Ovarian Endometrioma

Table 1.  Expectant management versus surgical techniques and IVF outcomes.

Study (year)	Type of study	Subjects	Treatment	Subjects (n)	Bilateral (%)	Oocytes retrieved (n)	MII oocytes (n)	Fertilization rate (%)	Implantation rate (%)	Pregnancy rate/cycle (%)	Live birth rate (%)	Cancellation rate (%)	Ref.
Expectant management
Kumbak et al. 2008)	Retrospective	IVF–ICSI and ovarian cyst	OE, EM	85	Unilateral only	13.9	10.3	82	19	43.4 per ET			[19]
			Other benign cyst	83	Unilateral only	16.4, p = 0.03	11.8, NS	79, NS	28, p = 0.02	48.2 per ET, NS
Almog et al. (2011)	Retrospective case–control	Infertility and first attempt IVF	OE, EM (group 1)	81	Unilateral only	0.98 A/C, NS p = 0.8, 11.4 ± 0.5 total							[40]
			No OE or endometriosis (group 2)	162		11.9 ± 0.8, NS p = 0.3, 1 vs 2
Opøien et al. (2012)	Retrospective cohort	Infertile	Stage III–IV endometriosis, no OE (group 1)	164		8.6 ± 5.3		62.5%	6.90	40.20	30.5 per ongoing pregnancy	2.3; groups 1 + 2	[23]
			Stage III–IV endometriosis, OE EM (group 2)	186		7.6 ± 5.5, NS group 1 vs 2		61.6; NS, group 1 vs 2	20.9, NS, group 1 vs 2	26.3; p < 0.01, 1 vs 2	18.8 per ongoing pregnancy, p < 0.05, group 1 vs 2
			Tubal factor infertility (group 3)	1171		9.2 ± 5.6, p < 0.01 group 1 + 2 vs 3		63.5; NS, group 1 + 2 vs 3	24.9; NS, group 1 + 2 vs 3	34.7; NS, group 1 + 2 vs 3	25.3; NS, group 1 + 2 vs 3	1.2; NS 1 + 2 vs 3
Benaglia et al. (2012)	Retrospective	OE, no prior surgery	Affected ovary	84	Unilateral only	6(4–8)							[92]
			Contralateral ovary			6(4–9), NS p = 0.18
Expectant management versus traditional treatments
Bongioanni et al. (2011)	Retrospective case–control	Infertility and first attempt IVF	OE, EM, (group 1)	142	14.10%	9.4 ± 4.3	71.20%	67.7	24.20	48.4 per ET	34.6 per ET	7.50	[20]
			OE, prior cystectomy (group 2)	112	19.60%	8.2 ± 5.3, NS 1 vs 2	68.60%	0.734	24.60	44.1 per ET	25.8 per ET	9.80
			Tubal factor infertility (group 3)	174		9.6 ± 4, NS 1 vs 3	66.9%, NS	70.2, NS	22.1; NS	40.1 per ET, NS	30.8 per ET, NS	2.9; p < 0.02, group 1 vs 3, group 2 vs 3
Barri et al. (2010)	Observational	Infertile	OE, surgery†, followed by IVF (group 1b)	483	Not reported		7.3 ± 5			30.40			[29]
			OE, EM with IVF (group 2)	173	Not reported		10.1 ± 2.2; p < 0.03, group 1b vs 2			32.20
			Male factor infertility (group 4)	334			10.3 ± 6 (significance not reported)				33.5 per patient; NS, group 1b + 2 vs 4
Expectant management versus aspiration with sclerotherapy
Salem et al. (2011)	Prospective controlled	Infertile and OE	Ultrasound guided aspiration with 95% EST	100	Not reported	8.7 ± 4.1		72 ± 12	18	30	28		[69]
			OE EM with IVF–ICSI	50	Not reported	6.0 ± 2.7		60.8 ± 10	14	22	18

†Mostly cystectomy, but actual procedures not reported.
A/C: Ratio affected/contralateral ovary; EM: Expectant management; EST: Ethanol sclerotherapy; ET: Embryo transfer; ICSI: Intracytoplasmic sperm injection; NS: Not significant (p < 0.05); OE: Ovarian endometrioma.

