Management of ovarian endometriomas: many options…but difficult decisions

The incidence of ovarian endometrioma continues to rise along with the improved accuracy of available imaging modalities allowing prompt diagnosis. Still, the clinical management of ovarian endometrioma remains a challenge with many factors to consider, such as the woman's age, fertility history and desire for a child, cyst growth rate, and the dominant complaints of pain versus subfertility. The effect of any intervention on the remaining ovarian egg reserve and on the subsequent fertility potential is fundamental in differentiating among the available treatment options. Methods to achieve adequate haemostasis following the stripping of the ovarian cyst wall laparoscopically seem to vary in their damage to the ovarian tissue with many studies suggesting increased loss when bipolar diathermy is used. (Ding et al. Reprod Biomed Online 2015;30.6:635–42.) The article by Chung et al. (BJOG 2019;126:1267–75) presents the findings of a randomised trial evaluating the use of FloSeal, a bovine-derived gelatine matrix with a human-derived thrombin component, as an alternative to bipolar diathermy to achieve haemostasis after ovarian cystectomy. The authors reported on the mean antral follicle count as the primary outcome to detect the change in each individual ovarian reserve postoperatively. Although supporting an overall protective effect with using FloSeal, the findings of this study should be interpreted with caution. The use of antral follicle count over other markers of ovarian reserve, such as anti-Müllerian and follicle-stimulating hormones, could be subject to performance bias especially when measured preoperatively in the presence of large endometriomas. Inter-patient variations in relation to age, size of endometrioma and fertility history could also bias the findings. Crucially, reporting on changes in ovarian markers offers limited clinical value as no long-term follow up was performed to report on key outcomes such as clinical pregnancy and live birth rate. FloSeal seems to offer an adequate method of haemostasis for ovarian surgery, but it is associated with a higher cost. For this reason, an argument to use intracorporeal suturing, where surgical experience allows, might have value. The findings of this trial should be looked at within a larger body of literature highlighting the need to question the immediate role of surgery for managing women with endometriomas. (Muzii et al. Semin Reprod Med 2017;35:25–30) This is particularly relevant to asymptomatic nulliparous women with incidental endometriomas. Several studies suggested an improved clinical outcome for both pain (Vercellini et al. Acta Obstet Gynecol Scand 2013;92:8–16) and fertility (Cantor et al. Reprod BioMed Online 2019;38.4:520–7) when more conservative treatments are employed. The use of validated prediction and decision aid models could help clinicians to better address this issue (Muzii et al. Semin Reprod Med 2017;35:25–30); however, such models remain scarce and of poor applicability. There remains a need for large, prospective randomised trials to evaluate combined and conservative treatment options for women with endometriomas and to enable more accurate evidence synthesis. None. A completed disclosure of interest form is available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.