Factors Influencing Postoperative Recurrence and Live Birth Achievement after Laparoscopic Surgery for Ovarian Endometrioma: A Retrospective Study in a Regional Core Hospital

Background: Ovarian endometrioma (OMA) is a common gynecological condition affecting women of reproductive age, often requir- ing laparoscopic surgery for removal. However, the management of OMA, including postoperative hormone therapy, is complex and must be tailored to the individual’s conditions. Therefore, to provide meaningful insights, we aimed to analyze 10 years of accumulated data from patients who underwent laparoscopic surgery for OMA, with a primary focus mainly on postoperative OMA recurrence and live birth outcomes. Methods: We reviewed the medical records of 158 patients who underwent laparoscopic surgery for OMA, includ- ing total laparoscopic cystectomy (TLC) (79 patients), total laparoscopic adnexectomy (TLA) (62 patients), or both unilateral TLA and contralateral TLC (17 patients), between January 2014 and December 2023. Among the OMA patients, we identified 7 cases of postop- erative OMA recurrence out of 158 patients, and 23 live births among 79 TLC patients. We performed a multivariate logistic regression analysis to assess the impact of each representative factor on postoperative OMA recurrence and live birth achievement. Results: The multivariate analyses of the 158 patients revealed that advance age and massive blood loss were significantly associated with an increased risk of postoperative OMA recurrence, while postoperative hormone treatment was associated with a decreased risk of recurrence. In the analysis of live birth achievement among the 79 TLC patients, advanced age, postoperative hormone treatment and cancer antigen 125 (CA125) positivity were significantly associated with a reduced likelihood of achieving live birth. Conclusions: Our data highlight the unfavorable effects of advanced age, massive blood loss and CA125 positivity on the outcomes of laparoscopic surgery for OMA. Additionally, postoperative hormone treatment was found to decrease postoperative OMA recurrence. These findings may offer more accurate information to guidance in selecting treatment options for patients with OMA.

ovarian endometrioma; postoperative ovarian endometrioma recurrence; live birth achievement; retrospective study; ad- vanced age; massive blood loss; CA125 positivity; postoperative hormone treatment; total laparoscopic cystectomy; total laparoscopic adnexectomy 1. Introduction Endometriosis is one of the most common gyneco- logical diseases, affecting approximately 5% of women of reproductive age. It most frequently involves the ovaries, leading to the formation of a cystic mass known as an ovar- ian endometrioma (OMA) [ 1,2]. OMA can be relatively easily to diagnosed using transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), but its treatments is complex. Among them, laparoscopic surgeries are com- monly performed to improve pain symptoms and fertil- ity [ 3–6]. However, postoperative management is often needed for patients who do not wish to conceive immedi- ately after surgery, as there is a relatively high risk of post- operative recurrence [2,7,8]. In one previous review, the re- currence rate has been reported to exceed 20% five years af- ter treatment [ 5]. Postoperative management includes hor- monal treatments, including dienogest, oral contraceptive pills (OCPs), and gonadotropin-releasing hormone (GnRH) analogues. Comprehensive management, including careful postsurgical follow-up, is essential, with the choice of treat- ment tailored to the individual patient’s situation and risk factors, such as age, parity, OMA cyst size, and American Society for Reproductive Medicine score (ASRM score). In particular, for