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Page 6 of 15 Tanos et al. Mini-invasive Surg 2020;4:39 I http://dx.doi.org/10.20517/2574-1225.2019.59

RESULTS
Pros and cons of surgical removal of endometrioma prior to IVF
The total population across both pro/con, including control and study patients was 40,724.

Pros of surgical removal of endometrioma prior to IVF
The total patient population of articles supporting removal of endometrioma before ART was 30,741. Table 1
summarizes the “pros” of surgical removal of endometrioma prior to IVF according to current evidence.

Three articles provided evidence that removal of endometriomas reduces the risk of abscess and infection.
The risk of endometrioma rupture with or without pelvic abscess development is supported by five studies
[17]
within the systematic review carried out by Somigliana et al. . The American Society of Reproductive
[18]
Medicine committee opinion reports that this rupture may result in abscesses, infection and further
progression of endometriosis as well as contamination of the ovary or peritoneum with endometrioma
content. Contamination of follicular fluid via accidental aspiration of endometrioma contents, which
occurred in 19/314 total patients (6.1%), resulted in lower adjusted clinical pregnancy (0.63; 95%CI: 0.49-
0.87, P = 0.005) and live birth RRs (0.60; 95%CI: 0.51-0.86, P = 0.003) amongst the exposed and control
groups respectively .
[19]

Ten articles, with a combined total patient population of 7313, provided evidence that removal of
endometriomas prior to IVF may improve IVF outcomes as measured by the increase in follicular
production, oocyte retrieval, fertilization, implantation, and pregnancy rates, and reduced cycle cancellation
rates. Three studies found that the removal of large endometriomas improves IVF outcomes [15,20,21] . One
study found that, among patients with unilateral endometriomas measuring > 5 cm, the differences in IVF
outcomes between the ovary with endometrioma and the healthy ovary were as follows: (1) less follicles
produced in the ovary with endometrioma vs. healthy ovary (total number of follicles: 2.6 +/- 1.3 and
4.8 +/- 2.0, respectively; P < 0.0001); (2) less total number of retrieved oocytes (2.0 +/- 1.2 and 4.2 +/- 1.7
respectively; P ≤ 0.01); and (3) less number of oocytes retrieved which were suitable for fertilization (0.5
[20]
+/- 1.1 and 3.3 +/- 1.5 respectively; P ≤ 0.01) . Four studies, including a combined total of 6895 patients,
demonstrated a lower mean oocyte retrieval during IVF/intracytoplasmic sperm injection (ICSI) in
women with endometriomas compared to normal [Standardized Mean Difference = -0.23 (95%CI: -0.37 to
[10]
[12]
[11]
-0.10) , (6.6 ± 3.74 vs. 10.4 ± 5.25; P < 0.001) , (5.7 ± 3.1 vs. 10.4 ± 4.4; P < 0.05) , (Mean Difference =
[22]
-1.50; 95%CI: -2.84 to -0.15, P = 0.03) ]. Among 64 total patients undergoing IVF, comparing 32 cases of
endometrioma and 32 tubal-associated cases, there was a higher cycle cancellation rate amongst patients
[11]
with endometrioma (18.3% and 1.7%, respectively; P < 0.05) . One study compared IVF outcomes in 85
patients with endometriomas measuring 10-50 mm vs. 83 patients with simple ovarian cysts measuring
10-35 mm, found lower implantation rates in women with endometriomas compared to the cyst group
(13.9 and 16.4, respectively; P = 0.03) . A randomized control study of 99 patients with endometriomas,
[9]
randomized to ovarian endometrioma cystectomy pre-ICSI or no surgery, found no statistically significant
difference in fertilization (86% and 88%, respectively), implantation (16.5% and 18.5%, respectively) and
[23]
pregnancy rates (34% and 38%, respectively) between pre-ICSI surgery and control groups .
Two articles, with a combined patient population of 23,114, provided evidence that the removal of
endometriomas can also help in the diagnosis of malignancy at an early stage. The lifetime probability of
[8]
developing ovarian cancer increases from 1% to 2% in the presence of endometriomas . In their pooled
[24]
analysis of case-control studies, covering a total patient population of 23,114, Pearce et al. found that
endometriosis is associated with increased risk for clear-cell (OR: 3.05; P < 0.0001), low-grade serous (OR:
2.11; P < 0.0001) and endometrioid invasive (OR: 2.04; P < 0.0001) ovarian cancers.