 1.44 ± 0.85 1/4 ± 0/84 0.79\nAFC (number) 4.23 ± 2.64 3.74 ± 2.50 3.96 ± 2.56 0.47\n\nPage 4 of 7Javedani Masroor et al. Middle East Fertility Society Journal           (2025) 30:19 \n82 (76.6%) A, 17 (15.9%) B, and 8 (7.5%) C in the endo -\nmetrioma group < 3 cm and 75(69.5%) A, 24 (22.2%) B, \n9(8.3%) C in the endometrioma group ≥ 3 cm. Grade D \n(uneven blastomeres with more than 50% fragment) was \nnot observed in the examined cases (P = 0.67) (Table 3).\nThe mean number of transferred embryos was investi -\ngated in the first, second, and third transfer times. For the \nfirst time in the < 3 cm endometrioma group, 1.92 ± 0.74 \nembryos were transferred, compared to 1.81 ± 0.60 in the \nother group (P = 0.47). For the second time in the group \nof endometrioma < 3 cm, 1.92 ± 0.48 embryos vs. 1.93 \n± 0.68 in the endometrioma group ≥ 3 cm were trans -\nferred (P = 0.93). For the third time in the endometrioma \ngroup < 3 cm, 1.73 ± 0.78 embryos compared to 1.81 \n± 0.75 embryos in the endometrioma ≥ 3 cm were trans -\nferred (P = 0.71). This indicates no significant differences \nin the number of transferred embryos between the two \ngroups (Table 4).\nTwo groups’ cumulative clinical pregnancy rate was \nevaluated, and no statistically significant differences \nexisted. In the first embryo transfer, 30.8% of the endo -\nmetrioma group < 3 cm had a positive clinical pregnancy. \nThis rate was 25.8% in the endometrioma group ≥ 3 cm \n(P = 0.678). In the second transfer, 11.5% of the endome -\ntrioma group < 3 cm had a positive clinical pregnancy. \nThis rate was 3.2% in the endometrioma group ≥ 3 cm \n(P = 0.387). In the third transfer, 34.6% of the endometri -\noma group under 3 cm had a positive clinical pregnancy, \nand this rate was 16.1% in the endometrioma group \nabove 3 cm (P = 0.137) (Table 5).\nIn terms of pregnancy outcome, 14(70.0%) patients in \nthe endometrioma group < 3 and 4 (28.6%) patients in \nthe endometrioma group ≥ 3 cm had a live birth, which is \nstatistically significant (P = 0.004) (Table 6).\nDiscussion\nOur study aimed to evaluate the effect of endometrioma \nsize on IVF outcomes of infertile women. We divided \npatients into two groups: those with endometriomas less \nthan 3  cm in diameter and those with 3  cm and larger \nendometriomas. Our findings indicate that the endo -\nmetrioma size does not significantly impact most of our \nmeasured variables, such as AMH level, FSH level, AFC, \nand retrieved oocyte and embryo quality, suggesting \nthat endometrioma size may not affect the oocyte and \nearly stage of embryo development or transfer. However, \nalthough there are no statistical differences in the clinical \npregnancy rate, a trend of higher pregnancy rate, particu-\nlarly on the third transfer, is observed among the smaller \nendometrioma group. This trend, while not statistically \nsignificant, may suggest that larger endometriomas could \naffect the implantation rate of uterine receptivity, poten -\ntially due to mechanical or inflammatory factors associ -\nated with larger cysts. There is a significant difference in \nlive birth rates, with a higher rate in the smaller endome -\ntrioma group than in the larger one (76.9% vs. 48.4%, P = \n0.028). This finding indicates that larger endometrioma \ncould negatively affect the pregnancy rate with mecha -\nnisms such as inflammatory response in the later stage of \npregnancy.\nSimilar to our observations, in a 2020 descriptive study, \nAkgul et  al. found no association between AMH level \nand endometrioma size (greater than 40 mm and less \nthan 40 mm) [23]. However, In contrast to our finding, a \ncase-control study by Marcellin et al. in 2019 showed that \nserum AMH levels increased with endometrioma size. \nChen et al. in 2014 discovered that the damage of ovarian \nreserve in endometrioma correlated with the presence \nTable 2 Comparison of oocyte quality and number\nP < 0.05 is considered statistically significant\nn sample size\nData presented as number of patients (n) and percentages (%)\nVariable Endometrioma < 3 \ncm\nEndometrioma ≥ 3 \ncm\nP-value\nM1 21 28 0.63\nM2 112 97\nGV 58 62\ntotal 191 187\nTable 3 Comparison of the number and quality of embryos\nP < 0.05 is considered statistically significant\nn Sample size\nData presented as number of patients (n) and percentages (%)\nVariable Endometrioma < 3 \ncm (n = 26)\nEndometrioma ≥ 3 \ncm (n = 31)\nP-value\nA 82 75 0.67\nB 17 24\nC 8 9\ntotal 107 108\nTable 4 Comparison of the number of embryos at three \ndifferent transfer cycles\nP < 0.05 is considered statistically significant\nn sample size\nData are presented as mean±standard deviation (SD)\nVariable Endometrioma < 3 cm Endometrioma \n≥ 3 cm\nP-value\nFirst transfer 1.92 ± 0.74 1.80 ± 0.60 0.51\nSecond transfer 1.92 ± 0.48 1.93 ± 0.68 0.93\nThird transfer 1.73 ± 0.77 1.80 ± 0.74 0.71\n\nPage 5 of 7\nJavedani Masroor et al. Middle East Fertility Society Journal           (2025) 30:19 \n \nof bilateral cysts and larger size (notably for cysts larger \nthan 7 cm), and larger endometrioma is associated with \nlower serum levels of AMH [24].