I-21: Management of Endometrioma

Endometrioma is defined as an ovarian pseudocyst arising from growth of ectopic endometrial tissue, which progressively invaginates the ovarian cortex . Nearly17-44% of women with endometriosis also have endometriomas. Whereas detection of peritoneal endometriosis and adhesions typically requires laparoscopic assessment of the pelvis, endometriomas can be reliably diagnosed by transvaginal ultrasound scan . The expanding ovarian cyst may cause pressure atrophy of the ovarian tissue or affect the normal vascularization of the ovary. Nakahara et al. (1998) found a higher incidence of apoptotic bodies in the ovarian membrana granulosa of patients with endometriosis than that of a control (male factor infertility) group. The incidence of apoptotic bodies correlated with the stage of endometriosis but was significantly higher in women with endometrioma. It has also been suggested by some investigators that oocyte quality may be affected by endometrioma. Currently, there is insufficient data to clarify whether the endometrioma-related damage to ovarian reserve precedes or follows surgery. In conclusion, the standard management of endometrioma in subfertile women before IVF remains controversial owing to the insufficient evidence to suggest superiority of one treatment strategy over another. A large, well-designed, adequately powered multicenter RCT that would compare the effects of surgical removal with expectant management of endometrioma on ovarian performance and pregnancy outcomes in women undergoing IVF is clearly overdue. Until such a trial is conducted and definite conclusions can be drawn, the management of women with endometrioma before IVF should be individualized. All the therapeutic options, including conservative, medical, or surgical treatment, as well as the advantages and disadvantages should be fully discussed with the patient. Any decision for surgery should be carefully considered and balanced against the risks, especially in women with previous adnexal surgery or women with suboptimal ovarian reserve. If the woman opts for surgical treatment, she should be appropriately counseled about the potential risks of reduced ovarian function after surgery, including the remote possibility of oophorectomy. The realities mentioned above about the diagnosis and treatment of endometrioma besides the existence of some evidence to suggest that untreated endometriosis may resolve spontaneously in up to a third of women, and the fact that Subfertile women with endometrioma comprise a small group among a heterogeneous population of women who suffer from endometriosis urges a comprehensive evidence based discussion about four groups of endometriotic patients: 1. Management of endometioma in patients with pelvic pain 2. Management of endometioma in asymptomatic patients 3. Management of endometioma in subfertile patients 4. Management of endometioma prior to IVF.