An update on the diagnosis, surgical management, and fertility outcomes for women with endometrioma

Endometriosis is estimated to affect up to 50% of infertile women, and severity of endometriosis stage appears to correlate with reduced fertility. Ovarian endometriomas are found in up to 44% of women with endometriosis, and are significantly associated with the presence of pelvic deep infiltrating endometriosis, ovarian adhesions, and pouch of Douglas obliteration. Through the use of MEDLINE and PubMed databases, we conducted a literature review of all available research related to the diagnosis, surgical management and fertility outcomes for women with endometrioma. The evolving use of specialized transvaginal ultrasound for the diagnosis of endometrioma and related endometriotic pathologies can allow for preoperative mapping/staging of the disease, as well as appropriate surgical planning and fertility counseling. Surgical management of endometriomas appears to reduce markers of ovarian reserve, such as anti-Mullerian hormone, prompting concern of reduced fertility following surgery. Ovarian cystectomy appears to be superior to ablation in terms of endometrioma recurrence, pain symptoms and increased spontaneous conception rate among subfertile patients. Research is inconclusive as to which surgical method least damages ovarian reserve in the long term; however, bipolar hemostasis appears to be the most damaging technique and should be avoided. Surgical management should be individualized for women with endometrioma, and strong consideration should be given to the preoperative ovarian reserve status prior to performing ovarian cystectomy. Current evidence suggests that ovarian cystectomy does not improve reproductive outcomes for women with endometrioma undergoing assisted reproductive technology; however, the majority of studies have been performed retrospectively and more prospective studies are needed.