patients with infertility, the timing of laparoscopic surgeries and postoperative management be- come more complex, as hormonal treatments can hinder pregnancy during the postoperative period [ 4–6]. For this reason, we have prioritize postoperative recurrence and live birth outcomes in our treatment to selection, aiming to im- prove quality of life for our patients. We have leveraged our hospital’s unique advantage as the sole perinatal medical center in a rural area to achieve this goal. Therefore, in this study, we analyzed 10 years of accumulated data from pa- tients who underwent laparoscopic surgery for OMA. Our aim was to identify significant factors associated with both favorable outcomes, such as live birth achievement, and un- favorable outcomes, such as recurrence. 2. Materials and Methods 2.1 Data Collection This retrospective case series study was reviewed and approved by the Human Ethical Committee of Kinan Hos- pital (Approval Number: 283, Clinical Outcomes of Endo- scopic Surgery: Retrospective Analyses, 2024/4/23). The study was conducted from January 2014 to December 2023. Informed consent was obtained from each patient prior to their inclusion in the study. The deidentified medical records of 158 female patients aged 50 years or younger, who underwent laparoscopic surgery for the treatment of OMA confirmed by TVUS and/or MRI prior to surgery, were reviewed retrospectively. Among these 158 patients, the surgical approaches used were total laparoscopic cystec- tomy (TLC) (79 patients), total laparoscopic adnexectomy (TLA) (62 patients), and a combination of unilateral TLA and contralateral TLC (17 patients). Bilateral OMA was detected in 28 patients in the TLC group, 10 patients in the TLA group, and 17 patients in the combined TLA and TLC groups. Concomitant laparoscopic myomectomy (LM) was performed in 8 patients. A total of 5 patients were excluded from the study due to recurrent OMA (3 patients) and post- operative detection of breast cancer (2 patients). Since the analysis was restricted to patients of reproductive age (those younger than 50 years) and excluded those who underwent both abdominal and laparoscopic hysterectomy, the number of patients excluded from the study was small. We extracted data on representative patient charac- teristics, such as age, delivery history, physical data, and presenting symptoms, from medical records. The follow- up period was calculated by subtracting the operation date of surgery from the last outpatient visit, postoperative hor- mone treatment included dienogest (61 patients), OCPs (37 patients), GnRH analogues (5 patients), and levonorgestrel- releasing intrauterine devices (2 patients). In 15 patients, multiple hormone treatment methods were used in combi- nation. 2.2 Analysis Method First, all 158 patients were divided into two groups according to the presence or absence of postoperative OMA recurrence. The 15 indicators listed in Table 1 were then compared via Student’s t-test and Pearson’s Chi-square test. Similarly, the 79 patients who underwent TLC were divided into two groups based on whether a live birth was achieved. The 12 indicators listed in Table 2 were then compared. Next, to identify risk factors for postoperative OMA recurrence, we performed a multivariate logistic regression analysis. Patients were divided into two groups according to the presence or absence of the following factors: (1) ad- vanced age, defined as ≥35 years; (2) high American So- ciety for Reproductive Medicine score (ASRM score), de- fined as a score ≥80; (3) large cyst, defined as a cyst mea- suring ≥80 mm; (4) elevated body mass index (BMI), de- fined as BMI ≥22 kg/m2; (5) nulliparity, defined as no pre- vious deliveries; (6) postoperative hormone