Ovarian function and fertility after plasma ablation or focused energy versus conventional cystectomy for endometriosis: a systematic review

Background: Deep ovarian endometriosis is a common disease of reproductive-aged women and surgical treatment is difficult because of the delicate balance between complete removal of the disease and preserving ovarian function. Conventional cystectomy, though effective, may cause damage to healthy ovarian tissue which may affect ovarian reserve. Emerging plasma and focused energy ablation techniques have theoretical advantages in that they selectively target the endometriotic tissue and have less collateral damage. This systematic review compares ablation techniques and conventional cystectomy in ovarian reserves and fertility outcomes. Methods: Following the PRISMA model, we systematically searched PubMed, Scopus, Cochrane Library and Web of Science databases from January 2015 to May 2025. Eligible studies were randomized controlled trials and prospective cohort studies that compared plasma or focused energy ablation versus cystectomy in the treatment of ovarian endometrioma which reported the anti-Mullerian hormone (AMH), antral follicle count (AFC), pregnancy rates and recurrence rates. Findings: 9 studies (all 822 patients) were included. Meta-analyses showed much better ovarian reserve preservation using ablation techniques than cystectomy. Ablation had a much lower impact on postoperative AMH decrease. The values of AFC were significantly higher after ablation. There was no significant difference in pregnancy rates between techniques. The rates of recurrence were greater in ablation. Conclusions: Plasma and focused energy ablation techniques provide better ovarian reserve preservation than conventional cystectomy for deep ovarian endometriosis with similar pregnancy results but an increased risk of recurrence. These results justify the use of ablation as a fertility-conserving option in the selected patients.