{"id":172,"date":"2025-07-08T10:19:53","date_gmt":"2025-07-08T00:19:53","guid":{"rendered":"https:\/\/escope.ages.com.au\/july-2025\/?p=172"},"modified":"2025-07-11T09:15:52","modified_gmt":"2025-07-10T23:15:52","slug":"journal-club-the-endometrioma-treatment-paradigm-when-fertility-is-desired-a-systematic-review","status":"publish","type":"post","link":"https:\/\/escope.ages.com.au\/july-2025\/journal-club-the-endometrioma-treatment-paradigm-when-fertility-is-desired-a-systematic-review\/","title":{"rendered":"Journal Club &#8211; The Endometrioma Treatment Paradigm when Fertility is Desired: A Systematic Review"},"content":{"rendered":"\n<h1>\n\t\t\tJournal Club &#8211; The Endometrioma Treatment Paradigm when Fertility is Desired: A Systematic Review\t<\/h1>\n\t\t\t<h3>In the Journal of Minimally Invasive Gynaecology<\/h3>\t\t\t\n\t\t\t\t<p><strong>Summary &#8211; Dr Michael Fahy\u00a0<\/strong><\/p>\n<p>The objective of Millar&#8217;s systematic review was to establish a decision tree regarding endometriomata when fertility is desired. A literature review yielded 59 relevant articles.<\/p>\n<p>The first step in the decision tree was to assess the risk of malignancy, quoting a 0.8-0.9% risk of occult malignancy in suspected endometriomata. In an Australian context, COGU imaging would usually be adequate, given the typical ground glass homogenous appearance of endometriomata.<\/p>\n<p>Pelvic pain in women with endometriomata is thought to be associated with peritoneal lesions, rather than the endometrioma itself. When peritoneal lesions are present along with the endometrioma, 85% experience pain. Whereas with an endometrioma alone, only 38% experience pain. Therefore, if the endometrioma is &lt;3cm and there is pain, medical therapy is preferred as first-line, as a small endometrioma is not thought to be the culprit for pain.<\/p>\n<p>If there is pain and the endometrioma is &gt;3cm, or the pain is not controlled by medical management, then surgical management is recommended. Ovarian cystectomy is preferred rather than drainage of the endometrioma, due to improved recurrence rates and improved spontaneous pregnancy rates (59-67% vs 23%).<\/p>\n<p>The management of endometriomata when IVF is intended is controversial, due to the inevitable loss of ovarian tissue during an ovarian cystectomy. This impact on ovarian reserve is exacerbated when endometriomata are large or bilateral. Endometriomata left in situ before IVF yield higher number of oocytes and require less gonadotropes during stimulation cycles, compared to surgical management.<\/p>\n<p>On the other hand, endometrioma may be associated with a faster decline in AMH, compared to patients with no endometrioma. Additionally, vaginal egg pickups are more technically challenging in the presence of an endometrioma and there is a risk of postprocedural infection when the endometrioma is ruptured during egg pickup. But meta-analyses have not demonstrated statistically significant changes in livebirth rate when comparing expectant and surgical management before IVF.<\/p>\n<p>The author suggests an ovarian cystectomy when the endometrioma is &gt;3-4cm and there is infertility. They then suggest attempting spontaneous conception. If the endometrioma is &lt;3-4cm, they suggest attempting spontaneous conception without surgery.<\/p>\n<p>If a spontaneous pregnancy is not achieved, they suggest proceeding to IVF. They offer the following as indications to perform an ovarian cystectomy:<\/p>\n<ul>\n<li>Risk of the endometrioma rupturing at egg pickup (due to infection risk)<\/li>\n<li>A low antral follicle count in the affected ovary (as a small study demonstrated improvement in AFC 3 years post-surgery)<\/li>\n<li>Recurrent implantation failure (as oocytes from patients with endometrioma exhibit lower implantation rates)<\/li>\n<\/ul>\n\t\t\t<h3>Conclusion<\/h3>\t\t\t\n\t\t\t\t<p>The author advises considering egg or embryo freezing before surgery. Ovarian cystectomy is preferred rather drainage of an endometrioma. The ovary should be sutured for haemostasis rather than using diathermy.<\/p>\n<p>They suggest these indications for ovarian cystectomy of an endometrioma:<\/p>\n<ul>\n<li>Endometrioma &gt;3cm with pain<\/li>\n<li>Endometrioma with pain which has not responded to medical therapy<\/li>\n<li>Endometrioma &gt;3-4cm with infertility<\/li>\n<li>Endometrioma deemed at risk of rupturing during vaginal egg pickup<\/li>\n<li>Low antral follicle count on the affected side, when IVF is planned<\/li>\n<li>Recurrent implantation failure after embryo transfers<\/li>\n<\/ul>\n\t\t\t<h3>Authors<\/h3>\t\t\t\n\t\t\t\t<img decoding=\"async\" src=\"https:\/\/escope.ages.com.au\/july-2025\/wp-content\/uploads\/sites\/10\/2025\/07\/escope-author__nyasha-gwata-001.avif\" alt=\"Nyasha Gwata\" title=\"Nyasha Gwata\" itemprop=\"image\"\/>\n\t\t\t\t<p>Dr Nyasha Gwata<\/p>\n\t\t\t\t<img decoding=\"async\" src=\"https:\/\/escope.ages.com.au\/july-2025\/wp-content\/uploads\/sites\/10\/2025\/07\/escope-author__michael-fahy-001.avif\" alt=\"Michael Fahy\" title=\"Michael Fahy\" itemprop=\"image\"\/>\n\t\t\t\t<p>Dr Michael Fahy<\/p>\n\n","protected":false},"excerpt":{"rendered":"<p>Systematic review establishes decision tree: assess malignancy risk, consider size and symptoms. Surgery preferred for >3cm with pain. IVF timing controversial due to ovarian reserve impact.<\/p>\n","protected":false},"author":1,"featured_media":72,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"site-sidebar-layout":"no-sidebar","site-content-layout":"","ast-site-content-layout":"full-width-container","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[1],"tags":[],"class_list":["post-172","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorised"],"acf":[],"_links":{"self":[{"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/posts\/172","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/comments?post=172"}],"version-history":[{"count":6,"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/posts\/172\/revisions"}],"predecessor-version":[{"id":218,"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/posts\/172\/revisions\/218"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/media\/72"}],"wp:attachment":[{"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/media?parent=172"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/categories?post=172"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/tags?post=172"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}