Limitations of Endometrioma Surgery in In Vitro Fertilization: Possibilities of Early Disease Control
Endometrioma can be diagnosed by transvaginal ultrasound scan at a very early stage; however, the identification of patients who will deteriorate by developing larger endometrioma remains a major challenge. Literature review was performed using key words for endometrioma surgery, in vitro fertilization (IVF), implantation rate, and pregnancy rate. Current guidelines by eight international gynecological societies were used to guide identification of evidence for clinical practice. Research also focused on the pros and cons as well as outcomes of endometrioma surgical treatment before IVF. Thirty-three articles matching our search criteria were categorized into pros/cons of endometrioma surgery prior to IVF. Only four retrospective studies matching our search criteria compared implantation and pregnancy rates between surgical removal of endometrioma and no surgery prior to IVF.
The total patient population of articles supporting removal of endometrioma before assisted reproductive technology and evidence against were 30,741 and 9983, respectively. However, the only study reporting a statistically significant result found an 8.2% implantation rate for the surgical removal group versus 12% in the direct-to-IVF group, and 14.9% pregnancy rate in the surgical removal group versus 24.9% in the direct-to-IVF group. Damage to ovarian reserve and function due to surgery is exacerbated by large cyst size and older age. Larger endometrioma and younger age are associated with recurrence of endometrioma. High-risk adolescents and older women seeking fertility treatment can thus benefit from early diagnosis of endometrioma. Therefore, early identification of eligible patients must be improved and standardized, through stepwise clinical reasoning and diagnostic testing. Individualization of management based on age, fertility preservation, and endometrioma characteristics is essential. An algorithm for management of endometrioma prior to IVF is proposed.