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ha-e,described by Sampson (1), could repre- opment of in vitro fertilization (IVF),SURGICAL TREATMENT OFENDOMETRIOMASUsing the PubMed database (searcterms: endometrioma AND conservtive management, surgical techniqu

Received May 16, 2012; revised and accepted June 15, 2012; published online July 3, 2012.P.J. has nothing to disclose. M.K. has nothing to disclose. O.D. has nothing to disclose. J.S. has nothing

to disclose. J.D. has nothing to disclose.Reprint requests: Pascale Jadoul, M.D., Cliniques Universitaires St Luc, Gynecology, Avenue Hippo-

crate 10, Brussels 1200, Belgium (E-mail: pascale.jadoul@uclouvain.be).are formed by invagination of the cor-tex after the accumulation of menstrualdebris from bleeding of endometrialimplants, which are located on theovarian surface and adherent to theperitoneum. The site of perforation, as

Controversy also surrounds thetreatment of ovarian endometriomas.Initial studies tried to demonstratea link between endometriomas andinfertility, and increased fertility afterendometrioma surgery. With the devel-

literature to help us forgeopinion on the two mainShould we perform surgerymetriomas? And if we perfowhich technique should wespread of peritoneal endometriosis.Hughesdon (2) suggested that adhe-sions are not the consequence but thecause of endometriomas. Hughesdon(2) demonstrated by serial section ofovaries containing an endometriomathat 90% of typical endometriomas

dometriomas result from metaplasia ofinvaginated epithelial inclusions fromthe ovarian surface into endometrialtissue, explaining how endometriomacan occur independently of peritonealendometriosis. Several arguments sup-port this metaplasia theory (4, 5).

various surgical techniques, mainlycystectomy and ablation, to determinethe technique that causes the leastovarian damage.

All these issues have been the sub-ject of thousands of papers on endome-triomas. We conducted a review of theO always been the subject ofcontroversy. The rst sourceof controversy was their pathogenesis.The original paper by Sampson (1) onovarian endometriosis reported thatperforation of so-called chocolate cystsled to spillage of adhesions and the

cortex after accumulation of menstrualdebris from bleeding of endometrialimplants (2). Other investigators haveclaimed that large endometriomasmay develop as a result of secondaryinvolvement of functional ovariancysts (3). A last theory suggests that en-

surwittorbegermecorvarian endometriomas have sent the stigma of invagination of the doubts were raised about the utility ofgery for fertility purposes in womenh endometriomas. Some investiga-s even suggested that fertility mayreduced as a result of traumatic sur-y, as it removes not only the endo-Pascale Jadoul, M.D.,a Michio Kitajimaand Jacques Donnez, M.D., Ph.D.a

a Department of Gynecology, Cliniques Ub Department of Obstetrics and GynecoloMedicine, Nagasaki, Japan

To dene the role of surgery in the treatmepublished data. We analyze the argumentniques. Pain relief and pregnancy rates of mand biologic markers of ovarian reserve shcases of repeated surgery. Considerable surbest surgical technique. Despite the risk ofdure, surgery has an important role in the ties are required to dene the most appr55663. 2012 by American Society for RKey Words: Cystectomy, endometrioma, l

Discuss: You can discuss this article withfertstertforum.com/jadoulp-surgical-treatmFertility and Sterility Vol. 98, No. 3, September 201Copyright 2012 American Society for Reproductivehttp://dx.doi.org/10.1016/j.fertnstert.2012.06.023

556.D., Ph.D.,b Olivier Donnez, M.D.,a Jea

rsitaires St. Luc, Universite Catholique de, Graduate School of Biomedical Sciences

f endometriomas, we review the literature afavor of and against surgical treatment ofe than 50% after surgery are the most impora risk of decreased ovarian reserve that shoal expertise is required, and the lack of comreased ovarian reserve due to the surgical ptment of ovarian endometriomas, and moreiate surgical technique. (Fertil Steril 201roductive Medicine.)r ablation, ovarian reserve, pregnancy rate

authors and with other ASRM members at ht-ovarian-reserve-endometriomas/2 0015-0282/$36.00Medicine, Published by Elsevier Inc.quifet, M.D., Ph.D.,a

vain, Brussels, Belgium; andgasaki University School of

ilable via PubMed and cross-reference thedometriomas and compare surgical tech-t arguments in favor of surgery. Histologicbe taken into consideration, especially inative studies yields no conclusions on thee-d-8:

