L26/O-239 IVF outcomes after transvaginal sclerotherapy for ovarian endometrioma versus expectant management: a systematic review and meta-analysis

Abstract Study question Does pre-stimulation transvaginal sclerotherapy for ovarian endometrioma improve live birth and clinical pregnancy rates compared with expectant management in women prior to undergoing IVF/ICSI? Summary answer Pre-IVF sclerotherapy was associated with higher clinical pregnancy and live birth rates versus expectant management, especially among women with prior cystectomy in pooled analyses. What is known already Ovarian endometriomas are common in reproductive-age women and can impair ovarian reserve, complicate oocyte retrieval, and reduce assisted reproduction success. Laparoscopic cystectomy reduces recurrence and symptoms but risks removal of healthy ovarian tissue and declines in AMH and AFC. Transvaginal ultrasound-guided sclerotherapy is a minimally invasive, ovary-sparing alternative that aspirates cyst contents and instills ethanol to ablate the lining. Prior studies and reviews have focused on recurrence, safety, and comparisons with surgery, suggesting preserved ovarian function after sclerotherapy, but evidence directly comparing sclerotherapy with expectant management for IVF outcomes remains limited and inconclusive. High-quality randomized data are lacking currently. Study design, size, duration Systematic review and meta-analysis of studies published through from 1980 until 2025 including one randomized trial and four nonrandomized comparative studies. Five studies contributed 303 women (151 sclerotherapy, 152 controls) and 394 IVF/ICSI cycles. Follow-up spanned the interval from sclerotherapy to completion of IVF cycles, typically two to twelve weeks postprocedure. Meta-analyses pooled live birth, clinical pregnancy, stimulation parameters, and oocyte outcomes and subgroup analyses by prior cystectomy. Participants/materials, setting, methods Infertile women with sonographically ovarian endometrioma undergoing IVF/ICSI were included. Intervention groups received transvaginal ultrasound-guided sclerotherapy (ethanol concentrations 95-100%, dwell times up to ten minutes) prior to stimulation; controls underwent ovarian stimulation without intervention on endometrioma. Data extracted included age, prior cystectomy status, stimulation duration, total gonadotrophin dose, follicle counts, total and MII oocytes, clinical pregnancy, and live birth. Study selection, data extraction, and quality appraisal were performed independently by two reviewers using standardized forms. Main results and the role of chance Across five studies (303 women, 394 cycles), sclerotherapy was associated with higher live birth and clinical pregnancy rates compared with expectant management. Pooled analysis showed increased live birth (OR 2.10; 95% CI 1.24–3.57; three studies, 297 cycles) and clinical pregnancy (OR 2.38; 95% CI 1.52–3.73; five studies, 394 cycles), with low statistical heterogeneity for primary outcomes. Subgroup analyses indicated larger effects among women with prior cystectomy (LBR OR 2.69; CPR OR 2.90). Total oocytes retrieved were modestly higher after sclerotherapy (MD 1.37; 95% CI 0.03–2.70), whereas mature (MII) oocytes, stimulation duration, and total gonadotrophin dose did not differ significantly. Confidence intervals for several secondary outcomes were wide and between-study heterogeneity varied, reflecting limited sample sizes and observational designs. The randomized trial contributed limited weight; observational studies predominated. Sensitivity analyses were limited by study count; publication bias assessment was not feasible. The magnitude and consistency of effects across studies support a real association, but randomized confirmation is required for clinical practice. Limitations, reasons for caution Evidence is limited by small study numbers, predominance of observational designs, variable ethanol protocols, heterogeneous inclusion of prior cystectomy, and imprecise secondary outcome estimates. Potential selection bias, residual confounding, and limited randomized data mean findings may overestimate benefit; results require confirmation in adequately powered, stratified randomized trials before routine adoption. Wider implications of the findings Pre-IVF sclerotherapy may offer an ovary-sparing option to improve pregnancy and live birth outcomes, particularly for women with prior cystectomy. If confirmed, sclerotherapy could reduce repeat surgery and preserve ovarian reserve, informing individualized pre-IVF management; however, guideline changes await high-quality randomized evidence and development of standardized procedural protocols and oversight. Trial registration number Yes