Table 2.  Surgical technique and follicle-stimulating hormone.

Study (year)	Type of study	Group	Treatment	Subjects (n)	Mean diameter (cm)	Bilateral (%)	Basal FSH days 3–5 (IU/l)	Ref.
Cystectomy
Almog et al. (2010)	Retrospective	OE and IVF	Cystectomy	38	3.9 ± 1.9	Unilateral only	7.6 ± 3.3	[111]
Biacchiardi et al. (2011)	Prospective cohort	Normo-ovulatory and OE	Cystectomy	43	3.68 ± 1.08	23.30	1.4 (MD); NS	[56]
Cystectomy versus three-stage technique
Tsolakidis et al. (2010)	Prospective, randomized control trial	OE, no prior surgery	Cystectomy (group 1)	10	3.79 ± 0.48	Unilateral only	9.1 (MD); NS baseline vs follow-up	[61]
			Three-stage (group 2)	10	3.68 ± 0.55	Unilateral only	3.4 (MD) NS, baseline vs follow-up; NS group 1 vs 2
Aspiration with sclerotherapy
Yazbeck et al. (2009)	Prospective	Infertile and recurrent OE	Aspiration with 95% EST (group 1)	31	3.86 ± 1.12	12.90	6 ± 1.5	[68]
			Control – moderate to severe endometriosis, no OE (group 2)	26			9 ± 4.8; p < 0.01 group 1 vs 2
Shawki et al. (2012)	Prospective case–control	Infertile and OE	Aspiration with MT	65	6.5 ± 1.53	Unilateral only	7.2 ± 1.5	[71]
Expectant management versus traditional techniques
Bongioanni et al. (2011)	Retrospective case–control	Infertile and first attempt at IVF	OE, no prior surgery (group 1)	142	Not reported but all <6 cm	14.10	7.2 ± 3.9	[20]
			OE, prior cystectomy (group 2)	112	Not reported but all <6 cm	19.60	7.9 ± 4.2
			Tubal factor infertility (group 3)	174			6.6 ± 3.5, NS

EST: Ethanol scleropathy; FSH: Follicle.stimulating hormone; MD: Mean difference (baseline vs follow-up); MT: Methotrexate; NS: Not significant p > 0.05; OE: Ovarian endometrioma.

Table 3.  Surgical technique and antral follicle count.