treatment; (7) bilateral cysts; (8) TLA; (9) cancer antigen 125 (CA125) positivity, defined as a serum CA125 level ≥35 U/mL; (10) long operation time, defined as an operation time ≥150 minutes; and (11) massive blood loss, defined as a blood loss amount ≥200 mL (see Table 3). Similarly, to iden- tify the factors influencing live birth achievement, we ana- lyzed the aforementioned 10 factors after excluding TLA (Table 4). The criteria for “large cyst”, “long operation time”, and “massive blood loss” were determined based on of the average (Avg) and standard deviation (SD) (mini- mum (Min) and maximum (Max)) of the aforementioned 158 and 79 patients. Statistical analyses were performed using Microsoft Excel 365 (Microsoft Corporation, Redmond, W A, USA) and JMP version 17 for MAC (SAS Institute, Inc., Tokyo, Japan) to determine the correlations between patient char- acteristics and the outcomes of laparoscopic surgery. The odds ratios (ORs) and 95% confidence intervals (95% CIs) were estimated to determine the strength of the correlations. p < 0.05 indicated statistical significance. 3. Results 3.1 Patient Characteristics The results obtained (Avg ± SD [Min–Max]) of the follow-up time, age, BMI, cyst size, and ASRM were 1304.6 ± 1094.3 (25–3731) days, 36.7 ± 7.2 (21–50) years, 21.6 ± 3.8 (14.5–35.1) kg/m 2, 62.1 ± 22.2 (14–146) mm, and 54.0 ± 32.1 (17–144), respectively (Table 1). Almost all patients (144/158 patients) experienced menstruation- related symptoms, including pain (122 patients) or hyper- menorrhea (120 patients). However, data on infertility were not available. In these cases, presenting symptoms were ex- cluded from the analyses. When comparing the postopera- tive OMA recurrence group with the control group, a sig- nificant difference was found only in the follow-up time, probably due to the small number of patients with postop- erative OMA recurrence. On the other hand, as shown in Table 2, the analysis of live birth achievement revealed sig- nificantly lower values for age, cyst size, and postoperative hormone treatment. 3.2 Risk Factors for Postoperative OMA Recurrence Postoperative OMA recurrence was detected in 7 of 158 patients, with all diagnoses confirmed via MRI. The re- currence rate observed in this study was relatively low. This was probably due to the presence of patients who were re- ferred to our hospital specifically for TLC or TLA. In these patients, the follow-up period was inevitably short. Ad- ditionally, only approximately 40% of patients underwent TLA (n = 62/158), and OMA recurrence was detected in 1 patient. 2 Table 1. Characteristics of patients who experienced postoperative OMA recurrence. Total (Avg. ± SD, Min–Max, Number) Postoperative OMA recurrence cases (Avg. ± SD, Min–Max, Number) Control (Avg. ± SD, Min–Max, Number) p-value Follow-up period (days) 1304.6 ± 1094.3, 25–3731, n = 158 2831.3 ± 991.7, 1585–3731, n = 7 1233.8 ± 1048.9, 25–3674, n = 151 <0.01 Age (years) 36.7 ± 7.2, 21–50, n = 158 38.1 ± 5, 33–45, n = 7 36.6 ± 7.3, 21–50, n = 151 0.58 BMI (kg/m2) 21.6 ± 3.8, 14.5–35.1, n = 154 20.6 ± 2.4, 17.9–24.5, n = 7 21.7 ± 3.8, 14.5–35.1, n = 147 0.45 Cyst size (mm) 62.1 ± 22.2, 14–146, n = 158 61.9 ± 27.3, 20–109, n = 7 62.1 ± 22.1, 14–146, n = 151 0.97 ASRM score 54.0 ± 32.1, 17–144, n = 158 64.1 ± 23.6, 33–92, n = 7 53.5 ± 32.4, 17–144, n = 151 0.39 Operation time (minutes) 115.5 ± 41.8, 43–262, n = 158 140.1 ± 44.1, 84–208, n = 7 114.4 ± 41.5, 43–262, n = 151 0.11 Blood loss amount (mL) 49.7 ± 91.5, 0–507, n = 158 80.4 ± 123.5, 0–306, n = 7 48.3 ± 90, 0–507, n = 151 0.36 Nulliparity n = 94/158 n = 4/7 n = 90/151 1.00 Postoperative hormone treatment n = 89/158 n = 2/7 n = 87/151 0.51 Bilateral cysts n = 55/158 n = 3/7 n = 52/151 0.98 CA125 positivity n = 101/158 n = 5/7 n = 