://

Use your smartphoneto scan this QR codeand connect to thediscussion forum forthis article now.*

* Download a free QR code scanner by searching for QRscanner in your smartphones app store or app marketplace.iane art?ovarian reserve, pregnancy rate, IVF)and cross-referencing, we conducted

VOL. 98 NO. 3 / SEPTEMBER 2012

Fertility and Sterilitya review of the literature on the impact of endometriomasthemselves and endometrioma surgery on fertility, payingparticular attention to the surgical technique used. Analysisof the literature yields arguments both in favor of and againstsurgery for endometriomas.

Arguments in Favor of Surgery

Several arguments can be proposed in favor of surgical treat-ment of endometriosis. First of all, most womenwith endome-triosis complain of menstrual or extramenstrual pain. It iswidely accepted that these symptoms will be greatly improvedby surgery (6).

Second, several studies have shown increased fertility af-ter surgical treatment of endometriomas. In the late 1980s,Donnez et al. (7) initiated a combined treatment regimenwith hormone therapy followed by surgery. Pregnancy ratesof more than 52% were achieved with moderate endometri-osis and over 45% in cases of severe endometriosis, thedifference attributed to the extent of the periovarian adhe-sions more frequently observed in severe cases. In a studypublished in 1996 that enrolled 814 women presenting withovarian endometriomas, the same teamobserved a cumulativepregnancy rate of 51% after combined treatment with a go-nadotropin-releasing hormone (GnRH) agonist and laparo-scopic surgery (4). The majority of pregnancies occurredwithin 10 months of surgery. Several other studies haveconrmed pregnancy rates of approximately 50% aftersurgical removal of endometriomas (810).

Third, a recent review of the literature by Nyhj et al.(11) showed a possible link between endometriosis andovarian cancer. The etiology of both diseases appears to bemultifactoral, with hormonal, genetic, and immunologicfactors potentially playing a role. With a twofold increasedrisk of developing ovarian cancer in patients with endome-triosis in general, and a further fourfold increased risk inhigh-risk endometriosis patients with infertility, the ndingsmay well be relevant and should be borne in mind whentreating patients with endometriosis. A 10-year cohort studyof women living in the Estrie region of Quebec identied2,521 women with endometriosis, 292 women with ovariancancer, and 41 women with ovarian cancer and endometri-osis (12). This study found that the number of cases ofovarian cancer has been steadily increasing and that endo-metriosis represents a serious risk factor that accelerates itsdevelopment by about 5.5 years. This increased risk factor isan argument for excisional surgery, especially in patientsover 45 years of age with ovarian endometriomas, andparticularly if the endometriomas are recurrent after cystec-tomy, which is probably indicative of a more aggressiveform of the disease.

Finally, in cases of IVF in women with endometriomas,one should take into account the possible difculty ofaccessing the follicles and the risk of pelvic infection afterinadvertent drainage of endometriomas at the time of oocyteretrieval (1316). Drainage of an endometrioma at the time ofoocyte retrieval may not only increase the risk of infection butalso affect the quality of oocytes contaminated by the

chocolate uid.

VOL. 98 NO. 3 / SEPTEMBER 2012Arguments against Surgery

Many publications have cast doubt on the benecial effect ofsurgical treatment of endometriomas on fertility, and indeedthey have raised increasing concerns about the deleterious ef-fect of surgery on the ovarian reserve and the higher risk ofpremature ovarian failure (17, 18). These concerns are basedon three types of studies: studies analyzing histologicsamples of endometriomas removed by surgeryand, morespecically, the presence of follicles in these samples; thoseanalyzing outcomes of IVF procedures in women aftersurgical removal of endometriomas; and those comparingthe markers of ovarian reserve in women before and aftersurgical treatment of endometriomas.

