Ovarian Endometrioma

Guidelines for Selection of Cases for Surgical Treatment or Expectant Management

Molly Carnahan; Jennifer Fedor; Ashok Agarwal; Sajal Gupta


Expert Rev of Obstet Gynecol. 2013;8(1):29-55. 

In This Article

IVF Protocols to Use With Endometriomas

In women with in situ unilateral endometriomas, Benaglia et al. found no significant difference in the ovarian responsiveness to COH or the number of follicles retrieved between the affected and unaffected ovary (Table 1),[39,107] which is in accordance with results from previous studies. Therefore, the presence of ovarian endometriomas does not negatively affect IVF outcomes.

The goal of research on ovarian endometriomas is to determine how to improve fertility outcomes in infertile women. Two different approaches need to be analyzed: reproductive surgery to improve IVF outcomes and IVF-only protocols.

Pabuccu et al. compared COH protocols with a GnRH antagonist and agonist in a prospective randomized trial for women with mild-to-moderate endometriosis, prior surgery for ovarian endometriomas and in situ ovarian endometriomas. The mild-to-moderate endometriosis group did not differ on any outcome measures. However, in women with prior endometriomas and in situ endometriomas, the GnRH analog resulted in significantly more mature oocytes retrieved and embryos available for transfer. In women needing to cryopreserve oocytes or embryos, the GnRH agonist was better than the GnRH antagonist. However, the implantation and pregnancy rates did not differ between the antagonist and agonist for both prior endometrioma and in situ endometrioma patients. Pabuccu et al. suggested that endometriosis negatively affects endometrial receptivity. More research is needed to explain their findings and to improve IVF protocols in women with endometriosis.[108]

As previously noted, some women require surgery for ovarian endometriomas and subsequent IVF. Several recent studies reported longer stimulation times and higher doses of gonadotropins in women who previously underwent surgery for ovarian endometriomas compared with controls and women with in situ endometriomas.[20,109] Similarly, Yazbeck et al. used an 'ultra-long' GnRH agonist protocol following aspiration with EST, which resulted in a higher cumulative pregnancy rate compared with the control group, which consisted of women with mild-to-moderate endometriosis – this included a woman with prior cystectomy for an ovarian endometrioma.[68] This study demonstrates the need for individualized IVF protocols for each type of surgical procedure. More research is needed on these individualized protocols.

In a systematic review by Sallam et al., three randomized trials were examined to assess the effectiveness of a GnRH agonist for 3–6 months prior to IVF in women with endometriosis compared with no treatment prior to IVF. The GnRH agonist group had a significantly increased live birth rate (OR: 9.19; 95% CI: 1.08–78.22).[110] A clinical trial is currently being conducted to assess a different drug – triptorelin acetate, which is a GnRH analog – 3 months prior to COH in women with endometriosis and ovarian endometriomas.[203]