96/151 0.98 TLC n = 79/158 n = 5/7 n = 74/151 0.72 TLA n = 62/158 n = 1/7 n = 61/151 0.59 Unilateral TLA and contralateral TLC n = 17/158 n = 1/7 n = 16/151 0.99 Concomitant LM n = 8/158 n = 1/7 n = 7/151 0.73 158 patients were divided into two groups according to the presence or absence of postoperative OMA recurrence, and 15 representative indices were compared. Avg, average; ASMR score, American Society for Reproductive Medicine score; BMI, body mass index; CA125, cancer antigen 125; LM, laparoscopic myomectomy; Max, maximum; Min; minimum; OMA, ovarian endometrioma; SD, standard deviation; TLA, total laparoscopic adnexectomy; TLC, total laparoscopic cystectomy. Table 2. Characteristics of patients who achieved a live birth. Total (Avg. ± SD, Min–Max, Number) Live birth achievement cases (Avg. ± SD, Min–Max, Number) Control (Avg. ± SD, Min–Max, Number) p-value Follow-up period (days) 1301.2 ± 1081.6, 25–3731, n = 79 1652 ± 1134.2, 208–3674, n = 23 1157.1 ± 1035.4, 25–3731, n = 56 0.06 Age (years) 31.5 ± 5.2, 21–45, n = 79 29.6 ± 4, 22–35, n = 23 32.3 ± 5.5, 21–45, n = 56 0.03 BMI (kg/m2) 21.9 ± 3.8, 15.7–33.3, n = 79 23.0 ± 4.8, 15.7–33.3, n = 23 21.5 ± 3.3, 16.6–32.0, n = 56 0.11 Cyst size (mm) 61.7 ± 20.6, 14–146, n = 79 48.7 ± 17.1, 20–90, n = 23 67.1 ± 19.6, 14–146, n = 56 <0.01 ASRM score 51.2 ± 28.9, 17–128, n = 79 45.5 ± 24.2, 17–108, n = 23 53.6 ± 30.6, 20–128, n = 56 0.26 Operation time (minutes) 124.2 ± 41, 58–221, n = 79 118.3 ± 41.9, 58–208, n = 23 126.7 ± 40.8, 62–221, n = 56 0.41 Blood loss amount (mL) 59.6 ± 105.9, 0–507, n = 79 41.1 ± 96.8, 0–350, n = 23 67.2 ± 109.4, 0–507, n = 56 0.32 Nulliparity n = 63/79 n = 21/23 n = 42/56 0.44 Postoperative hormone treatment n = 46/79 n = 6/23 n = 40/56 <0.01 Bilateral cysts n = 28/79 n = 5/23 n = 23/56 0.45 CA125 positivity n = 21/79 n = 6/23 n = 15/56 1.00 Concomitant LM n = 2/79 n = 1/23 n = 1/56 0.93 79 patients were divided into two groups according to whether a live birth was achieved, and 12 representative indices were compared. Avg, average; ASMR score, American Society for Reproductive Medicine score; BMI, body mass index; CA125, Cancer Antigen 125; LM, laparoscopic myomectomy; Max, maximum; Min; minimum; SD, standard deviation. 3 Table 3. Risk factors for postoperative OMA recurrence. Factors OR (95% CI, Number) p-value Advanced age ≥35 years old 4.1 (0.5–34.6, n = 6/96) <0.01 High ASRM score ≥80 2.6 (0.6–12.1, n = 3/37) 0.57 Large cyst ≥80 mm 0.9 (0.1–7.7, n = 1/25) 0.47 Above standard BMI ≥22 kg/m2 0.8 (0.2–4.3, n = 2/52) 0.80 Nulliparity 0.9 (0.2–4.2, n = 4/94) 0.77 Postoperative hormone treatment 0.3 (0.1–1.6, n = 2/89) 0.03 Bilateral cysts 1.4 (0.3–6.6, n = 3/55) 0.27 TLA 0.2 (0.0–2.1, n = 1/62) <0.01 CA125 positivity 1.4 (0.3–7.6, n = 5/101) 0.48 Long operation time ≥150 minutes 1.8 (0.3–9.5, n = 2/30) 0.78 Massive blood loss ≥200 mL 3.9 (0.7–22.1, n = 2/16) 0.03 Multivariate analysis was performed on 158 patients to examine the effects of 11 representative factors based on data collected from med- ical records. Table shows the number of patients with each factor, the ORs and 95% CIs for postoperative OMA recurrence, and the p-values. ASMR score, American Society for Reproductive Medicine score; BMI, body mass index; CA125, cancer antigen 125; CI, confidence interval; OMA, ovarian endometrioma; OR, odds ratio; TLA, total laparoscopic adnexectomy. To identify significant factors affecting the likelihood of postoperative OMA recurrence while controlling for con- founding factors, a multivariate analysis of 11 represen- tative factors was performed (Table 3). This analysis re- vealed that advanced age (OR: 4.1, p < 0.01) and mas- sive blood loss (OR: 3.9, p < 0.05) were significant fac- tors that increased the likelihood of postoperative OMA re- currence. Conversely, postoperative OMA recurrence was significantly and negatively associated with postoperative hormone treatment (OR: 0.3, p < 0.05) and TLA (OR: 0.2, p < 0.01). 