Histologic analyses by Muzii et al. (19) have shown thatremoving ovarian cysts with a well-dened capsule resultsin removal of normal ovarian cortex in 6% of cases, and nor-mal ovarian tissue containing primordial follicles is removedin more than 50% of endometriomas (19, 20). More recentstudies have demonstrated, by serial section, the presence ofadjacent ovarian tissue in more than 90% of excisedendometrioma wall specimensand the larger the cystdiameter, the more tissue is removed (21, 22).

There is no doubt that healthy ovarian tissue is removedduring excisional surgery. During use of ablation techniques,capsule ablation probably leads to thermal damage to the un-derlying ovarian cortex, depending on the energy used (23).Moreover, besides the deleterious effect of endometriomaexcision itself, the use of electrosurgical coagulation duringhemostasis could play an important role in terms of damageto ovarian stroma and vascularization (17).

Multiple studies have evaluated IVF outcomes after surgi-cal treatment of endometriomas, but the results of thesestudies have been somewhat contradictory. Many show a de-creased number of obtained oocytes and/or mature oocytesafter IVF in women who underwent previous surgery for en-dometriomas (2432). In some studies, implantation andfertilization rates are statistically signicantly lower afterprevious endometrioma surgery (25, 27), but in others theyare signicantly higher (26, 33, 34). Almost all studiescomparing the number of retrieved and mature oocytesbetween operated ovaries and contralateral nonoperatedovaries show a statistically signicant increase in favor ofnonoperated ovaries (25, 29, 30).

Studies analyzing markers of ovarian reserve before andafter surgical treatment of endometriomas have, over thesepast few years, increased concerns about premature ovarianfailure (23, 3544). In these studies, the effects of surgerywere evaluated by comparing ovarian volume, antral folliclecount (AFC), and antimullerian hormone (AMH) levelsbefore and after surgery. Decreased ovarian volume andAFC were described after endometrioma surgery comparedwith nonoperated contralateral ovaries (35) or preoperativevalues (23). Many investigators have investigatedpreoperative and postoperative AMH concentrations (3644). Most of them found decreased levels of AMH aftersurgery (3643). In studies with a nonendometriotic cystcontrol group, the decrease in AMH was statistically

signicantly greater in the endometrioma group (36). AMH

557

favor of or against surgery? In our opinion, it is an argument infavor of surgery. Indeed, by performing surgery, we decrease

On the other hand, can we discount the other argumentsagainst surgery? That is, histologic analyses show thathealthy follicles are being removed and ovarian volume is be-ing decreased, as are the AFC and AMH levels. However, thestudies on ovarian volume and AFC are somewhat contradic-tory. The reduced volume and AFC described by Mokdad et al.(35) and Var et al. (23) were not conrmed in studies by Tso-lakidis et al. (43) and Donnez et al. (53).

As far as AMH levels are concerned, although all but onestudy (44) showed a decrease after surgery, the mechanisms ofAMH secretion are not yet completely elucidated and some re-sults are difcult to explain scientically. How can we ex-plain, for example, that in the study by Lee et al. (41) thedecrease in AMH levels was similar between the unilateralcystectomy and oophorectomy groups? Some investigatorshave found a decrease followed by an increase in AMH levelsafter cystectomy (36) with 65% recovery after 3 months, whileothers have shown a continuous decrease up to 6months aftersurgery (42). It is also known that AMH levels are lower dur-ing early childhood (54, 55) but the ovarian reserve is higher.There might be some differences between in situ AMHproduction and serum AMH levels. Vascular phenomena,

Photomicrograph of ovarian cortex. (Masson's trichrome staining.) (A)In this sample obtained from a contralateral healthy ovary, numerousfollicles are present. (B) In this sample from an ovary with anendometrioma, cortex-specic stroma have disappeared and beenreplaced with brosis. Follicles are absent in this specimen.Jadoul. Surgical treatment of endometriomas. Fertil Steril 2012.symptoms, increase the chances of spontaneous pregnancyby 50%, and avoid the need for IVF, a psychologically andlevels also decreased signicantly more in case of bilateralendometriomas (36, 40, 42).

