Limitations of Endometrioma Surgery in IVF

Endometrioma affects 17%-44% of women with endometriosis. Approximately 17% of women suffering from infertility are diagnosed with this disease. The pathogenesis of this disease is characterized by sequential and progressive damage of healthy ovarian tissue. During menses, implantation of regurgitated endometrial cells on the ovarian surface (via tubal lumen) causes a series of biochemical mechanisms including persistent inflammation, bleeding (at implantation site) and invagination of the ovarian cortex, adhesions, cystic formations, tissue alterations, and deformity.

Invagination of the ovarian cortex secondary to metaplasia of celomic epithelium in the context of cortical inclusion cysts has also been proposed as a possible mechanism of endometrioma formation. Hence, the endometrioma pseudo-capsule is ovarian epithelium containing the follicular structures and oocytes. Upon opening the endometrioma after irrigation, endoscopic imaging reveals pinkish tissue that is the ovarian epithelium. The ovarian tissue that is identifiable during endoscopic imaging is embedded thus with endometriotic cells that can continue to proliferate and even migrate if not destroyed.

In addition, ovarian endometriosis, whether superficial or deep, is a marker of more significant pelvic and intestinal endometriotic lesions. Despite the fact that diagnosis of this disease can be done by transvaginal ultrasound examination at a very early stage, the identification of which patients will deteriorate by developing larger endometrioma remains a major challenge.

Although cyclic pelvic pain, dyspareunia, bleeding, dysuria, and infertility are the most common presentations, symptomatology does not indicate the extent or progression of the disease. Endometriosis awareness among general practitioners and the public is still very poor. Misdiagnosis and under-treatment occur frequently. As a result, endometrioma is often diagnosed when the cyst is very large, or the disease has reached an advanced stage. Hence, many infertility patients present with endometrioma and tubal factor problems with an indication for an in vitro fertilization (IVF) treatment.

A systematic research was performed to identify the course of action in treating endometrioma prior to IVF. In addition, current guidelines by international gynecological societies were used as a tool for clinical practice. Research also focused on the pros and cons as well as outcomes of this disease surgical treatment before IVF. Based on the evidence and conclusions of the research, the conclusion below for the options in the management of this disease prior to IVF is proposed.


Reputable international gynecological societies published guidelines on diagnosis and treatment of endometriosis and endometrioma in patients with infertility and pain. However, all acknowledge the lack of strong evidence regarding endometrioma management.

Surgery for endometriosis/endometriomas provides good chances for spontaneous pregnancy and increases ART pregnancy rate. Surgery outcomes depend significantly on the patient’s age, size of endometrioma, interest in fertility preservation, and the surgeon’s skills and experience. Endometriosis is a very aggressive disease that severely compromises the quality of life and fertility of women, and TVHL can provide the best way for early diagnosis and treatment of high-risk patients.

Minimal invasive surgery of the endometriomas offers safe and effective management. Several reports demonstrated that recurrent operations of endometriomas, operating on bilateral endometriomas and big endometriomas larger than 7 cm are associated with diminished pregnancy rates; this evidence must guide the laparoscopic gynecologist in his or her adjustment and modification of surgery protocols and especially the timing of operation.

An individualized approach to decision-making on surgical removal of endometrioma and a well-trained laparoscopic surgeon are essential to guiding management and improving fertility outcomes.

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