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Page 2 of 15 Tanos et al. Mini-invasive Surg 2020;4:39 I http://dx.doi.org/10.20517/2574-1225.2019.59

pseudocapsule and older age. Larger endometrioma, ablation of the endometrioma base and younger age are
associated with higher recurrence rate.

Conclusion: The patient’s age, in addition to the size and type of endometrioma, can direct and indicate the timing
of surgical management. Bilateral endometriomas and those larger than 7 cm are associated with more damage to
ovarian reserve due to disease and surgery, as compared with unilateral lesions and those smaller than 7 cm. High-
risk adolescents and very young women seeking fertility treatment can thus benefit from an early diagnosis of
endometrioma. Treatment by trans vaginal hydro-laparoscopy of selected cases can probably be suggested for the
treatment of small endometriomas, since 5fr instruments are used following microsurgery principles. Therefore, an
early diagnosis of endometrioma, especially in young patients, must be encouraged, improved and standardized,
through stepwise clinical reasoning and diagnostic testing.

Keywords: Endometriosis, endometrioma, assisted reproductive therapy, in vitro fertilization, surgery, adolescents

INTRODUCTION
[1]
Endometriomas affect 17%-44% of women with endometriosis . Approximately 17% of women suffering
[2]
from infertility are diagnosed with an endometrioma . The pathogenesis of endometrioma is characterized
by sequential and progressive damage of healthy ovarian tissue. During menses, the implantation of
regurgitated endometrial cells on the ovarian surface (via tubal lumen) causes a series of biochemical
reactions including persistent inflammation, bleeding (at the implantation site) and invagination of the
[3]
ovarian cortex, adhesions, cystic formations, tissue alterations and deformity . Invagination of the ovarian
cortex secondary to metaplasia of celomic epithelium in the context of cortical inclusion cysts has also been
[4]
proposed as a possible mechanism of endometrioma formation . Hence, the endometrioma pseudocapsule
itself is ovarian epithelium containing follicular structures and oocytes. Upon opening the endometrioma
after irrigation, endoscopic imaging reveals pinkish tissue that is the ovarian epithelium. The ovarian tissue
that is identifiable during endoscopic imaging is thus embedded with endometriotic cells that can continue
[5]
to proliferate and migrate even, if not destroyed .
In addition, ovarian endometriosis, is a marker of more significant pelvic and intestinal endometriotic
[6]
lesions . Despite the fact that the diagnosis of an endometrioma can be done by transvaginal ultrasound
examination at a very early stage, the identification of patients who will deteriorate through development of
larger endometriomas remains a major challenge.

Although cyclic pelvic pain, dyspareunia, bleeding, dysuria and/or infertility are the common presentations,
symptoms do not indicate the extent and/or progression of the disease. Endometriosis awareness among
general practitioners and the public is still very poor. Misdiagnosis and under-treatment occur not
infrequently. As a result, endometriomas are often diagnosed when the cyst is very large, and/or the disease
has reached an advanced stage - this is especially the case among adolescent women . Hence, many
[7]
infertility patients present with endometrioma and tubal factor problems with an indication for in vitro
fertilization (IVF) treatment.

A systematic review of the literature was performed to identify the course of action in treating
endometriomas prior to IVF. In addition, 9 current guidelines by international gynecological societies
were used as a tool to guide identification of the current gaps in research and evidence for clinical
practice. Research was also focused on the pros and cons, as well as outcomes of surgical treatment for
endometrioma before IVF. Based on the evidence and conclusions of our research, an algorithm for the
management options in endometrioma prior to IVF is proposed.