Analysis of These Arguments

When analyzing arguments in favor of and against surgicaltreatment, it is important to examine them according toeach patient's situation and to consider them in context. Preg-nancy rates should clearly be the main outcome measure.

A 2009 meta-analysis of 92 studies on IVF after endome-trioma surgery concluded that there were no statistically sig-nicant differences in pregnancy or clinical pregnancy ratesper cycle after IVF between women undergoing surgery forendometriomas and women with endometriomas receivingno treatment (odds ratio for pregnancy rate per cycle: 0.92[95% condence interval, 0.61, 1.38]; odds ratio for clinicalpregnancy rate per cycle: 1.34 [95% condence interval,0.82, 2.20]) (45). This meta-analysis clearly shows the pitfallsof evaluating the real risk to fertility. From a selection of 92relevant articles, only 20 could be included for systematic re-view, with just ve eligible for the meta-analysis (33, 34, 4648) to address the specic question of pregnancy rates inwomen with treated and untreated endometriomas. MostIVF studies compare women with surgically removedendometriomas with women with tubal factor, male factor,or idiopathic infertility, or women undergoing cystectomyfor other kinds of cysts, or those with peritonealendometriosis. Other studies compare treated ovaries withcontralateral nonoperated ovaries. In this context, it isimportant to note that ovarian endometriosis itself maycompromise fertility and that IVF results viewed in the lightof other infertility groups or contralateral ovaries should beanalyzed with caution. Indeed, it has been shown thatovaries with endometriotic cysts already exhibit reducedfollicle numbers and vascular activity compared with othertypes of benign cysts (4951). Kitajima et al. (51)demonstrated that follicular density in cortex from ovarieswith endometriomas less than 4 cm in size is statisticallysignicantly lower than in cortex from contralateral normalovaries. In addition, histologic alterations in cortical tissue,such as formation of brosis and concomitant loss ofcortex-specic stroma, were found in cortex from ovarieswith endometriomas (Fig. 1). Multivariate analysis revealedthat the presence of endometrioma and brosis were signi-cantly and independently associated with follicular density.

Despite all this possible bias in IVF studies, and even if weinclude IVF studies with control groups other than nonoper-ated endometriomas, signicant differences in pregnancyrates were found in only two studies, one favoring surgery(30) and the other not (24). An absence of effect of endome-trioma surgery on clinical pregnancy rates in an IVF settingwas also the conclusion of a Cochrane review in 2010 (52).

Should we consider this rst conclusion as an argument in

VIEWS AND REVIEWSphysically invasive procedure. Even if IVF is required after-ward, pregnancy rates will not be adversely affected.

558FIGURE 1especially important in cases of surgery, might explaintemporary or long-term variations in AMH levels (56). For

VOL. 98 NO. 3 / SEPTEMBER 2012

inadvertently removed together with the endometrioma

and washed, and its wall is exposed and inspected to conrmthe diagnosis of an endometrioma. After identifying the cor-rect plane of cleavage between the cyst wall and the ovariantissue by applying opposite bimanual traction with two 5-mmgrasping forceps, providing strong but nontraumatic traction,the inner lining of the cyst is stripped from the normal ovariantissue (Fig. 2). The bed of the cyst needs to be carefully in-spected to detect possible bleeding zones that may require co-agulation with bipolar forceps. The endometrioma is removedthrough a 10-mm trocar. If the volume exceeds the dimen-sions of the trocar, an endobag can be used. The ovary doesnot usually require suturing.

