Surgical treatment of ovarian endometriomas: state of the art?

Capsule:
Surgery has a fundamental role to play in the treatment of endometriomas. Considerable surgical experience is required, however, to minimize ovarian damage.

Authors:
Pascale Jadoul, M.D., Michio Kitajima, M.D., Ph.D., Olivier Donnez, M.D., Jean Squifflet, M.D., Ph.D., Jacques Donnez, M.D., Ph.D.

Volume 98, Issue 3, Pages 556-563, September 2012

Abstract:

To define the role of surgery in the treatment of endometriomas, we review the literature available via PubMed and cross-reference the published data. We analyze the arguments in favor of and against surgical treatment of endometriomas and compare surgical techniques. Pain relief and pregnancy rates of more than 50% after surgery are the most important arguments in favor of surgery. Histologic and biologic markers of ovarian reserve show a risk of decreased ovarian reserve that should be taken into consideration, especially in cases of repeated surgery. Considerable surgical expertise is required, and the lack of comparative studies yields no conclusions on the best surgical technique. Despite the risk of decreased ovarian reserve due to the surgical procedure, surgery has an important role in the treatment of ovarian endometriomas, and more studies are required to define the most appropriate surgical technique.

 

  • I also congratulate to the authors for this excelent review and I would like to introduce other question not resolved. Do the endometriomas affect the oocyte quality?. I think it is not only important to consider the effect of the presence or abscence of the endometrioma on the number of follicles, but also the quality of oocytes obtained from ovaries with endometrioma. This aspect could help to decide whether it is good to remove the endometriomas in infertile patients.

    • Elin there a great study from your group at ivI some years ago that looked at splitting eggs from donors with endometriomas and splitting recipients — I think it showed clearly the effects are on the ovary and egg locally more than on the uterus.

      • Thank you for your comment Dr Palter. I agree
        with you and I am familiar with that study. We know that endometriosis affects
        oocyte quality, but not if the presence of endometrioma is related to the
        behavior of oocytes in the affected ovary.

        Therefore the question is:
        Is there a difference between the oocytes obtained from the
        ovary with endometrioma compared with the ovary without it in the same patient?

  • Sérgio Soares

    I believe one relevant parameter studies frequently don’t emphasize enough is the ecographic impression of how much functional ovarian tissue we will be left with in case surgery is performed. In occasions, even with big cysts, surgery may not be a good idea because it may mean the end of any possibility of ovarian response.

  • I was also surprised with the authors conclusion that surgery should be performed for endometriomas. In patient’s seeking infertility treatment especially ovulation induction or IVF the size of the endometrioma plays an important role. If the endometrioma is less than 3 – 4 cm, I don’t believe it should be removed. There was really no mention of this in the article. Does anyone else use a particular size as their criteria for surgical intervention prior to infertility treatments?

    • Micah Hill

      I agree Ravi. I also do not routinely perform surgical removal of endometriomas for infertility. There seems to me to be limited evidence for benefit after removal and a meta-analysis in JCEM in Sep. by Raffi et al. demonstrated a significant reduction in AMH after surgery. Typically I consider removing them if they appear to limit the ability to successfully perform oocyte retrieval. While not a size criteria per se, it seems similar to what you suggest.

    • Jacques Donnez

      in my opinion endometrioma more than 2 cm size should be removed because their presence interferes with follicular maturation. moreover, If IVf is required there is more risk of infection after ovum pick up . High pregnancy rate after surgery more than 50% is one of the main arguments in favor of surgery.

  • laurenwroth

    This is an interesting look at a controversial topic. I think it is nice that they present both the pros and cons of surgery but was surprised that the authors concluded that surgery should be performed. I think their conclusion is appropriate for patients with pain symptoms but not so sure surgery should be performed solely for infertility. It seems that more studies need to be performed to access if surgery for endometriomas is appropriate for fertility only (with live birth as the outcome rather than surrogate markers like AMH).

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