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Tanos et al. Mini-invasive Surg 2020;4:39 I http://dx.doi.org/10.20517/2574-1225.2019.59 Page 9 of 15

Ovarian reserves
Most studies employ the stripping technique to treat endometriomas in order to reduce recurrence, at the
expense of significant damage to healthy ovarian tissue. One retrospective cross-sectional study found that
AMH was not reduced in patients with endometriomas independently, but that it was reduced in patients
[46]
with previous endometrioma removal surgery . However, another study showed that among young
women (aged 18-22) there were statistically significant lower median AMH levels even prior to surgery in
[47]
those with bilateral endometriomas as compared to controls and those with unilateral endometriomas .
In a recent prospective case-control study which compared women without endometriomas, women with
endometriomas, and women who had surgical removal of endometriomas, it was found that damage to
ovarian reserve increased respectively across all three groups . This presents the possibility that ovarian
[27]
reserve damage may be proportional to the extent and frequency of surgery, again, with all employing
the stripping technique. In many of these studies, it is suggested therefore to assess ovarian reserve
before undertaking surgical removal of endometriomas, and that this factor may be significant enough to
recommend against surgical removal. Proper preoperative evaluation, and adequate training and experience
of the laparoscopist, are crucial parameters that determine the long-term success of the endoscopic
approach [48,49] .

Surgery as a means of preserving ovarian tissue
Surgical removal of endometriomas can enable cryopreservation of ovarian tissue. During surgical removal
of endometriomas, healthy fragments of ovarian cortex can be isolated and subsequently cryopreserved,
[50]
[50]
reportedly a highly effective technique for fertility preservation . Furthermore, Carrillo et al.
recommended that ovarian tissue preservation through cryotherapy be individualized based on factors that
overlap with those we have identified as priorities for the surgical management of endometrioma: patient’s
age, ovarian reserve status, presence of bilateral lesions, and repeated surgery. In the adolescent population,
ovarian tissue and/or oocyte cryopreservation is especially important to optimize future fertility as
suggested by Benagiano et al. .
[40]
Since endometriomas progressively damage ovarian reserves, it seems logical that the surgical treatment
of an endometrioma of a smaller size, preferably lower than 3 cm, would preserve healthy ovarian tissue.
The problem is we lack the scientific knowledge to identify those patients that will rapidly deteriorate and
develop larger lesions. Gynaecologists who perform TVHL can operate on small endometriomas less than
3 cm with precision and safety using 5Fr instruments .
[51]
Adolescent population
Adolescents and very young women with endometriomas present a very high risk of premature ovarian
[40]
failure and infertility. Endometriomas in adolescents may have a different pathophysiological origin
as well as different manifestation from that of adult endometriosis. The diagnosis of endometriosis in
adolescents is often delayed. This delay is attributable to several factors including a puzzling clinical
[52]
picture such as the presence of both cyclic and acyclic pain , lower proportion of incidental findings
[53]
(23%) as compared to adults , or lesions which are difficult to identify laparoscopically due to clear color
[37]
and benign appearances . Yet, up to 80% of adolescents with chronic pelvic pain refractory to medical
[54]
treatment end up with a diagnosis of endometriosis . Currently, the diagnostic pathway involves presence
of relevant symptoms (i.e., chronic pelvic pain, dysmenorrhea), response/no response to medical treatment,
and finally diagnostic laparoscopy . Once endometrioma is diagnosed, treatment follows guidelines
[37]
mentioned previously - surgery is indicated if refractive to medical treatment. There are currently no
original studies investigating the early detection and subsequent surgical removal of endometriomas
in the adolescent population as it relates to the patients’ fertility goals. Much of the existing body of
research focuses on older adults because these are the women presenting with concerns for fertility or are
actively seeking IVF; however, as endometriosis may often be present but lying dormant and undiagnosed