A 32-year-old woman presents to our office regarding difficulty conceiving. She and her partner have been attempting conception for 13 months. The patient reports regular every 28-day painful menstrual cycles since menarche at age 13. She reports her cycles have become more painful. Usually, her dysmenorrhea is relieved with nonsteroidal anti-inflammatory medications. However, while still happening occasionally, she is more frequently absent from work during menses due to pain. She denies a history of sexually transmitted infections and prior pelvic surgery. Her partner has no children. The referring provider initiated an evaluation and sent you results of a normal semen analysis demonstrating normal morphology, hysterosalpingogram demonstrating bilateral tubal patency and normal endometrial morphology, and day 21 progesterone consistent with ovulation. Pelvic ultrasonography showed a 6.8 cm retroverted uterus with a 3.4 cm left complex ovarian cyst with a “ground glass” background and one thin septation suggestive of an endometrioma cyst. The patient previously used barrier contraception and withdrawal. She used oral contraceptives for a brief interval, but discontinued them due to side effects.
On review of symptoms, she reports positional dyspareunia. She denies dyschezia or other gastrointestinal symptoms. The patient has no significant medical problems and has never had surgery. She takes no medications other than a prenatal vitamin with folic acid and nonsteroidal anti-inflammatory drugs during her menses. She does not smoke, drink, or use illicit substances. She has no allergies. She denies any significant family history. Vaccinations are up to date. Cystic fibrosis carrier testing and HIV tests were negative. She is immune to rubella and varicella.
Endometrioma Cyst and Infertility
Endometriosis is estimated to be present in 6-10% of women of childbearing age, 30-50% of women with infertility, and over 70% of women with chronic pelvic pain. There appears to be a genetic component. Endometriosis requires histologic confirmation for definitive diagnosis, but the laparoscopic appearance is characteristic and allows for staging based on visual inspection at the time of surgery. Staging endometriosis allows the clinician to quantify the disease burden and potential distortion in anatomy caused by the endometriosis and cyclic bleeding. Stage has not been found to be correlated with measures of pain or infertility. Endometriomas are a form of endometriosis and are pseudo-encapsulated ovarian cysts filled with hemosiderin-laden macrophages, which are present in the ovarian stroma. Endometriomas occur in up to 44% of women with endometriosis. Endometriomas may be asymptomatic or associated with intermittent or continuous pelvic pain and dyspareunia.
Endometriomas have a classic appearance on ultrasound. This appearance includes low-level echogenicity in smooth-walled cysts and a ground glass appearance. These ultrasound findings have a sensitivity of .93 and specificity of .96 for the diagnosis of endometriomas. Multiple locules, hyperechogenic wall foci, combined cystic and solid lesions, and purely solid lesions have all been described. MRI can be used to further differentiate an endometrioma cyst from a cystic teratoma or hemorrhagic cyst when diagnosis is difficult on ultrasound. Cysts with classic endometrioma cyst findings that appear stable may be followed conservatively while fertility treatments and pregnancy are achieved. If serial evaluation with ultrasound shows significant growth or change in appearance, surgical intervention may be warranted.
Symptomatic endometriomas are generally surgically excised. Excision is difficult, but preferred over drainage and pseudo-cyst wall obliteration. The dense adherence of the pseudo-capsule to ovarian stroma makes it difficult to remove all the endometriotic tissues. Postoperative recurrence has been described in up to 29% of endometrioma cyst resections. Endometriomas have been rarely associated with endometrioid tumors of the ovary as well as clear cell adenocarcinoma of the ovary.
Women with endometriomas have lower AMH levels, indicating decreased ovarian reserve and diminished fertility. Removal of an endometrioma cyst further diminishes AMH levels, presumably from ovarian trauma and damage to the ovarian cortex during the procedure. Removal does not negatively affect success with assisted reproductive technology. Current evidence suggests ovarian cystectomy does not improve reproductive outcomes in women with endometriomas. Women undergoing IVF/ICSI after resection of endometrioma cyst show similar implantation and clinical pregnancy rates compared to women with endometriomas that were not resected.
The indications for removal of endometriomas <4 cm are primarily related to pain treatment, confirmation of an endometrioma cyst when the differential is unclear, decreased recurrence of endometriosis, and related symptoms. Potential harms of surgical excision include surgical risks, costs, and potential for decreased ovarian reserve. Among women undergoing assisted reproduction after surgery, success rates are improved when excision of the endometrioma cyst is performed compared to drainage or ablation of the cyst wall. Medical therapies administered before or after surgery have not been found to improve fertility rates and should not be used as they delay assisted reproduction and pregnancy. Medical therapy alone with gonadotropin-releasing hormone agonists, continuous contraceptive pills, has not been found to enhance fertility in women with endometriomas. Evidence for the use of aromatase inhibitors is limited.
Endometriomas are frequently found in women with endometriosis. They may be asymptomatic or associated with pelvic pain and infertility,
Endometriomas have a classic characteristic appearance on ultrasound,
Endometriomas have been associated with diminished ovarian reserve and infertility,
Excision of small endometriomas prior to undergoing assisted reproductive technologies does not improve success,
Surgical excision has been associated with further decrease in ovarian reserve as measured by AMH level, but this does not decrease success rates with IVF,
Ovarian cystectomy is indicated for improvement in symptoms or if the diagnosis of the mass is not clear on imaging.