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Endometrioma-related Infertility: Surgery or IVF?

Endometriosis, and perhaps especially intra-ovarian endometriosis, is associated with infertility. The classic endometrioma or “Chocolate cyst” represents a benign ovarian cyst lined with uterine lining-like cells which contains viscous, old blood. They occur in 20-40% of patients with endometriosis and tend to distort normal ovarian anatomy and induce a chronic inflammatory reaction. This local inflammation can decrease the total amount of viable ovarian tissue and may diminish egg reserve.

In the IVF setting women with endometriomas have higher cancellation rates and a lower number of eggs retrieved than those without endometriomas; however, the live birth rates are similar in the two groups. That is, although the numbers of eggs and resulting embryos are fewer, the embryo quality and implantation rates are not substantively different.

Patients with endometrioma-related infertility may be offered surgery, surgery then IVF, or IVF directly as modes of treatment. Risks of endometrioma surgery include but are not limited to the skill of the surgeon, possible surgical complications, negative impact on ovarian reserve, possible incomplete excision with recurrence, delay in IVF treatment, and costs. The risks of IVF without prior endometrioma surgery are possible progression of endometriosis, cycle cancellation, challenging egg retrieval, fewer eggs retrieved, endometrioma infection, follicular fluid contamination, peritonitis, and undiagnosed ovarian cancer. In short, the decision for or against surgery prior to IVF must be carefully considered and individualized with baseline ovarian reserve testing (AMH, Cycle day 2-3 FSH and estrogen levels, and antral follicle counts) and associated pain levels important variables in the decision-making process. For example, the younger patient with presumed endometriosis-related pain and excellent reserve is a better candidate for pre-IVF endometrioma surgery than the older patient without pelvic pain and diminished ovarian reserve. It is along the disease continuum, and between these two patient types, that there are infinite shades of gray.

Reference: In part after Donnez, J: https://doi.org/10.1016/j.fertnstert.2018.10.002

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