Ablative Surgery

After adhesiolysis of the ovary, a 3- to 4-mm portion of thetop of the cyst is excised, the chocolate-colored material is as-pirated, and the cyst is completely opened and washed outwith irrigation uid. After being washed, the interior wallof the cyst is carefully examined to conrm the diagnosis ofan endometrioma and the absence of any intracystic lesions

cyst (Fig. 3). Vaporization continues until no further pigment

Fertility and Sterilitywall. Indeed, the experience of the surgeon may affect thelive-born rate after IVF in women with surgically removedendometriomas (61).

AVAILABLE SURGICAL TECHNIQUESOvarian Cystectomy

Ovarian cystectomy begins with adhesiolysis. Once the ovaryis mobilized, the cortex is grasped with forceps introducedthrough a second trocar, and is incised using laser, scissors,or a unipolar needle hook. The incision must be made onthe antimesenteric surface, as far as possible from the ovarianhilus. The incision is extended with scissors, and hydrodissec-tion can be used to separate the cyst wall from the ovarianstroma. If the cyst is opened and spillage occurs, peritoneal ir-rates, and AMH levels needs to be interpreted according topatient age and desire to become pregnant, but these dataare not available at present.

So What Should We Do?

In our opinion, based on this research and analysis of the ar-guments, surgery has a major role to play in the managementof endometriomas. However, indications for surgery shouldbe adapted to the age of the patient, her symptoms, whethershe wants to conceive soon, previous surgery, other possibleindications for IVF and endometrioma size. Patients wishingto conceive and without other infertility factors or previoussurgery will clearly benet from surgical management. Inolder patients with (multiple) previous surgical interventionsand possibly decreased fertility, the indications for surgeryshould be discussed thoroughly, and nonsurgical manage-ment and IVF may be preferred. In case of doubt, evaluationof the ovarian reserve, with all its limitations, may be of helpin making the right choice. As far as the endometrioma size isconcerned, there is no consensus concerning a cutoff abovewhich surgical treatment is warranted. According to theESHRE guidelines (59), endometriomas larger than 3 cmshould be removed before IVF.

What clearly emerges from this review is that surgerymust be performed carefully to keep to a minimum anydamage to the ovary. To achieve this, we need experiencedsurgeons and an appropriate technique. Muzii et al. (60)showed that the level of expertise in endometriosis surgeryinversely correlates with the amount of ovarian tissuethis reason, we believe that AMH results after surgery shouldbe interpreted with caution.

However, histologic studies clearly show that oocytes areremoved in the great majority of cases, so there may be a riskof premature ovarian failure, especially in cases of repeatedsurgery. Unfortunately, there has been a lack of long-termfollow-up of patients in the literature and little informationabout their desire to conceive. Two studies evaluated patientsup to 49 and 60 months and encountered recurrence rates upto 57% (57, 58), but little is known about the pregnancy ratesin these patients. Analysis of pregnancy rates, recurrencerigation must be performed to remove the chocolate-coloreduid. The cyst is then decompressed by suction drainage

VOL. 98 NO. 3 / SEPTEMBER 2012Endometrioma cystectomy. The inner lining of the cyst is strippedfrom the normal ovarian tissue. The arrows shows limit betweencan be seen. Vaporization with the SurgiTouch (Lumenis) al-lows quick and easy vaporization of the internal wall, withminimal thermal damage to the normal ovarian cortex.

Two-Step Procedure

A two-step procedure may be used for large endometriomas(more than 5 to 6 cm in size) (4). During diagnostic laparos-copy, the endometrial cyst is emptied, completely opened,

FIGURE 2suspected of being malignant (ovarian cystoscopy). The cystwall is then destroyed using either bipolar coagulation or laservaporization. With the CO2 laser, at a power setting of 40 Wand using continuous mode application, the interior wall ofthe cyst is vaporized to destroy the mucosal lining of thethe ovarian cortex and cyst wall.Jadoul. Surgical treatment of endometriomas. Fertil Steril 2012.

559

Thus, when approaching the hilus, where the ovarian tis-

Which Technique Should We Choose?

