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Table 1. Pros of surgical removal of endometriomas before ART
Benefits of endometrioma excision prior to IVF n Types of Study Ref.
Risk of ruptured endometrioma, abscess, infection, progression of - Systematic review Somigliana et al. [17]
endometriosis, contamination with endometrioma content Committee opinion ASRM [18]
Contamination of follicular fluid with endometrioma contents can 314 Retrospective, case-control Benaglia et al. [19]
affect IVF outcome study
Removal of large (5 cm) endometriomas improves follicular 26 Retrospective analysis study Ferrero et al. [20]
production and number of oocytes retrieved during IVF
Removal of large > 4 cm endometriomas can improve fertility - Committee opinion ASRM [18]
outcomes
Surgical removal of endometriomas > 4 cm increases pregnancy - Literature review Rizk et al. [21]
rate and decreases rate of endometrioma recurrence
Lower mean oocyte retrieval and higher cycle cancellation rate 5753 Meta-analysis Hamdan et al. [10]
during IVF/ICSI in women with endometriomas vs. those without 103 Prospective cohort study Ashrafi et al. [12]
64 Retrospective cohort study Mao et al. [11]
1039 Meta-analysis Yang et al. [22]
No difference in fertilization, implantation and pregnancy rates 99 Prospective randomized study Demirol et al. [23]
between pre-ICSI endometrioma surgery and control groups
Higher live birth rate post-IVF in patients without endometrioma 61 Retrospective cohort study Benaglia et al. [64]
vs. those with
Implantation rate lower in women with endometrioma as small as 168 Retrospective case-control Kumbak et al. [9]
0.25 mm vs. women with simple ovarian cyst study
Surgical removal avoids risk of malignancy associated with - Scientific impact paper Jayaprakasan et al. [8]
endometrioma 23,114 Pooled analysis of case-control Pearce et al. [24]
studies
ASRM: American Society for Reproductive Medicine; IVF: in vitro fertilization; ART: assisted reproductive therapy; ICSI: intracytoplasmic
sperm injection

Table 2. Cons of surgical removal of endometriomas before ART
Disadvantages of endometrioma excision prior to IVF n Types of Study Ref.
Surgical removal can result in reduced ovarian reserve 428 Retrospect case control study Bongioanni et al. [15]
- Scientific impact paper Jayaprakasan et al. [8]
63 Prospective case-control study Turkcuoglu and Melekoglu [27]
1642 Retrospective analysis Hwu et al. [25]
60 Prospective cohort study Uncu et al. [26]
291 Meta-analysis Raffi et al. [28]
5753 Meta-analysis Hamdan et al. [10]
- Systematic review Somigliana et al. [29]
Decreased post-surgery pregnancy rates vs. other types 359 Retrospective observational cohort Maignien et al. [33]
of endometriosis study
Laparoscopic removal reduces ovarian reserve (low 193 Prospective study Alborzi et al. [30]
AMH) and increases FSH
Excision of endometriomas may remove healthy ovarian 326 Retrospective cohort study Perlman and Kjer [32]
tissue 59 Prospective study Muzii et al. [31]
Lower mean number of oocytes retrieved in women with 167 Retrospective case-control study Roustan et al. [65]
decreased ovarian reserves caused by endometrioma
cystectomy vs. idiopathic
Lower embryo quality and implantation rates associated 168 Retrospective case-control Kumbak et al. [9]
with endometriotic cyst presence during IVF, potentially comparative study
caused by disease itself vs. the cystic mass
Requirement of higher doses of gonadotrophins for - Scientific impact paper Jayaprakasan et al. [8]
ovarian stimulation post-surgical removal 99 Randomized control trial Demirol et al. [23]
Ovarian responsiveness and oocyte quality did not 29 Prospective observational study Filippi et al. [34]
significantly differ between endometrioma and non-
endometrioma in women undergoing IVF
Oocyte quality unimproved after surgery - Literature review Ruiz-Flores and Garcia-
Velasco [35]
Presence of endometrioma in controlled ovarian 243 Retrospective case-control study Almog et al. [39]
hyperstimulation is not associated with reduced absolute (unilateral endometrioma)
quantity of oocytes retrieved from the affected ovary
Endometrial receptivity similar in both endometrioma 103 Prospective cohort study Ashrafi et al. [12]
and control groups; no significant impact on implantation, (unilateral/bilateral, < 3 cm)
pregnancy rates
IVF: in vitro fertilization; ART: assisted reproductive technology; AMH: anti-Mullerian hormone; FSH: follicle-stimulating hormone