Study (year)	Type of study	Group	Treatment	Subjects (n)	Mean diameter (cm)	Bilateral (%)	AFC	Ref.
Cystectomy
Ercan et al. (2011)	Prospective cohort	OE, no prior surgery	Cystectomy (group 1)	36	5.2 ± 1.4	Unilateral only	-0.8 (MD)	[112]
			Contralateral ovary (group 2)				1.2 (MD); p < 0.05, group 1 vs 2
Almog et al. (2010)	Retrospective	OE and IVF	Cystectomy, operated cyst	38	3.9 ± 1.9	Unilateral only	4.5 ± 3.8	[111]
			Nonoperated ovary				7.4 ± 5.2; p = 0.003 group O vs N
Biacchiardi et al. (2011)	Prospective cohort	OE	Cystectomy	43	3.68 ± 1.08	23.30%	1.8 (MD), NS	[56]
Cystectomy versus ablation
Roman et al. (2011)	Retrospective	OE >3 cm, no prior surgery	Plasma ablation (group 1)	16	3.8 ± 1.3	Unilateral only	5.5 ± 3.9, 0.83 ± 0.31 (O/N)	[64]
			Cystectomy (group 2)	15	4.7 ±1.6, p = 0.10 group 1 vs 2	Unilateral only	2.9 ± 2.4; p = 0.03, group 1 vs 2, 0.33 ± 0.25 (O/N); p < 0.001, group 1 vs 2
Cystectomy versus three-stage technique
Tsolakidis et al. (2010)	Prospective, randomized control trial	OE, no prior surgery	Cystectomy (group 1)	10	3.79 ± 0.48	Unilateral only	0.4 (MD)	[61]
			Three-stage technique (group 2)	10	3.68 ± 0.55	Unilateral only	3.06 (MD); p = 0.02, baseline vs follow-up; p = 0.002, group 1 vs 2
Combined cystectomy and ablation
Donnez et al. (2010)	Prospective	OE, no prior surgery	Combined cystectomy and ablation (group 1)	52	4.6 ± 1.3	61.50%	6.1 ± 3.2	[65]
			Combined cystectomy and ablation, unilateral (group 1b)	20			0.98 (O/N), NS
			Male factor infertility, no OE (group 2)	20			6.2 ± 4.8, NS, group 1 vs 2
Aspiration with sclerotherapy
Yazbeck et al. (2009)	Prospective	Infertile and recurrent OE	Aspiration with 95% EST (group 1)	31	3.86 ± 1.12	12.90%	9.6 ± 4.7	[68]
			Control – Stage III–IV Endometriosis, no OE (group 2)	26	–	–	10.6 ± 6.8, NS
Shawki et al. (2012)	Prospective case–control	Infertile and OE	Aspiration with MT (group 1)	65	6.5 ± 1.53	Unilateral only	9.6 ± 1.7	[71]
			Contralateral ovary (group 2)			11.7 ± 2.3, NS, group 1 vs 2
Expectant management
Almog et al. (2010)	Retrospective	Ovarian cyst	Endometrioma cyst	53	2.7 ± 0.2	Unilateral only	0.806 (A/C), p = 0.03	[30]
			Functional cyst	198	1.9 ± 0.07	Unilateral only	0.966 (A/C), NS, p = 0.39
			Dermoid cyst	14	2.1 ± 0.3	Unilateral only	1.29 (A/C), NS, p = 0.16
			Multioculated cyst	8	2.3 ± 0.3	Unilateral only	0.96 (A/C), NS, p = 0.9
Expectant management versus traditional treatments
Bongioanni et al. (2011)	Retrospective case–control	Infertility and first attempt at IVF	OE, no prior surgery (group 1)	142	All <6 cm	14.10%	16.9 ± 11.1	[20]
			OE, prior cystectomy (group 2)	112	All <6 cm	19.6%, NS	11.7 ± 9.4; p < 0.001, group 1 vs 2; p < 0.001, group 2 vs 3
			Tubal factor infertility (group 3)	174			16.6 ± 9.5
Barri et al. (2010)	Observational	Infertile	OE, surgery†, then IVF(group 1b)	483	5.8 ± 2.1	Not reported	5.9 ± 6.1	[29]
			OE, EM with IVF (group 2)	173	5.4 ± 3.2	Not reported	7.8 ± 5.1; p < 0.03, group 1b vs 2
			Male factor infertility (group 4)	334			10.2 ± 5.1; p < 0.004, group 1b + 2 vs 4

†Mostly cystectomy but actual procedures not reported.
A/C: Ratio affected ovary:contralateral ovary; AFC: Antral follicle count; EM: Expectant management; EST: Ethanol sclerotherapy; MD: Mean difference (baseline vs follow-up); MT: Methotrexate; NS: Not significant (p > 0.05); O/N: Ratio operated:nonoperated ovary; OE: Ovarian endometrioma.

Table 4.  Surgical techniques and IVF outcomes.