FIGURE 4

Combined technique. When approaching the hilus, where theovarian tissue is more functional and the plane of cleavage lessand washed out with irrigation uid (saline solution). A bi-opsy sample is also obtained at this time. For the next 12weeks, GnRH agonist (Zoladex; AstraZeneca) therapy is pro-vided to decrease the cyst size. After drainage followed bythe 12-week course of GnRH agonist, a decrease of 50% incyst diameter is generally observed. Drainage alone (if notassociated with a GnRH agonist) is ineffective; indeed, 12weeks after drainage alone, ovarian cyst diameter has beenfound to be unchanged compared with that observed beforedrainage.

Three months after rst-look laparoscopy, the second-look laparoscopy is performed. The endometrioma is opened,and the interior wall of the cyst is vaporized, as previously de-

Laser vaporization of endometrioma wall. The interior wall of the cystis vaporized with a CO2 laser to destroy the mucosal lining of the cyst.Jadoul. Surgical treatment of endometriomas. Fertil Steril 2012.FIGURE 3

VIEWS AND REVIEWSscribed. After 12 weeks of GnRH-agonist therapy, the thick-ness of the endometrial cyst will be dramatically reduced,and the epithelial lining will be atrophic and white. Vaporiza-tion with the CO2 laser allows very quick and easy vaporiza-tion of the internal wall, with minimal thermal damage to thenormal ovarian cortex. This two-step or even three-step (if weconsider GnRH-agonist therapy as a step) procedure is alsowidely used (43, 62).

Combined Technique

A combined technique of excisional and ablative surgery isalso available (53). A large part of the endometrioma is rstexcised according to the cystectomy technique. The endome-trial cyst is opened and washed out with irrigation uid. Afterthe plane of cleavage between the cyst wall and ovarian tissuehas been identied by applying opposite bimanual tractionand countertraction with two grasping forceps, providingstrong but nontraumatic force, the inner lining of the cyst isstripped from the normal ovarian tissue. If the excision pro-vokes bleeding or the plane of cleavage is not clearly visible,the cystectomy is stopped because of the risk of removingnormal ovarian tissue containing primordial, primary, andsecondary follicles along with the endometrioma.

560sue is more functional and the plane of cleavage less visible,resection of the dissected tissue (partial cystectomy) is per-formed (Fig. 4). The stripping technique allows removal of80% to 90% of the cyst. After this rst step (partial cystec-tomy), CO2 laser is used to vaporize the remaining 10% to20% of the endometrioma close to the hilus (Fig. 5). Caremust be taken to vaporize all the residual cyst wall to avoidrecurrence. At the end of the procedure, the ovary is notsutured.visible, resection of the dissected tissue is performed.Jadoul. Surgical treatment of endometriomas. Fertil Steril 2012.For years, a debate has been under way as to the most appro-priate technique for surgical treatment of endometriomas,

FIGURE 5

Combined technique. A CO2 laser is used to vaporize the remaining10% to 20% of the endometrioma close to the hilus.Jadoul. Surgical treatment of endometriomas. Fertil Steril 2012.

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comparing the most commonly used techniques: cystectomy,fenestration and bipolar coagulation, or fenestration and la-ser vaporization of the cyst wall. These techniques are usuallyevaluated in terms of their effect on the ovarian reserve andthe risk of recurrence. One should note, however, that endo-metriosis is generally an extensive and recurrent disease.Saleh and Tulandi (57) described recurrence rates of 23.6%at 4 years after cystectomy for endometriomas. Real recur-rence can only be avoided by bilateral oophorectomy, so thecorrect surgical technique is not one that avoids recurrencebut one that avoids disease persistence due to incompletesurgery.

In a Cochrane review, Hart et al. (6) concluded that exci-sional surgery for endometriomas results in a more favorableoutcome than drainage and ablation in terms of recurrence,pain symptoms, subsequent spontaneous pregnancy in previ-ously subfertile women, and ovarian response to stimulation.However, this review was based on three randomized trialscomparing cystectomy and ablation by bipolar coagulation(6365), none of which prospectively analyzed the ovarianreserve after surgery. On the other hand, anotherrandomized, controlled trial compared cystectomy versusablation and coagulation (23) and, while a decrease in AFCand ovarian volume was found with both techniques, thedecrease was statistically signicantly more frequent incystectomized ovaries than in coagulated ovaries. In IVFcycles, too, the ovarian response to ovulation induction wasstatistically signicantly reduced in cystectomized ovariescompared with coagulated ovaries.

