options for endometriomas before IVF include conservative, medical and surgical; however, there is no robust evidence to support one treatment over others. As a result, treatment should be individualized to optimize the outcome and minimize the short and long‐term risks.
Conservative management of endometriomas prior to IVF should be the first option for small endometriomas (≤3 cm). A systematic review has demonstrated that surgical treatment of endometriomas before IVF does not improve pregnancy rate or ovarian response to stimulation [11]. Surgical excision or ablation of endometriomas may lead to damage to healthy ovarian tissue, which in turn can reduce ovarian reserve and performance [12,13]. Women with previous history of multiple surgeries on the ovaries or those known to have reduced ovarian reserve should be advised against surgical treatment if attempting pregnancy by IVF, as this may further compromise the low ovarian reserve.
Surgery for endometrioma may be advocated in women with larger endometriomas (common thresholds for defining “large” being > 3 cm or > 4 cm). Laparoscopy is the preferred surgical approach as this is associated with less postoperative pain, shorter hospital stay, less risk of adhesions and quicker recovery compared with laparotomy [14]. Excision of endometrioma has been demonstrated to be superior to drainage or ablation of the cystic capsule in terms of recurrence and spontaneous pregnancy rate [15]. A scoring system to aid the clinician in the decision‐making process has been suggested by Muzii and colleagues (16). It would make sense that any potential surgery is planned and undertaken by a gynecologist with special interest and expertise in the management of endometriosis and infertility, as they may be more considerate towards preserving the normal ovarian tissue.
Medical management can reduce the size of the endometrioma by up to 57% [17,18]. Older studies suggested that administration of gonadotropin releasing hormone (GnRH) agonist for a period of 3–6 months prior to IVF significantly improves clinical pregnancy rate [19], although a 2020 randomized placebo‐controlled trial showed no difference [20]. Segmentation of the cycle especially for older patients is an approach which may also be beneficial and with the optimization of freezing techniques is gaining in popularity. Transferring the cryopreserved blastocysts in a subsequent scheduled cycle could eliminate the compromise to endometrial performance associated with controlled ovarian stimulation [21,22].
Currently, there are only a few well‐conducted trials that have evaluated the management of endometriomas in infertile women undergoing IVF [23]. Due to the lack of robust evidence on the benefits of the available options for the treatment of endometriomas, as well as the potential risks of compromising the ovarian reserve after surgical intervention, management should be highly tailored. Furthermore, women should be made aware of the advantages and disadvantages of each approach to help them make a well‐informed decision.
Practical considerations for the treating clinician include:
Careful monitoring of the cycle, as ultrasound imaging may be suboptimal.
Access at the time of transvaginal oocyte retrieval, as this can be challenging.
Risk of infection during oocyte retrieval.
At the time of oocyte retrieval, it is important to avoid draining or puncturing the endometrioma as the cyst fluid has toxic effect on gametes and embryos and may also cause pelvic infection. In the event of inadvertently entering the endometriotic cyst during oocyte recovery, the needle must be washed with culture media before continuing to aspirate other follicles. To reduce the risk of pelvic infection and abscess following oocyte retrieval, intraoperative prophylactic antibiotics are recommended to all women with an endometrioma.
Key points
Challenge: The patient with an endometrioma.
Background:
Occurs in around 5% of IVF patients.
Reduces ovarian response to stimulation.
IVF is commonly recommended, particularly if other infertility factors coexist.
Surgical treatment before IVF does not increase pregnancy rate.
Management options:
Diagnose endometriomas by transvaginal ultrasound scan.
Establish outcomes of previous surgical and/or medical treatments.
Check ovarian reserve (AMH, AFC).
Evaluate access for oocyte retrieval.
Recommend treatment with IVF and consider segmentation of the cycle.
Consider laparoscopic excision for symptomatic patients with large (common thresholds for “large” is > 4 cm) endometriomas, no previous surgery, adequate ovarian reserve and difficult vaginal access to the ovaries for oocyte retrieval
Avoid surgery in patients with previous history of surgeries and reduced ovarian reserve.
If the cyst is large and surgical treatment is not planned, GnRH agonists pretreatment for at least 3 consecutive months before the IVF cycle may be considered.
Avoid puncturing or draining the endometrioma during oocyte retrieval.
Give intravenous antibiotics at oocyte retrieval.
Answers to questions patients ask
1 Q1 Can IVF flare up my endometriosis? A1. As stimulation only lasts for a short period of time this is unlikely. However, using a less aggressive stimulation protocol may be preferable.
2 Q2 Can you drain my endometrioma during the egg collection? A2. This is something that we actually try to avoid as it can cause infection which can occasionally be serious. Still this may inadvertently happen and is one of the recognized complications of the procedure. You will be receiving prophylactic antibiotics during your egg collection to decrease the risk of an infection.
3 Q3 Do I need surgery to remove the endometriomas before IVF? A3. This is controversial and answered on a case by case basis. Removing the endometriomas per se will not increase your chances of success.
4 Q4 Are my chances of conceiving good? A4. Women with endometriosis appear to have similar chances of live birth after IVF compared with women who don’t suffer with endometriosis.
References
1 1 Brosens IA, Puttemans PJ, Deprest J. The endoscopic localization of endometrial implants in the ovarian chocolate cyst. Fertil Steril. 1994; 61:1034–6.
2 2 Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities. Fertil Steril. 1997; 68:585–96.
3 3 Jenkins S, Olive DL, Haney AF. Endometriosis: pathogenetic implications of the anatomic distribution. Obstetr Gynecol. 1986; 67:335–8.
4 4 Redwine DB. Ovarian endometriosis: a marker for more extensive pelvic and intestinal disease. Fertil Steril. 1999; 72:310–15.
5 5 Al‐Azemi M, Bernal AL, Steele J, Gramsbergen I, Barlow D, Kennedy