Study (year)	Type of study	Subjects	Treatment	Subjects (n)	Bilateral (%)	Oocytes retrieved	MII oocytes	Fertilization rate (%)	Embryos/cycle	Implantation rate (%)	Pregnancy rate/cycle (%)	Live birth rate (%)	Cancelation rate	Ref.
Cystectomy
Somigliana et al. (2008)	Prospective case–control	Infertile	OE, prior cystectomy (group 1)	68	All bilateral	5.7 ± 4			2 ± 1.9	7	7	8	17/68 (28%)	[54]
			Male or tubal factor (group 2)	136		7.2 ± 3.6; p = 0.023, group 1 vs 2			2.8 ± 2; p = 0.024	16; p = 0.048	19; p = 0.037	24; p = 0.049	8/136 (6%); p < 0.001
Almog et al. (2010)	Retrospective	OE	Cystectomy, operated cyst	38	Unilateral only	4.3 ± 3.9								[111]
			Nonoperated ovary			7.6 ± 4.8; p < 0.001, group O vs N
Ablation
Donnez et al. (2001)	Retrospective	OE	OE, prior CO2 ablation (group 1)	85	54%		10.6 ± 4.2	60.9	2.5 ± 0.1	15	37.4			[62]
			Tubal factor infertility (group 2)	289			8.6 ± 6.3; NS	61.4; NS	2.3 ± 0.9; NS	14.9; NS	34.6; NS
Shimizu et al., (2010)	Retrospective	OE	KTP ablation, operate		Unilateral only	7.3 ± 3.6								[63]
			Nonoperated ovary			4.6 ± 2.7; NS p = 0.99, group O vs N
Aspiration with sclerotherapy
Yazbeck et al. (2009)	Prospective	Infertile and recurrent OE	Aspiration with 95% EST (group 1)	31	12.90%	11.4 ± 6.1	10.4 ± 5.4	60.8 ± 26	6.1 ± 3.1	31.5 ± 38.4	48.3			[68]
			Stage III/IV endometriosis, no OE (group 2)	26		7 ± 4.7; p = 0.03, group 1 vs 2	6.1 ± 3.8; p = 0.02, group 1 vs 2	80.1 ± 25, NS	4.5 ± 2.8, NS	32.3 ± 43.1, NS	19.2; p = 0.04
Shawki et al. (2012)	Prospective case–control	Infertile and OE	Aspiration with MT (group 1)	65	Unilateral only	8.1 ± 1.5		67.5 ± 1.32	5.8 ± 1.7	30.70	32.3	66.6		[71]
			Contralateral ovary (group 2)			10.2 ± 0.5; NS		70 ± 0.55, NS	7.2 ± 0.5, NS

EST: Ethanol sclerotherapy; ICSI: Intracytoplasmic sperm injection; KTP: Potassium-titanyl-phosphate; NS: Not significant (p < 0.05); OE: Ovarian endometrioma.

Table 5.  Surgical technique and recurrence rates.