One weak point of these randomized, controlled trialsmight be the use of bipolar electrocoagulation instead ofCO2 laser as the source of energy in case of ablation. Indeed,CO2 laser allows an adequate depth of vaporization with lim-ited surrounding thermal damage in contrast to the uncon-trolled destruction of bipolar electrocoagulation. With CO2laser, experimental histologic studies have shown char-freeresidual damage of just 0.1 mm in depth (66). However, norandomized controlled trials have been conducted to comparecystectomy and one-step laser ablation in terms of pregnancyrates, recurrence rates, or ovarian reserve.

Recently, a randomized controlled trial compared the im-pact of cystectomy and a three-step laser ablation techniqueon ovarian reserve markers, mainly AMH (43). Administra-tion of GnRH analogs between the two operations reducedendometrioma size by up to 50%, as well as mitotic glandularactivity, stromal vascularization, and the presence of func-tional cysts like corpus luteum, and enhanced apoptosis of en-dometriotic cells (67). All of these effects may serve tominimize surgical trauma, subsequent follicle loss, and therisk of premature ovarian failure. Using this technique, Tsola-kidis et al. (43) demonstrated that functional ovarian tissue, asdetermined by AFC and AMH levels, was less compromisedafter the three-step procedure than after cystectomy forendometriomas.

The advantages of the two/three-step technique may alsobe found in the combined technique, without the inconve-nience of two different surgical procedures. The combined

technique (53, 68) associates the positive effects of bothcystectomy and ablation. In a recent study using this

VOL. 98 NO. 3 / SEPTEMBER 2012combined technique, vaginal ultrasound revealed a normalAFC and normal ovarian volume 6 months after surgery (53).

Given the heterogenicity and limitations of the fewavailable studies, further well-designed trials are needed toaddress the complicated issue of the most effective treatmentfor ovarian endometriomas, a study that takes into accountnot only relief from symptoms, early cyst recurrence, andpregnancy rates, but also ovarian function and reserve aftersurgery. Use of GnRH agonists should be further investigatedas well, especially in endometriomas associated with exten-sive inammation. Such studies are difcult to perform,however, as most surgeons have a preferred technique andmay not be as experienced in other techniques.

Other ablation techniques also can be developed andcompared. Very recently, Roman et al. (69) demonstratedthat ablation is very precise if the ovarian parenchyma is re-spected when plasma energy technology is used. The key tosuccessful surgery is to avoid bleeding, a sign of trauma tothe ovary that requires hemostasis, which will further increasethe damage (70).

CONCLUSIONIn our opinion, surgery has a fundamental role to play in thetreatment of endometriomas. Despite concerns about the ef-fects of this surgery on the ovarian reserve, the benets interms of pain relief and spontaneous pregnancy rates favorthis approach. However, in cases of recurrent endometriomasor decreased ovarian reserve, the risks of repeated surgeryshould be taken into account.

As far as the ideal surgical technique is concerned, there isa great lack of well-conducted comparative studies. Morestudies are needed to compare excisional, laser ablation,and combined techniques and to evaluate the utility ofGnRH agonists and two-step surgery. It is clear that consider-able surgical expertise (60) is required to decrease ovariandamage and avoid incomplete surgery.

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Surgical treatment of ovarian endometriomas: state of the art?Surgical treatment of endometriomasArguments in Favor of SurgeryArguments against SurgeryAnalysis of These ArgumentsSo What Should We Do?

Available surgical techniquesOvarian CystectomyAblative SurgeryTwo-Step ProcedureCombined TechniqueWhich Technique Should We Choose?

ConclusionReferences