Does Pre-cycle Resection of Endometriomas Affect IVF Outcomes?
The question of whether resection of endometriomas either enhances or has a deleterious effect on IVF cycle outcome is addressed in detail elsewhere. However, two recent reviews of the literature are helpful. Tsoumpo et al published a meta-analysis of the effect of surgical treatment of endometriomas or expectant management on subsequent IVF cycles. Meta-analysis was performed on 5 of 20 eligible studies. These authors noted no significant differences in pregnancy rates or gonadotropin responses between the groups, suggesting little benefit in surgical intervention. In a more recent Cochrane Database review, Benschop and coworkers confirmed a lack of evidence of any benefit from either aspiration or cystectomy compared with expectant management with regard to clinical pregnancy rates or number of mature oocytes retrieved. Cystectomy was associated with a decreased response to controlled ovarian hyperstimulation in comparison with expectant management.
One of the presumed benefits of endometrioma resection was purported to be the avoidance of inadvertent exposure of oocytes to endometrioma fluid at the time of aspiration. However, at least one group of investigators has shown that such exposure has no impact on fertilization or early embryo development rates. Nevertheless, it does make sense to make every effort to avoid entering an endometrioma during oocyte retrieval procedures to prevent peritoneal leak of contents.
If resection of endometriomas prior to IVF is generally not beneficial, then can this intervention cause harm? Several investigators have shown that the response to gonadotropins of operated versus nonoperated ovaries was significantly reduced after unilateral cystectomy.[33,34,35,36] Somigliana et al calculated that this corresponded to a 53% reduction in response (95% CI, 35 to 72) that was not affected by the size of the cyst excised. In fact, this same group reported that, of 93 women who underwent pre-cycle surgery for unilateral endometriomas, an absence of follicular growth in the operated but not the contralateral ovary occurred in 13% of cases. Others have failed to show such a deleterious effect, however.[38,39,40]
Given the lack of convincing evidence supporting benefit of routine resection and potential surgical risk as well as damage to ovarian function, one would ask if there are any indications for removing an endometrioma prior to an IVF cycle. Garcia-Velasco and Somigliana recently published an elegant opinion article that addresses this issue. They claimed that it would be reasonable to consider surgical intervention in patients who have never previously undergone laparoscopy to confirm the diagnosis of endometriosis, those with progressive pain, those masses that exhibit rapid growth and/or have suspicious ultrasound features, those of a significant enough size to create concern for rupture in pregnancy, and an inability to access the remainder of the ovary. Others should be managed expectantly (Table 3). However, when surgical intervention is undertaken, it is critical to use meticulous techniques with a goal of carefully avoiding compromise of ovarian blood supply and destroying otherwise healthy normal tissue.
Semin Reprod Med. 2013;31(2):154-163. © 2013 Thieme Medical Publishers