L26/P-314 Optimal Laparoscopic Surgical Technique for Preserving Fertility and Ovarian Reserve in Patients with Endometrioma: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Abstract Study question Which laparoscopic surgical technique for endometrioma management is the most effective in maximizing postoperative fertility while minimizing ovarian reserve loss in reproductive-aged women? Summary answer Fenestration with bipolar coagulation (FBC) yielded the highest pregnancy rates, while vasopressin-assisted (VCBC) and cystectomy with bipolar coagulation (CBC) best preserved ovarian reserve (OR). What is known already Endometrioma is a complex type of endometriosis, which causes ovarian tissue stretching and induction of inflammation. It can affect ovarian reserve (OR) and interfere in fertility outcomes (FO) in post-operative moment. Surgeons face a balancing act between complete excision and OR preservation. While laparoscopic excision is still the gold standard in surgical treatment, variations in excision methods and hemostasis approaches may directly affect FO. The optimal surgical technique, specially for women who wish to conceive, is still debated, and there are no studies that compare all the surgical techniques for endometrioma management currently available. Study design, size, duration A systematic review and frequentist network meta-analysis of randomized controlled trials(RCTs) comparing nine laparoscopic surgical techniques(ST) for endometrioma management. The search strategy led to 258 articles, we included twelve RCTs (1,076 women) in the final analysis. Literature search covered PubMed, Embase, Cochrane, and Scopus up to July 2025. Included studies had to report at least one outcome, the primary outcome being pregnancy rate 12-months post-operation, and the secondary outcome being anti-Müllerian hormone(AMH) decline 3-months post-operation. Participants/materials, setting, methods RCTs enrolling women between 18-40 years old,with unilateral/bilateral endometriomas,undergoing primary surgery,were included. The network compared nine surgical techniques for endometrioma management, such as drainage followed by CO2 laser vaporization(DLV), FBC, cystectomy followed either by suturing(CS), hemostatic sealants(CHM), or ultrasonic scalpel(CUS), pre-cystectomy with vasopressin(VCBC) or saline(SCBC) injection, CBC,and cystectomy-only(C). Using software R, we calculated risk ratios (RR) for pregnancy rate, and mean differences(MD) for AMH-decline, with 95% confidence intervals(CI). P-Scores were employed to rank surgical techniques. Main results and the role of chance Twelve RCTs, from seven different countries, were included(1,076 women). For pregnancy rate 12-months post-operation (9 RCTs, 483 women), seven surgical techniques were analysed. Across all comparisons, point-estimates suggested a possible advantage of DLV compared with CS (RR = 2.77; 95%CI 0.45–16.91) and FBC (RR = 1.44; 95%CI 0.15–13.70), although highly uncertain. Similarly, CBC showed a tendency compared to FBC (RR = 1.70; 95%CI 0.89–3.27), but without statistical significance. Adjunctive therapies, such as SCBC or VCBC indicated no clear differences in efficacy for pregnancy rate. Ranking of interventions with P-scores showed that FBC ranked highest (P-score:0.82), followed by CS (P-score:0.59), while DLV ranked lowest (P-score:0.27). However, no comparison reached statistical superiority. For AMH-decline (8 RCTs, 715 women), six surgical techniques were analysed. Across comparisons, CBC was associated with a significantly greater AMH-decline compared with CS (MD= -0.99 ng/ml; 95% CI -0.72 to -0.26). All other pairwise contrasts (CHM,CUS,DLV,VCBC) were imprecise with CI crossing null. Treatment ranking indicated that VCBC was most likely to minimize AMH-decline (P-score:0.73), followed by CBC (P-score:0.65) and CUS (P-score:0.60). These rankings complete but do not supersede the pairwise results. Funnel plots showed no evidence of small-study effects (Egger’s test: p = 0.58 for pregnancy; p = 0.46 for AMH-decline). Node-splitting analysis indicated no inconsistency. Limitations, reasons for caution FBC, which ranked highest for pregnancy rate, could not be evaluated for its impact on AMH-decline due to a lack of reported AMH data in the included trials. Consequently, remains uncertain whether FBC apparent reproductive benefit. Wider implications of the findings Surgical techniques with greater AMH-decline, such as CS, may still yield higher pregnancy rates, suggesting AMH reduction does not equate to reduced fertility. AMH should be interpreted cautiously, with pregnancy and live birth as primary outcomes. Future RCTs, particularly focused on FBC, should access pregnancy/live-birth rates, recurrence rates, and OR. Trial registration number Yes