3.3 Factors Influencing Live Birth In total, 24 out of 158 patients achieved a live birth, including 23 out of 79 patients who underwent TLC. Next, data from 79 patients who underwent TLC and were aged between 21 and 45 years old were analyzed via multivari- ate analysis of 10 representative factors to identify signifi- cant factors affecting the likelihood of achieving a live birth (Table 4). The present analysis revealed that three factors, namely, advanced age (OR: 0.4, p < 0.05), postoperative hormone treatment (OR: 0.1, p < 0.01), and CA125 posi- tivity (OR: 0.3, p < 0.05), had significant negative effects on live birth achievement. 4. Discussion Laparoscopic surgery has become a commonly per- formed procedure for the treatment of OMA due to its rel- atively short recovery time, brief hospital stay, and min- imal surgical wound [ 3]. However, managing OMA after surgery is complex due of its relatively high recurrence rate. Table 4. Factors influencing live birth achievement. Factors OR (95% CI, Number) p-value Advanced age ≥35 years old 0.4 (0.1–1.4, n = 4/23) 0.02 High ASRM score ≥80 0.8 (0.2–2.7, n = 4/16) 0.72 Large cyst ≥80 mm 0.2 (0.0–1.5, n = 1/12) 0.19 Above standard BMI ≥22 kg/m2 1.7 (0.6–4.4, n = 11/31) 0.08 Nulliparity 3.5 (0.7–16.8, n = 21/63) 0.09 Postoperative hormone treatment 0.1 (0.0–0.4, n = 6/46) <0.01 Bilateral cysts 0.4 (0.1–1.2, n = 5/28) 0.28 CA125 positivity 0.3 (0.1–0.7, n = 9/49) 0.02 Long operation time ≥150 minutes 1.0 (0.3–2.9, n = 6/21) 0.75 Massive blood loss ≥200 mL 0.6 (0.1–2.9, n = 2/10) 0.80 Multivariate analysis was performed on the data of 79 patients to examine the effects of 11 representative factors for which data were collected from medical records. Table shows the number of patients with each factor, the ORs and 95% CIs for live birth achievement, and the p-values. ASMR score, American Society for Reproductive Medicine score; BMI, body mass index; CA125, cancer antigen 125; CI, confidence interval; OR, odds ratio. Therefore, postoperative follow-up, including postopera- tive hormone treatment, is crucial [2,9]. In particular, when performing TLC to preserve fertility, complete removal of the endometriotic lesion is often not feasible. In this anal- ysis, TLA was found to have a significant negative impact on postoperative OMA recurrence. To improve OMA treat- ment and inform the selection of appropriate management strategies, whether expectant, medical, or surgical manage- ment [10], comprehensive analyses of patient data, includ- ing surgical outcomes and follow-up durations, are becom- ing increasingly important. Therefore, in this study, since more than 70% of patients (n = 115/158) were followed up after surgery for over 1 year, we collected data on both good and unfavorable outcomes, specifically, live birth achieve- ment and recurrence. In evaluating postoperative OMA recurrence as an unfavorable result, we found that three factors—advanced age, massive blood loss, and postoperative hormone treatment—were significant. As expected, postopera- tive hormone treatment proved effective in decreasing en- dometriosis recurrence [ 2,9]. Among the aforementioned 115 patients who were followed up for over 1 year, more than 65% (n = 75/115) received postoperative hormone treatment. This tendency might have contributed to the rel- atively low recurrence rate observed in our study, consistent with findings reported in previous reports [ 11]. The other two factors may indicate advanced endometriosis and in- creased surgical difficulty. Advanced age also had a signif- icant negative impact on