Study (year)	Type of study	Subjects	Treatment	Subjects (n)	Mean diameter (cm)	Bilateral (%)	Recurrence rates	Average time to recurrence	Ref.
Aspiration
Zhu et al. (2011)	Retrospective	Infertile and OE	Aspiration	129	9.3 ± 6.2	20.90	91.5% after first treatment, 66.7% after second, 46.5% after third, 21.7% after fourth, 9.3% after fifth, 5.4% after sixth	At 24-month follow-up	[59]
Cystectomy
Porpora et al. (2010)	Prospective, observational	OE	Cystectomy	166	4.9 ± 2.4	31.30	15/166 (9.6%)	At 5-year follow-up	[49]
Hayasaka et al. (2011)	Retrospective	OE, no prior surgery	Cystectomy	173	5.4 ± 1.8 nonrecurrent, 6.0 ± 2.0 recurrent		78/173 (45%) after first surgery, 10/22 (45.4%) re-recurrence after second surgery		[47]
Barri et al. (2010)	Observational	Infertile	OE, surgery†	144	5.8 ± 2.1	Not reported	32/144 (22.2%)		[29]
Ablation
Shimizu et al. (2010)	Retrospective	Subfertile and OE	KTP laser ablation	45	3.3 ± 1.6	71.10	11/45 (24.4%)	4.9 ± 1.6 months	[63]
Ablation versus cystectomy
Carmona et al. (2011)	Prospective, randomized clinical trial	OE, no prior surgery	Cystectomy (group 1)	36	6.28 ± 1.72	22.20	4/36 (11%) 8/36 (22%)	At 12 months At 60 months	[48]
			Laser ablation (group 2)	38	6.25 ± 1.68	31.60	12/38 (31%); p = 0.04, group 1 vs 2 14/38 (37%) NS; group 1 vs 2	At 12 months At 60 months
Combined cystectomy and ablation
Donnez et al. (2010)	Prospective	OE, no prior surgery	Combined cystectomy and ablation (group 1)	52	4.6 ± 1.3	61.50	1/52 (2%)	At 6-month follow-up	[65]
Aspiration with sclerotherapy
Yazbeck et al. (2009)	Prospective	Infertile and recurrent OE	Aspiration with 95% EST	31	3.86 ± 1.12	12.90	4/31 (12.9%)	10 months	[68]
Shawki et al. (2011)	Randomized control trial	OE, no prior aspiration	Aspiration with saline (group 1)	95	6.59 ± 1.85	Unilateral only	70/95 (73.6%) after first treatment, 56/95 (58.9%) after second treatment, 43/95 (45.3%) after third treatment	At 12-month follow-up	[71]
			Aspiration with MT (group 2)	93			31/93 (33.3%) after first treatment; p < 0.05, group 1 vs 2, 20/93 (21.5%) after second treatment; p < 0.05, group 1 vs. 2, 13/93 (14%) after third treatment; p < 0.05, group 1 vs 2	At 12-month follow-up

†Mostly cystectomy but exact number not reported.
EST: Ethanol sclerotherapy; KTP: Potassium-titanyl-phosphate; MT: Methotrexate; NS: Not significant (p > 0.05); OE: Ovarian endometrioma.

Table 6.  Surgical technique and spontaneous pregnancy rates.

Reference	Type of study	Subjects	Treatment	Subjects (n)	Mean diameter (cm)	Bilateral (%)	Spontaneous pregnancy rate	Average time to pregnancy post-operation	Ref.
Aspiration
Zhu et al. (2011)	Retrospective	Infertile and OE	Aspiration	129	9.3 ± 6.2	20.90	44/129 (34.1%)	7–18 months	[59]
Cystectomy
Porpora et al. (2010)	Prospective, observational	OE	Cystectomy	166	4.9 ± 2.4	31.30	28/52 (53.8%)	Within 24 months	[49]
Hayasaka et al. (2011)	Retrospective	OE, no prior surgery	Cystectomy	173	5.4 ± 1.8 nonrecurrent, 6.0 ± 2.0 recurrent		24/173 (13.8%) after first surgery, 3/22 (13.6%) after second surgery		[47]
Barri et al. (2010)	Observational	Infertile	OE, surgery† (group 1a)	483	5.8 ± 2.1	Not reported	262/483 (54.2%)	11.2 months	[28]
			OE, no treatment (group 3)	169	Not reported	Not reported	20/169 (11.8%); p < 0.0001, group 1 vs 3	Within 8-year period
Ablation
Shimizu et al. (2010)	Retrospective	Subfertile and OE	KTP ablation	45	3.3 ± 1.6	71.10	22/45 (48.9%)	10.4 ± 12.6 months	[63]
Ablation versus cystectomy
Carmona et al. (2011)	Prospective, randomized clinical trial	OE, no prior surgery	Cystectomy (group 1)	36 (26 desired pregnancy)	6.28 ± 1.72	22.20	8/26 (30.8%)	At 60-month follow-up	[48]
			Laser ablation (group 2)	38 (24 desired pregnancy)	6.25 ± 1.68	31.60	8/24 (33.3%)	At 60-month follow-up
Combined ablation and cystectomy
Donnez et al. (2010)	Prospective	OE, no prior surgery	Combined cystectomy and ablation	52 (37 desire pregnancy)	4.6 ± 1.3	61.50	15/37 (41%)	8.3 months	[66]

†Mostly cystectomy but actual numbers not reported.
KTP: Potassium-titanyl-phosphate; OE: Ovarian endometrioma.

