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Page 8 of 15 Tanos et al. Mini-invasive Surg 2020;4:39 I http://dx.doi.org/10.20517/2574-1225.2019.59

is similar both in the presence of endometriomas and without. When comparing normal and affected
ovaries in patients with unilateral endometriomas, there is no statistical significance in the difference in
[12]
fertilization rates (72.4% and 69.6%, P = 0.644) .
Surgical removal of endometriomas to improve fertility in the adolescent population
The few international guidelines which explicitly address treatment of adolescent ovarian endometriomas
unanimously present a stepwise treatment plan commencing with medical treatment first, followed by
surgical management, and finally combination treatment when necessary. The European Society of Human
Reproduction and Embryology 2016 guidelines state that laparoscopy may be indicated in adolescents
[36]
with chronic pelvic pain who do not respond to medical treatment . Similarly, in their 2018 statement
on adolescent endometrioma, the American College of Obstetricians and Gynecologists recommend
conservative surgical treatment, followed by 6 months of GnRH as adjunct treatment if surgical
[37]
management was inadequate . In 2019, the Endometriosis Treatment Italian Club also recommended
that laparoscopic surgical treatment of endometriomas in adolescents with moderate-severe dysmenorrhea
should not be carried out until medical treatment with estrogen-progestins or progestins has been
[38]
attempted .
Regarding the specific techniques and decision-making for surgical removal of endometriomas in this
population, transvaginal hydrolaparoscopy (TVHL) has been recommended in adolescent patients with
[40]
ovarian endometriomas measuring < 3 cm . More recently in 2018, Benagiano et al. suggested TVHL
[39]
for endometriotic cysts measuring < 20 mm and laparoscopic surgical removal of endometriotic cysts
measuring > 20 mm in the context of disease that is refractive to medical treatment.
There are very few studies addressing the specific topic of surgical removal of endometriomas for fertility
[16]
preservation in adolescents. Statistically significant findings from Coccia et al. retrospective cohort study
inclusive of women of all reproductive age with endometriomas who underwent IVF/ICSI showed an 8.2%
implantation rate for the surgical removal group vs. 12% in the direct-to-IVF group, and 14.9% pregnancy
rate in the surgical removal group vs. 24.9% in the direct-to-IVF group. Additional studies not limited to
the adolescent population revealed that older age was found to be associated with lower AMH for both
cystectomy and control groups . Moreover, amongst women who had endometriomas removed surgically
[25]
pre-IVF, higher pregnancy rates were found among women aged < 35 (34.3%) as compared to women aged
> 35 (25.9%) . One study described an 11-year-old patient with endometrioma who presented initially
[41]
[42]
with amenorrhea and had spontaneous menarche post-surgical removal .
DISCUSSION
Size and type of endometrioma can influence appropriateness of surgical management
Studies have shown that bilateral endometriomas and those larger than 7 cm are associated with more
[43]
damage to ovarian reserve due to surgery, as compared to those that are unilateral and smaller than 7 cm .
Regarding laparoscopic surgical removal, damage to ovarian tissue may be proportionally related to the size
[44]
of the endometrioma: excision of cysts measuring > 4 cm results in more significant damage . Recently,
Coccia et al. reported that size is perhaps the most significant factor with regard to ovarian retrieval:
[16]
for each mm increase in size, there is a decline in predicted number of oocytes retrieved. Bilateral ovarian
endometrioma removal presents a worse outcome as compared to unilateral endometriomas: the decline
in ovarian reserve, independent of age and destruction of the ovarian parenchyma, still predicts a worse
outcome vs. unilateral and no surgery . On the other hand, Ashrafi et al. found in their prospective
[12]
[16]
cohort study that clinical outcomes - such as fertilization, maturation rate and total formed embryos - were
no different between unilateral endometriomas and no endometrioma. This is consistent with findings by
[45]
Yu et al. that there were no significant associations found among laterality of endometrioma, ovarian
reserve, and pregnancy outcomes of IVF/ICSI for women with infertility having undergone laparoscopic
cystectomy.