\nRegarding the size of the endometrioma and its effect \non IVF outcomes, in line with our results, Almog et  al. \n(2011) compared the impact of endometrioma larger \nthan 25 mm with smaller endometriomas on the num -\nber of oocytes retrieved And determined no relation -\nship between the size of the endometrioma and the total \nnumber of oocytes retrieved [25]. In agreement with \nour findings, in a cross-sectional study by Zareii et al. in \n2023, patients with unilateral and bilateral endometrioma \nwere divided into three groups based on the size of the \nendometrioma (1–3 cm, 3–6 cm, 6–10 cm). Although \nthe AMH level declined as the size of the endometrioma \nincreased, this difference was not statistically significant \n(P = 0.07). Additionally, there was no significant differ -\nence in embryo quality between the groups based on the \nendometrioma size. However, this study did not evaluate \nthe effect of endometrioma size on pregnancy complica -\ntions and LBR [20].\nUnlike the outcomes observed in our study, in \n2020, Somigliana et  al. concluded that endometrio -\nmas greater than 4  cm could reduce ovarian respon -\nsiveness during IVF cycles [26]. Furthermore, Orazov \net al. (2019) found a deterioration in oocyte quality in \npatients with endometriomas larger than 3  cm, and \nendometriomas adversely impact oocyte quality [27]. \nA 2017 study by Ferrero et al. reported that the quality \nand number of oocytes retrieved were lower in ovaries \nwith large endometriomas (≥  5 cm) compared to con -\ntralateral healthy ovaries. However, it did not compare \nthis endometrioma size with a smaller group [19].\nThere are many reasons for our study’s findings \nto vary from those of others. This study specifically \nexamines the impact of endometrioma size on IVF \noutcomes. In contrast, many others evaluate broader \ncomparisons such as endometrioma vs. no endome -\ntriomas or unilateral vs. bilateral. For instance, Ferrero \net al. and Somigliana et al. focused on larger endome -\ntrioma (≥  5 cm or ≥ 4 cm), while our cutoff was 3 cm. \nIn addition, our sample size and selection criteria can \nlimit the patient pool and explain the lack of significant \ndifferences compared to studies such as Somigliana \net al., which include a more heterogeneous population \n[19, 26].\nAn increasing number of studies have examined the \nimpact of endometrioma itself and endometrioma sur -\ngery on ovarian reserve and IVF outcomes [4 , 12, 14, \n15, 28]. Still, there is a lack of sufficient data regarding \nthe influence of endometrioma size on ovarian reserve \nand fertility outcomes, including the number and qual -\nity of retrieved oocytes and embryos, fertilization rate, \nand pregnancy outcomes and complications. Since dif -\nferent results have been obtained regarding the effect \nof endometrioma surgery on reproductive function \nand IVF outcomes, examining the impact of the size \nof endometrioma size can prevent unnecessary, inef -\nfective, and optimizing future treatment strategies [15, \n29– 32].\nSome limitations of the present study should be con -\nsidered. Our sample size is relatively small, especially \nafter dividing participants into two groups, which lim -\nits the statistical power to detect subtle differences. \nMoreover, it is a single-center study, and the findings \nmay not be generalizable to other populations or set -\ntings. This study also does not evaluate bilateral endo -\nmetrioma, the severity of endometriosis (beyond \nTable 5 Comparison of the cumulative clinical pregnancy rate after 3 times of embryo transfer\nP < 0.05 is considered statistically significant\nn sample size\nData presented as number of patients (n) and percentages (%)\nVariable Endometrioma < 3 cm Endometrioma ≥ 3 cm P-value\nFirst