Table 7.  Surgical technique and AMH.

Study (year)	Type of study	group	Treatment	Subjects (n)	Mean diameter (cm)	Bilateral (%)	AMH (ng/ml)	Ref.
Cystectomy
Kitajima et al. (2011)	Prospective cohort	Ovarian cyst	OE, cystectomy† (group 1)	19	6.7 ± 1.9	Unilateral only	-1.25 (MD), -24.6%D	[113]
			Non-OE cyst, cystectomy (group 2)	13	6.8 ± 2.1, NS, group 1 vs 2	Unilateral only	3.3%D; p = 0.02, group 1 vs 2
Ercan et al. (2010)	Prospective cohort	OE, no prior surgery	Cystectomy†, unilateral OE (group 1)	33	0.59 ± 0.08	Unilateral only	-0.79 (MD)	[98]
			Cystectomy†, bilateral OE (group 2)	14	0.86 ± 0.11	Bilateral only	-0.27 (MD); NS, group 1 vs 2
			Control – fertile, no OE (group 3)	12			2.06 ± 0.51; NS, group 2 vs 3 (baseline and follow-up)
Biacchiardi et al. (2011)	Prospective cohort	Normo-ovulatory and OE	Cystectomy†	43	3.68 ± 1.08	23.30%	-1.7 (MD); p < 0.001	[56]
Ercan et al. (2011)	Prospective cohort	OE, no prior surgery	Cystectomy†	36	5.2 ± 1.4	Unilateral only	-0.08 (MD), NS	[112]
Lee et al. (2011)	Prospective cohort	OE, no prior surgery	Cystectomy†	13	4.0 ± 1.8	Unilateral only	-1.4 (MD); p < 0.002, baseline vs follow-up	[114]
Hirokawa et al. (2011)	Prospective cohort	OE, no prior surgery	Cystectomy†, unilateral (group 1)	20	6.1 ± 2.5	Unilateral only	-1.2 (MD)	[99]
			Cystectomy†, bilateral (group 2)	18	6.7 ± 1.8, p = 0.125, group 1 vs 2	Bilateral only	-2.4 (MD); p < 0.001, group 1 vs 2
Cystectomy versus three-stage technique
Tsolakidis et al. (2010)	Prospective, randomized controlled trial	OE, no prior surgery	Cystectomy† (group 1)	10	3.79 ± 0.48	Unilateral only	-1 (MD); p = 0.026, baseline vs follow-up	[61]
			Three-step (group 2)	10	3.68 ± 0.55	Unilateral only	-0.51' NS, baseline vs follow-up, p = 0.026, group 1 vs 2
Aspiration with sclerotherapy
Yazbeck et al. (2009)	Prospective	Infertile and recurrent OE	Aspiration with 95% EST (group 1)	31	3.86 ± 1.12	12.90	3.1 ± 2	[68]
			Contro – Stage III/IV endometriosis, no OE (group 2)	26			2.2 ± 2.9; p = 0.03, group 1 vs 2
Shawki et al. (2012)	Prospective case–control	Infertile and OE	Aspiration with MT	65	6.5 ± 1.53	Unilateral only	3.3 ± 0.4	[71]
Expectant management versus traditional treatments
Hwu et al. (2011)	Retrospective	Tubal or male infertility (group 1)	No treatment	1323			3.94 (≤30 years old), 3.31 (31–35 years), 1.98 (≥36 years)	[37]
		In situ OE, no prior surgery (group 2)	No treatment	141	≥3 cm (mean not reported)	22.60	2.97 (≤30 years old); p < 0.05, group 1 vs 2; 2.34 (31–35 years); p < 0.001, group 1 vs 2; 1.35 (≥36 years); p < 0.05, group 1 vs 2
		Unilateral (group 2a)		109			2.45 ± 0.17
		Bilateral (group 2b)		32			1.56 ± 0.24; p < 0.05, group 2a vs 2b
		Prior cystectomy OE (group 3)	Prior cystectomy	147	≥3 cm (mean not reported)	44.90	1.74 (≤30 years old); p < 0.001, group 1 vs 3; p < 0.05, group 2 vs 3; 1.53 (31–35 years); p < 0.001, group 1 vs 3, p < 0.05, group 2 vs 3; 0.53 (≥36 years); p < 0.001, group 1 vs 3; p < 0.05, group 2 vs 3
		Unilateral (group 3a)		81			1.48 ± 0.14
		Bilateral (group 3b)		66			1.01 ± 0.11; p < 0.05, group 3a vs 3b
		In situ OE cystectomy (group 4)	Cystectomy†	31	≥3 cm (mean not reported)	Unilateral only	-1.94 (MD); p < 0.01

