P-320 Optimal management of large endometriomas (≥4 cm) before IVF: ethanol sclerotherapy, cystectomy, or no intervention?

Abstract Study question What are the comparative outcomes of ART cycles in infertile women with endometriomas ≥4 cm managed by expectant management, ethanol sclerotherapy (EST), or laparoscopic cystectomy? Summary answer EST before ART results in a higher number of retrieved oocytes, transferable embryos, and cumulative pregnancy rates compared with endometriomas in situ or laparoscopic cystectomy. What is known already Endometriomas, especially those ≥4 cm, can negatively impact ART outcomes by reducing the number of retrievable oocytes and potentially impairing oocyte and embryo quality. Laparoscopic cystectomy, while effective in removing endometriomas, is associated with a significant reduction in ovarian reserve. EST has emerged as a promising alternative, with recent studies suggesting improved ART outcomes compared to expectant management or cystectomy. Study design, size, duration This single-center retrospective cohort study included 90 infertile women with at least one endometrioma ≥4 cm who underwent ART between January 2020 and December 2023. Participants were divided into three groups: endometrioma in situ (n = 39), EST (n = 20), and laparoscopic cystectomy (n = 31). Participants/materials, setting, methods Infertile women aged 20-42 years with at least one endometrioma ≥4 cm were included. Exclusion criteria included severe male factor infertility, adenomyosis, fibroids, and uterine abnormalities. EST was performed via transvaginal ultrasound-guided aspiration and ethanol injection within 3 menstrual cycles before ART. Laparoscopic cystectomy was performed within 12 months before ART. Ovarian stimulation, oocyte retrieval, and embryo transfer were conducted following standard protocols. Main results and the role of chance Demographic characteristics such as age, BMI, and duration of infertility were similar across all groups (P > 0.05). However, the size of the largest endometrioma was significantly smaller in the in situ group (4.5±0.9 cm) compared to the EST (6±1.7 cm) and cystectomy groups (5.6±1.3 cm) (P < 0.001). The EST group had a significantly higher number of mature oocytes (10.1±3.9) and transferable embryos (2.8±2.1) compared to the in situ (5.7±4.3 and 2.1±2.1) and cystectomy groups (4.2±3.5 and 1.3±1.3) (P < 0.001). Cycle cancellation rates were significantly higher in the cystectomy group (35.5%) compared to the EST (10%) and in situ groups (12.8%) (P = 0.028). Pregnancy rates following the first embryo transfer were significantly lower in the in situ group (35.3%) compared to the EST (72.2%) and cystectomy groups (60%) (P = 0.027). Cumulative clinical pregnancy rates were 33.3% (in situ), 65% (EST), and 32.3% (cystectomy) (P = 0.035). Cumulative ongoing pregnancy rates were 30.8% (in situ), 65% (EST), and 29% (cystectomy) (P = 0.017). Limitations, reasons for caution The study is retrospective, which may introduce selection bias. The sample size, particularly in the EST group (n = 20), is relatively small, which may limit the generalizability of the findings. Long-term follow-up data on ovarian reserve and endometrioma recurrence after EST are lacking. Wider implications of the findings This study suggests that EST is an effective option for endometriomas ≥4 cm before ART, offering better outcomes of oocyte yield, and pregnancy rates compared to expectant management or laparoscopic cystectomy. These findings could influence clinical practice by encouraging the use of EST as a less-invasive and more fertility-preserving approach. Trial registration number No