transfer Positive 8(30.8%) 8(25.8) 0.67\nNegative 18(69.2%) 23(74.15%)\nSecond transfer Positive 3(11.5%) 1(3.2%) 0.38\nNegative 15(57.7%) 22(71%)\nThird transfer Positive 9(34.6%) 5(16.1%) 0.13\nNegative 6(23.1%) 14(45.2%)\nTable 6 Comparison of pregnancy outcomes among \nparticipants with positive clinical pregnancy\nP < 0.05 is considered statistically significant\nn sample size\nData presented as number of patients (n) and percentages (%)\nVariable Endometrioma \n< 3 cm (n = 20)\nEndometrioma \n≥ 3 cm (n = 14)\nTotal P-value\nLive birth rate 14(70.0%) 4(28.6%) 28 0.004\n\nPage 6 of 7Javedani Masroor et al. Middle East Fertility Society Journal           (2025) 30:19 \nendometrioma size), fertilization rate, chemical preg -\nnancy, and inflammatory markers. However, this study \nhas several notable strengths compared to previous \nstudies. First, it is among the few to specifically inves -\ntigate the impact of endometrioma size (stratified by a \nclinically relevant 3 cm cutoff) on live birth rates (LBR), \na critical IVF outcome often overlooked in prior stud -\nies focusing solely on ovarian reserve or embryo qual -\nity. Second, our hybrid design—combining prospective \noutcome tracking with rigorous baseline data verifica -\ntion—enhances the reliability of findings while mini -\nmizing recall bias. Third, we isolated the effect of cyst \nsize by excluding confounders (e.g., bilateral cysts, \nprior ovarian surgery) and controlling for age (20–37 \nyears). Finally, using standardized IVF protocols and \ncentralized embryology assessments ensures consist -\nency in outcome measurements.\nFuture research should involve larger groups from mul-\ntiple centers to improve the generalizability and statistical \npower. A prospective design could provide more reliable \nevidence and reduce biases. Furthermore, categorizing \nparticipants into more specific size groups (e.g., < 3 cm, \n3–5 cm, > 5 cm) could yield more accurate insights into \nthe effects of size. Also, Investigating inflammatory or \noxidative stress markers associated with endometriomas \nand their potential difference in variable cyst size could \nclarify the mechanisms that affect infertility.\nConclusion\nOur study evaluates the effect of endometrioma size on \novarian reserve and IVF outcomes in infertile women. \nThe findings indicate that the endometrioma size does \nnot significantly affect ovarian reserve parameters, \nincluding AMH, AFC, or FSH levels. It also does not \naffect the quality of retrieved oocytes, the number and \nquality of embryos, or the clinical pregnancy rate. How -\never, a larger size could negatively impact the live birth \nrate compared to a smaller size. Future multicenter pro -\nspective studies with a larger sample size and broader \ncomparison are necessary to confirm these findings.\nAbbreviations\nDIE  Deep infiltrating endometriosis\nAFC  Antral follicle count\nIR  Implantation rate\nLBR  Live birth rate\nIVF  In vitro fertilization\nTVUS  Trans vaginal ultrasonography\nBMI  Body mass index\nFSH  Follicular stimulating hormone\nHCG  Human chorionic gonadotropin\nWHO  World Health Organization\nAcknowledgements\nAcknowledgements: We acknowledge using ChatGPT-4 (OpenAI) for \nlanguage editing and improving paragraph structure in this manuscript. We \nconfirm that the authors solely developed all research content, data analysis, \ninterpretations, and conclusions. The AI tool was used strictly for linguistic \nrefinement and did not contribute to the scientific content or conclusions of \nthe study.\nConflicts of interest\nThe authors declare that they have no conflicts of interest.\nAuthors’ contributions\nM.J.M. Conception, supervision, data revising; S.G. original draft preparation. \nCollecting data; Z.Z. Statistical analysis; E.GH: collecting data; S.SH: Writing – \noriginal draft. Review article.\nFunding\nNo financial support/funding was received for this study.\nData availability\nThe corresponding author can provide the datasets used in the current study \nupon a reasonable request.\nDeclarations\nEthics approval and consent to participate\nThe ethics committee of Iran University of Medical Science approved the \nstudy (approval number: IR.IUMS.FMD.REC.1401.124).\nConsent for publication\nNot applicable.\nConflict\nThe authors declare no competing interests.\nReceived: 16 February 2025   Accepted: 31 May 2025\nReferences\n 1. 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