Endometrioma (or chocolate cyst of the ovary) is estimated to affect 17-44% of women suffering from endometriosis (1). Its presence is often associated with infertility and/ or chronic pelvic pain and its surgical management may be indicated. What are the available methods of surgical management of endometrioma and what outcomes are they linked with? In this article, we will examine the influence of surgical management options on the ovarian reserve and fertility outcomes.   

  Let us start by saying that there are various ovarian reserve tests available but the most widely used are anti-mullerian hormone (AMH), checked by a blood test on any day of the menstrual cycle, and antral follicular count (AFC), checked by transvaginal ultrasound in the beginning of the cycle (2). Various studies have demonstrated that the presence of endometrioma per se is associated with lower levels of AMH and AFC (3-5).

  We recognize 4 surgical approaches to endometrioma: surgical excision (cystectomy), ablation of the cyst wall (laser, plasma energy, bipolar diathermy), ethanol sclerotherapy and, finally, combined approaches. With few exceptions only, all the above mentioned methods can be performed, in the hands of surgeons with appropriate experience in endometriosis surgery, laparoscopically or robotically. Let us, now, have a look in each surgical approach separately.

  Cystectomy of endometrioma is the most- commonly employed method worldwide. Studies have demonstrated that, in comparison to other methods, cystectomy may be associated with lower recurrence rates (6), and higher rates of spontaneous conception (7). At the same time, however, this approach appears to be associated with greater damage to the ovarian cortex and, consequently, greater decline in post-operative ovarian reserve (8,9). The drop in AMH appears to be, at least partly, temporary (10,11) and may be associated with a number of other factors, such as ovarian cyst size, use of diathermy, pre-operative ovarian reserve levels and surgeon experience (12-15). In contrast to the evidence regarding AMH, studies have demonstrated that cystectomy does not reduce (and may even increase) post-operative AFC (16,17).

  As regards ablative methods, the idea is based on sparing, as much as possible, the healthy ovarian parenchyma. Use of bipolar diathermy has largely been replaced by newer technologies, such as laser or plasma energy, that allow ablation of the cyst wall only (and not the healthy ovarian cortex) (18,19). Indeed, studies have demonstrated that, compared to ovarian cystectomy, ablative methods cause less reduction in AMH and AFC (20-22). One limitation may be the size of the endometrioma. In my opinion, ablative methods may be used for endometriomas of maximum diameter up to 5 centimetres.

  Ethanol sclerotherapy includes drainage of the cholocate cyst fluid followed by ‘’filling’’ of the cyst cavity with ethanol for up to 10 minutes. The fluid is then meticulously removed from the pelvic cavity with minimal spillage. This approach has, also, been employed vaginally as part of medically-assisted reproduction techniques. Up to this point, there are only 2 published studies available on laparoscopic ethanol sclerotherapy (23,24), 1 of which reports a significant decline in AMH and a non-significant AFC rise post-operatively (23). In my view, this technique may have a role in large endometriomas (eg. Larger than 5 centimetres in maximal diameter), in patients with low pre-operative ovarian reserve and in whom ablative methods may be technically challenging, due to endometrioma size.

  Combined approaches also aim to reduce the damage to ovarian cortex caused by traditional endometrioma cystectomy. Donnez and co-workers described a technique that combines surgical excision of 80-90% of the endometrioma cyst wall and ablation of the remaining 10-20% (25). The combined approach may lead to improved AFC compared to cystectomy, however, this finding has not been confirmed by a randomised study (26).

  What happens, though, to fertility outcomes after endometrioma surgery? A meta-analysis found that the combination of surgery with IVF yielded better outcomes than IVF alone (27). A multi-centric study did not find a statistically significant difference in pregnancy probability between cystectomy and ablation with plasma energy (28), whereas a retrospective study linked ablation with plasma energy to higher post-operative pregnancy rates (29). Of interest, another study found that cystectomy by ‘’experienced surgeons’’ led to higher post-operative AFC and living embryos per IVF cycle, compared to cystectomy by ‘’inexperienced surgeons’’ (30).

  In conclusion, there is no ideal surgical approach to ovarian endometrioma. Each method has pros and cons. The newer methods previously mentioned aim to reduce surgery-induced damage to healthy ovarian cortex by traditional cystectomy. Due to complexity of the topic and conflicting evidence, personalisation of care is highly recommended and the decision on the correct surgical approach should be made after extensive patient counselling. In an attempt to summarize, I would say: Cystectomy may be preferrable in younger patients with adequate pre-operative ovarian reserve, when post-operative spontaneous conception is a priority, in patients with chronic pelvic pain, when endometrioma recurrence prevention is prioritised as well as older patients, in whom fertility preservation is not a concern. On the other hand, alternative methods have a role in carefully-selected cases, mostly in patients with low pre-operative ovarian reserve or when cystectomy is not technically feasible.

For more information on this topic, I recommend you to read our published study ‘’Surgical Management of Ovarian Endometrioma: Impact on Ovarian Reserve Parameters and Reproductive Outcomes’’.

Link to free full text: https://www.mdpi.com/2077-0383/12/16/5324#

References:

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