likelihood of achieving of a live birth. In this study, we were unable to identify any cases where nulliparous women aged 36 years or older delivered a baby after laparoscopic surgery. The negative impact of CA125 positivity may indicate the presence of undetectable 4 endometriosis, while the negative of postoperative hormone treatment could be attributed to its to suppression of ovula- tion. In contrast to previous reports [ 2,12], we did not find a significant effect of cyst size or the ASRM score. Addi- tionally, to validate our findings regarding significant fac- tors, additional data and analyses may be required. Unfor- tunately, this study had several limitations due to its retro- spective nature and the fact that it was conducted at a rural general hospital. Specifically, the data were not always suf- ficient, particularly regarding presenting symptoms. Ad- ditionally, there was variability in follow-up periods, and the number of variables for which data were extracted was limited. To address these limitations, data analysis at hos- pitals with advanced capabilities, such as university hospi- tals, may be necessary. The management methods, includ- ing surgical techniques and postoperative infertility treat- ments, were also limited by physician skill and institutional capacity. In rural hospitals, introducing new techniques, such as laser vaporization [ 13], laparoscopic ovarian su- turing [14,15], and assisted reproductive technologies, can be challenging. Therefore, further large-scale studies are needed to obtain more accurate and comprehensive infor- mation. 5. Conclusions We identified the factors that negatively impact the outcomes of laparoscopic surgery for OMA, including ad- vanced age, massive blood loss, and CA125 positivity. Ad- ditionally, postoperative hormone treatment was associated with a reduction in postoperative OMA recurrence. These

offer valuable insights to guide the selection of treat- ment methods for OMA. However, due to limitations asso- ciated with using retrospective data from medical records, further studies are needed. Abbreviations ASRM score, American Society for Reproductive Medicine score; Avg, average; BMI, body mass index; CA125, cancer antigen 125; GnRH, gonadotropin-releasing hormone; LM, laparoscopic myomectomy; MRI, magnetic resonance imaging; CI, confidence interval; OCP , oral con- traceptive pill; OMA, ovarian endometrioma; OR, odds ra- tio; SD, standard deviation; TLA, total laparoscopic ad- nexectomy; TLC, total laparoscopic cystectomy; TVUS, transvaginal ultrasound. Availability of Data and Materials The datasets used and analysed during the current study are available from the corresponding author upon rea- sonable request. Author Contributions RA and WI collected and analysed the data and wrote the manuscript. WI supervised the entire study. SH, RA, WI, HF, JT and AM performed medical care on the sub- jects. SH determined the surgical method and supervised all medical procedures. All the authors have read and ap- proved the final manuscript. All authors contributed to ed- itorial changes in the manuscript. All authors have partici- pated sufficiently in the work and agreed to be accountable for all aspects of the work. Ethics Approval and Consent to Participate This study was reviewed and approved by the Hu- man Ethical Committee of Kinan Hospital (approval num- ber 283). Informed consent was obtained from all patients. Acknowledgment This research was supported by Kina Hospital regard- ing the provision of medical information. Funding The authors disclose the receipt of financial support from the Wakayama Prefecture Obstetrician Secure Fund for the preparation and publication of this article. Conflict of Interest The authors declare no conflict of interest.

