Surgery versus conservative management of endometriomas in subfertile women. A systematic review

Abstract

Introduction. Endometriomas are present in up to 44% of all women with endometriosis and have a detrimental effect on fertility. However, it is controversial whether endometriomas should be surgically removed before assisted reproduction technology. Our purpose was to evaluate whether surgical stripping of endometriomas in subfertile women improves the chance of a live birth. Secondary outcomes were impact on ovarian reserve and pain. Material and methods. We conducted a systematic review and meta-analysis with results reported in accordance to the PRISMA guidelines. A summary of findings table was developed using GRADE. We searched Medline and Embase. Two reviewers performed the screening. Results. Of 686 manuscripts, we included one randomized controlled trial and nine retrospective cohort studies, mostly of low quality. The odds ratio for live birth after surgery [compared with conservative management before in vitro fertilization (IVF)/ intracytoplasmic sperm injection (ICSI)] was 0.87 (95% CI 0.64-1.18, six studies, I 2 = 3%; ⨁◯◯◯, VERY LOW quality). The mean difference of antral follicle count was À2.09 (95% CI À4.84 to 0.67, four studies). No difference was observed regarding antral follicle count between the two groups (MD À2.09, 95% CI À4.84 to 0.67, four studies, ⨁◯◯◯, VERY LOW quality). Pain outcome was not reported in the included studies. Conclusion. The very low quality evidence suggests no difference in odds ratio of live birth between women who underwent surgery for endometriomas before IVF/ICSI compared with conservative management. Further high quality studies are needed, but due to a lack of convincing evidence favoring surgery, we recommend considering conservative treatment if the only indication is subfertility.

Differentiation of Endometriomas from Ovarian Hemorrhagic Cysts at Magnetic Resonance: The Role of Texture Analysis

“…First, due to its retrospective design it could have had selection bias, but it remains debatable whether the inclusion of both pathologically confirmed and unconfirmed lesions could be regarded as a pitfall. The diagnosis of endometriomas and functional hemorrhagic cysts is also based on clinical and paraclinical criteria, and an important part of these lesions is treated conservative [ 44 ]. Moreover, a previously published paper that evaluated the utility of the “T2 shading” sign [ 3 ] stated that the choice of including only histologically proven lesions produced a “greater selection bias”, decreasing the specificity of the reported findings.…”

Effect of endometrioma and its surgical excision on fertility (Review)

“…Surgical excision may increase the possibility to achieve pregnancy by restoring the anatomy of the affected ovaries in patients with endometrioma (46). However, pre-cycle surgical treatment of endometrioma does not appear to increase pregnancy rates in ART, along with a further detrimental impact on ovarian reserve (76)(77)(78)(79)(80). Considering the insufficient evidence favoring surgical excision before ART, cystectomy should only be suggested in specific situations, such as suspicious features, progressive symptoms and large cysts (87).…”

“…Recently, a meta-analysis including 28 studies investigated whether pre-ART cystectomy improved fertility, and no evidence showed any benefit of surgery, instead reporting similar CPR rates and LBR between females having undergone surgery for endometriomas and those who did not (76). Additionally, evidence from other studies demonstrated that females having undergone surgery for endometrioma before in vitro fertilization (IVF) or intracytoplasmic sperm injection exhibited similar fertility results compared with controls (77)(78)(79)(80). To the best of our knowledge, meta-analyses published to date did not detect any improvement in ART outcomes in patients undergoing cystectomy for OMA (Table I).…”

When more is not better: 10 ‘don’ts’ in endometriosis management. An ETIC* position statement

“…Larger RCTs are lacking but may be now considered ethically questionable. In fact, according to the results of systematic literature reviews, surgical excision of small endometriomas before IVF is associated with a need for higher amounts of gonadotrophins, lower peripheral estrogens levels, reduced number of follicles, and lower number of oocytes retrieved, but no effect on the chances of pregnancy (Brink Laursen et al ., 2017; Tao et al ., 2017; Nickkho-Amiry et al ., 2018). Excision of small endometriomas before IVF is particularly discouraged in case of repetitive surgery or bilateral cysts.…”