What is the recommended management of a young woman with an intact endometrioma desiring future fertility?

Johnny S. Younis, Younis JS, Scott M. Nelson
Frontiers in endocrinology · 2022 · vol. 13 , pp. 1005597 · doi:10.3389/fendo.2022.1005597 · PMID:36440194 · PMC9685664 · W4308878226
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⚙ AI-generated summary by claude@2026-06, 2026-06-07 ⓘ

This opinion piece reviews the recommended management of young women with intact endometriomas who desire future fertility, focusing on current guidelines and potential therapeutic strategies.

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⚙ AI-generated deep summary by claude@2026-06, 2026-06-07 · read from full text ⓘ

This commentary reviews evidence on how intact endometriomas and endometrioma cystectomy affect ovarian reserve and ART outcomes in women desiring fertility, synthesizing data from prospective studies, systematic reviews, and meta-analyses. It reports that serum AMH is often lower in women with intact endometrioma (meta-analytic difference), but that unilateral versus bilateral disease shows no significant AMH difference in prospective data, creating uncertainty; the paper also emphasizes that many ART/complication and ovarian-reserve studies are limited by predominantly retrospective designs and small samples. For surgery, it summarizes histologic and functional findings that cystectomy can cause a measurable and often seemingly non-reversible decline in ovarian reserve (including POI risk mainly with bilateral or repeat surgery) and that bipolar coagulation may be more detrimental than non-thermal methods. The paper’s conclusions also state that IVF outcomes (oocyte yield, clinical pregnancy, live birth) appear comparable with or without cystectomy for many endpoints, but that stronger prospective evidence is needed, and it explicitly frames these issues within endometriosis endometrioma management for fertility. This paper is centrally about endometriosis — it specifically addresses management of young women with intact endometriomas who desire future fertility and evaluates ovarian reserve changes and ART outcomes.

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Abstract

OPINION article Front. Endocrinol., 10 November 2022Sec. Reproduction Volume 13 - 2022 | https://doi.org/10.3389/fendo.2022.1005597
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Is

The likelihood of developing ovarian cancer within an endometrioma is rare at reproductive age. The lifetime ovarian cancer risk in the general population is estimated to be 1.31% compared to 1.80% in women with endometriosis, with a low relative risk of 1.42% ( 32 ). In a recent nationwide Dutch study of 131,240 women with histologically diagnosed endometriosis and 132,654 matched controls, a higher incidence of clear-cell, endometrioid, and all ovarian cancer subtypes was found in women with histologically proven endometriosis ( 33 ). However, in many of these women, endometriosis and ovarian cancer were diagnosed synchronously after the average menopausal age. This suggests that the risk of ovarian cancer in endometriosis patients remains, even when symptoms are no longer present. This would indicate that long-term follow-up is required.

Does

Low-quality evidence suggests deep invasive endometriosis may progress with controlled ovarian stimulation ( 31 ). In contrast, there is moderate evidence to suggest that IVF-ET does not worsen pain related to endometriosis nor increase the risk of endometriosis recurrence ( 31 ).

What

Histological studies revealed that endometriotic cystectomy is commonly complicated by the inadvertent removal of normal ovarian follicles adjacent to the pseudo-capsule, which seems unavoidable even in the hands of experienced surgeons ( 12 – 14 ). This iatrogenic damage may result from inevitable manipulation of the cortex with tearing of tissue planes and even minimal bleeding associated with coagulation damage. Endometriotic stripping cystectomy has also been shown to have an adverse impact on serum AMH levels ( 15 ). In a recent systematic review and meta-analysis, the weighted mean difference (WMD) of serum AMH levels dropped significantly by 1.65 ng/ml (95% CI: 1.15 to 2.15) and by 2.03 ng/mL (95% CI: 1.47 to 2.58) at 9-12 months postoperatively as compared to basal levels in the unilateral and bilateral endometriotic cystectomy groups, respectively, equivalent to 39% and 57% decrease following the operation ( 11 ). In this regard, several systematic reviews and meta-analyses have examined whether different hemostasis means during endometriotic cystectomy may have an altered impact on ovarian reserve ( 16 – 18 ). In all of these studies, bipolar coagulation was more detrimental than other non-thermal methods (sutures or hemostatic sealants). In one meta-analysis, the mean decline in serum AMH levels was about 7% less with non-thermal methods than with bipolar coagulation ( 16 ). Notably, these meta-analyses included retrospective studies, a modest number of women (n = 105-312), and evaluated serum AMH levels only once, three months following surgery. Collectively, this histological and functional data would suggest that endometrioma cystectomy has an immediate impact on the ovarian reserve, which is clinically detectable by AMH. Bipolar coagulation should be cautiously limited in these cases.