†Study included in Raffi et al. (2012) meta-analysis [50].
%D: Percent difference baseline versus follow-up; AMH: Anti-Müllerian hormone; EST: Ethanol sclerotherapy; MD: Mean difference (baseline vs follow-up); MT: Methotrexate; NS: Not significant (p > 0.05); OE: Ovarian endometrioma.

Authors and Disclosures

Molly Carnahan, Jennifer Fedor, Ashok Agarwal and Sajal Gupta*

Center for Reproductive Medicine, Glickman Urological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk A19, Cleveland, OH 44195, USA

Financial & competing interests disclosure
The authors have no relevant affliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.

*Author for correspondence
Tel.: +1 216 444 8182 Fax: +1 216 445 6049 guptas2@ccf.org

Sidebar

Key Issues

• Ovarian endometriomas are associated with infertility in women of reproductive age.

• Ovarian endometrioma infertility is associated with a decreased oocyte retrieval rate and reduced oocyte quality, but is not associated with reduced embryo quality.

• Traditional treatment options, such as cystectomy and ablation, are associated with lower recurrence and higher spontaneous pregnancy rates, but can potentially cause ovarian damage.

• Traditional treatments such as ablation and cystectomy do not improve IVF outcomes.

• Newer, combined techniques are being developed that are less invasive and reduce ovarian damage, but more research is needed to determine how these procedures affect IVF outcomes.

• Because invasive surgery is often associated with postoperative reductions in fertility, including diminished ovarian reserve and premature ovarian failure, fertility preservation is an important consideration for women undergoing surgical intervention for ovarian endometriomas.

• Potential methods for fertility preservation are combined surgical techniques, autotransplantation of cryopreserved or fresh healthy ovarian tissue and oocyte or embryo cryopreservation for future IVF.

• Expectant management is a potential treatment plan, as recent literature reports suggest that ovarian endometriomas do not negatively affect IVF outcomes.

• Treatment depends on a number of factors, including ovarian reserve prior to treatment, laterality, size and hindering effects of a cyst, patient age, prior surgical treatment and the patient's desire for fertility.

• In women who have undergone prior surgery for endometriomas and in those with in situendometriomas, gonadotropin-releasing hormone agonists increase the number of mature oocytes and embryos available for transfer, but do not improve implantation or clinical pregnancy rates. More research is needed on optimizing IVF protocols for specific treatment plans.

• Understanding the treatment paths and ovarian endometrioma factors that affect fertility outcomes can help fertility specialists create individualized treatment plans.