Risks of conservative management in women with ovarian endometriomas undergoing IVF

BACKGROUND: Classical surgical management of endometriotic ovarian cysts using the laparoscopic stripping technique has been recently questioned because of the surgical-related injury to the ovarian reserve. Accordingly, available guidelines suggest that endometriomas with a mean diameter below 4 cm should not be systematically removed before IVF procedures. However, conservative management may have some potential drawbacks and risks. The presence of the endometrioma may theoretically interfere with ovarian responsiveness to hyperstimulation and oocyte competence, the retrieval of the oocytes may be more difficult and risky, the disease may progress during the procedure, pregnancy outcome may be affected and there is the risk of missing occult malignancies with cancer development later in life. In the present review, we aimed at assessing whether these risks do exist and, if so, at estimating their clinical relevance. METHODS: We searched PubMed for articles published in the English language between January 1990 and August 2014 that reported on endometriomas and assisted reproductive techniques. Special care was given to studies reporting data purporting to distinguish the effects of ovarian endometriomas per sé from those consequent to surgery for endometriosis or from endometriosis in general. RESULTS: Based on the evidence reviewed in the present study, it can be concluded that conservative management may actually expose women to four of the following theoretical risks, i.e. infection of the endometriomas, follicular fluid contamination with the endometrioma content, higher risk of pregnancy complications and cancer development later in life. The first three conditions do not justify surgery because these events are uncommon and the number of women needed to be treated would be exceedingly high and would not justify the costs and risks of the intervention. Albeit also very rare, the possibility of developing ovarian cancer later in life is more troublesome because it is a life-threatening condition. However, this alarmism is supported by only one cohort study and this risk can be effectively prevented by postponing surgery until after the IVF programme is concluded or when women have definitely satisfied their reproductive wishes. CONCLUSION: The available evidence on the risks of conservative management does not support systematic surgery before IVF in women with small ovarian endometriomas.