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


This review has outlined the current treatment techniques and factors that need to be taken into consideration prior to selection of patients for treatment. As outlined in Figure 1, based on these factors, we propose three treatment paths for women with ovarian endometriomas who wish to conceive: reproductive surgery to achieve spontaneous pregnancy following treatment, reproductive surgery to enhance IVF outcomes, or expectant management with IVF. Reproductive surgery to achieve spontaneous pregnancy following treatment is advised for patients who wish to conceive naturally due to either religious beliefs, costs or other personal preferences. Women with an intact ovarian reserve, unilateral cyst and/or no prior surgical treatment may benefit from this treatment path. We recommend combined ablation and cystectomy due to the high rates of spontaneous pregnancy with reduced risk of ovarian failure. Reproductive surgery to enhance IVF outcomes is advised for women with pain, male factor infertility or women who do not want to wait to try natural conception following surgery. Women with large, hindering cysts may benefit from this treatment path. The authors recommend the three-stage technique or aspiration with sclerotherapy as less invasive procedures to enhance IVF outcomes. An ultra-long GnRH agonist is the recommended IVF protocol. In women with no pain and male or tubal factor infertility, the authors advise the treatment path of expectant management with IVF. Women with reduced ovarian reserve, bilateral endometriomas, small cysts and prior surgical treatment may benefit from this treatment path. The authors recommend a GnRH agonist for 3–6 months prior to IVF for this treatment plan.

Figure 1.

Treatment paths for women with ovarian endometriomas who wish to conceive. GnRH: Gonadotropin-releasing hormone.

Furthermore, this current review emphasizes the need for research and new treatment techniques based on the three individual treatment paths and factors (ovarian reserve, age, laterality, size/location and prior surgery) to achieve the best fertility outcomes. In women undergoing IVF, different IVF protocols are needed based on prior surgical treatment, patient age and ovarian reserve. Women choosing a treatment path with surgery need to be counseled on the potential for ovarian failure. More research is needed on fertility preservation techniques in women with ovarian endometriomas and how IVF protocols may need to be adapted in these cases. Understanding the different treatment paths for reproductive success can help in the selection of cases based on current research, and promotes future research for the development of specific surgical and IVF protocols based on a patient's ovarian endometrioma factors.