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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 11 of 15

Figure 2. Treatment options for adolescents with endometriomas according to their clinical characteristics. TVU: transvaginal
ultrasound; MRI: magnetic resonance imaging; US: ultrasound; OC: oral contraceptive; LNG-IUD: levonorgestrel intrauterine device

Limitations of review
There are important limitations in both the quality and quantity of the available evidence. The lack
of randomized control trials (RCTs) investigating surgical management of endometriomas and IVF
significantly impacts the quality of evidence. This lack of RCTs results in (1) the inability to have
internationally consistent guidelines and (2) a high level of inconsistency and contradiction in the pros and
cons analysis of results. Overall, despite endometriosis and endometrioma being two relatively high yield
research areas, endometriomas in IVF is a contemporary issue, which is reflected in limited existing data;
available data often refer to endometriosis as whole, which resulted in their exclusion from our analysis,
and among studies specific to endometriomas there are very limited material evaluating surgical treatment
in the context of IVF. This is evidenced by the minimal number of recent studies matching our search
criteria on the surgical removal of endometriomas vs. non-surgical as pre-IVF treatments (four studies). In
addition to these limitations, which affect the yield for adolescent-focused endometrioma research, there is
a dearth of studies on the effect on long-term fertility following surgical removal of ovarian endometriomas
in adolescents. Despite making exceptions to the exclusion criteria to include more studies, the analysis was
extremely limited.