[1] Viganò P , Parazzini F, Somigliana E, V ercellini P . Endometrio- sis: epidemiology and aetiological factors. Best Practice & Re- search. Clinical Obstetrics & Gynaecology. 2004; 18: 177–200. [2] Nezhat FR, Cathcart AM, Nezhat CH, Nezhat CR. Pathophysi- ology and Clinical Implications of Ovarian Endometriomas. Ob- stetrics and Gynecology. 2024; 143: 759–766. [3] Hart RJ, Hickey M, Maouris P , Buckett W. Excisional surgery versus ablative surgery for ovarian endometriomata. The Cochrane Database of Systematic Reviews. 2008; CD004992. [4] Benschop L, Farquhar C, van der Poel N, Heineman MJ. Inter- ventions for women with endometrioma prior to assisted repro- ductive technology. The Cochrane Database of Systematic Re- views. 2010; CD008571. [5] Brown J, Farquhar C. Endometriosis: an overview of Cochrane Reviews. The Cochrane Database of Systematic Reviews. 2014; 2014: CD009590. [6] Daniilidis A, Grigoriadis G, Kalaitzopoulos DR, Angioni S, Kalkan Ü, Crestani A, et al . Surgical Management of Ovarian Endometrioma: Impact on Ovarian Reserve Parameters and Re- productive Outcomes. Journal of Clinical Medicine. 2023; 12: 5324. [7] Choi SH, Kim S, Lee SW, Won S, Shim SH, Lee N, et al . Re- currence, Reoperation, Pregnancy Rates, and Risk Factors for Recurrence after Ovarian Endometrioma Surgery: Long-Term Follow-Up of 756 Women. Y onsei Medical Journal. 2023; 64: 204–212. [8] Ngernprom P , Klangsin S, Suwanrath C, Peeyananjarassri K. Risk factors for recurrent endometriosis after conservative surgery in a quaternary care center in southern Thailand. PLoS ONE. 2023; 18: e0289832. [9] Koga K, Takamura M, Fujii T, Osuga Y . Prevention of the re- currence of symptom and lesions after conservative surgery for endometriosis. Fertility and Sterility. 2015; 104: 793–801. 5 [10] Muzii L, Galati G, Mattei G, Chinè A, Perniola G, Di Donato V , et al. Expectant, Medical, and Surgical Management of Ovarian Endometriomas. Journal of Clinical Medicine. 2023; 12: 1858. [11] V ercellini P , DE Matteis S, Somigliana E, Buggio L, Frattaruolo MP , Fedele L. Long-term adjuvant therapy for the prevention of postoperative endometrioma recurrence: a systematic review and meta-analysis. Acta Obstetricia et Gynecologica Scandinav- ica. 2013; 92: 8–16. [12] Zheng L, Han J. Analysis of Risk Factors for Bleeding and Re- currence of Ovarian Endometriomas after Laparoscopic Surgery and Its Impact on Pregnancy Outcomes. Clinical and Experi- mental Obstetrics & Gynecology. 2024; 51: 5. [13] Adamyan L, Kasyan V , Pivazyan L, Isaeva S, Avetisyan J. Laser vaporization compared with other surgical techniques in women with ovarian endometrioma: a systematic review and meta- analysis. Archives of Gynecology and Obstetrics. 2023; 308: 413–425. [14] Kitajima M, Khan KN, Harada A, Taniguchi K, Inoue T, Ka- neuchi M, et al. Association between ovarian endometrioma and ovarian reserve. Frontiers in Bioscience-Elite. 2018; 10: 92– 102. [15] Riemma G, De Franciscis P , La V erde M, Ravo M, Fumiento P , Fasulo DD, et al. Impact of the hemostatic approach after laparo- scopic endometrioma excision on ovarian reserve: Systematic review and network meta-analysis of randomized controlled tri- als. International Journal of Gynaecology and Obstetrics. 2023; 162: 222–232. 6