Could

Although reported in both the immediate and late postsurgical period ( 20 – 22 ) and associated with an increased risk of earlier menopause ( 21 ), POI is an uncommon complication affecting up to 2.4% of women after endometriotic cystectomy ( 20 ). POI primarily developed in women having bilateral endometriotic cystectomy or in conjugation with repeat surgery ( 20 , 22 ). This risk relationship was further modified by age, with older women at the time of surgery having a greater risk of POI (correlation coefficient: -0.63, Spearman’s correlation coefficient by rank test) ( 22 ).

Intro

Endometriosis is a common, chronic, and inflammatory illness, with endometrioma a distinct advanced and progressive manifestation of the disease associated with reproductive dysfunction, infertility, and the need for ART treatment. Endometrioma is the most frequently diagnosed form of the disease, identified in up to 44% of affected women. However, the temporal management of endometriomas in women wishing to conceive or relative to ART treatment is not standardized, with surgery frequently advised pre-conceptually and before IVF treatment ( 1 , 2 ). Despite recent guidelines suggesting that clinicians may consider laparoscopy to treat infertility, routine endometrioma removal before ART is not indicated ( 3 ). Reevaluation of this practice within a critical framework that addresses the impact of endometrioma on ovarian reserve and whether its removal is beneficial in terms of fecundity and efficacy of ART treatment is, therefore, timely. This commentary explores recent evidence in a pragmatic question-driven approach and proposes a suggested clinical management strategy.

Which

Previous systematic reviews and meta-analyses have either evaluated antral follicle count (AFC) or AMH with discordant outcomes and confusing clinical messages ( 15 , 23 ). A recent meta-analysis undertook a different methodology to overcome potential measurable and non-measurable confounders, evaluating repeat, concomitant, and parallel measures of AMH and AFC in the same women, settings, and periods ( 19 ). Fourteen prospective studies and 650 women were included. Endometriotic cystectomy in the pooled prospective studies was associated with a significant reduction in serum AMH but not AFC, with detrimental effects consistently detectable for AMH at the early, intermediate, and late postoperative time intervals corresponding to 1.77 ng/mL (95% CI: 0.77 to 2.77), 1.17 ng/mL (95% CI: 0.66 to 1.67) and 2.13 ng/mL (95% CI: 1.61 to 2.65), respectively. In contrast, AFC estimates did not change significantly in the parallel periods despite being simultaneously measured in the same women. These results suggest that AMH is a more sensitive biomarker of ovarian reserve than AFC and should be routinely incorporated in women’s pre and post-operative counseling considering endometriotic surgery.

Conclusion

Collectively these data would support conservative management of endometrioma until reproductive aspirations are realized. Our recommendation for the avoidance of routine endometriotic cystectomy is consistent with international guidelines. It is based on multiple synergistic and interconnected queries directly related to the effect of ovarian endometrioma on ovarian reserve and the probability of attaining pregnancy. Conservative management should be encouraged even when ART is performed unless there is a considerable risk of endometrioma complications. We do, however, acknowledge the lack of evidence either way for surgery when ART has failed repeatedly. Other situations where diagnostic laparoscopy should be considered include women with endometriosis-associated pelvic pain when medical therapy has failed. Surgical treatment should also be discussed in ART cases where developing follicles cannot be reached during oocyte retrieval. In addition, in patients with endometrioma developing manifestations of endometriosis-associated ovarian cancer, although rare in reproductive age, surgery and histologic evaluation may be inevitable for final diagnosis and treatment. We appreciate that many of the presented studies have been retrospective. Future prospective studies will refine risk estimates further; until then, avoiding iatrogenic deleterious and sustained effects on the ovarian reserve with little upside should be avoided. In addition, future studies should explore other advanced (non-conservative) modalities of endometrioma treatment impacting ovarian reserves, such as ultrasound-guided sclerotherapy or laser vaporization, compared to cystectomy to advise young women desiring future fertility properly. Furthermore, fertility preservation should be discussed in these women, especially when surgery is unavoidable and in cases where ovarian reserve is a priori impaired.

Disclaimer

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Coi Statement

SN reports personal fees from Access Fertility, personal fees from Merck, personal fees from Ferring, grants and personal fees from Roche Diagnostics, personal fees from The Fertility Partnership, and personal fees from Modern Fertility, outside the submitted work. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Author Contributions

JSY contributed to the conception and design of the manuscript and drafted the article. SN edited and revised the manuscript for important intellectual content. All authors contributed to the article and approved the submitted version.

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Condition tags

endometriosisendometrioma

MeSH descriptors

Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis

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