Fertility Outcomes – Reducing Ovarian Damage During Endometriosis Surgery

Ovarian endometriomas are cysts on or within the ovarian parenchyma that contain chocolate-like fluid. Ovarian endometriomas are a typical manifestation of the disease, and their prevalence is between 17% and 44% of patients with endometriosis (Jenkins et al., Obstet Gynecol 67(3):335–338, 1986; Redwine, Fertil Steril 72(2):310–315, 1999; Busacca and Vignali, Curr Opin Obstet Gynecol 15:321–326, 2003). According to the European Society of Human Reproduction and Embryology (ESHRE) guidelines, ovarian cystectomy is the preferred modality of treatment of endometriomas, so as to prevent recurrence of endometriosis-associated symptoms and in order to increase the spontaneous pregnancy rate (Dunselman et al., Hum Reprod 29(3):400–412, 2014). However, the guidelines suggested a possible postsurgical reduction in the number and quality of the follicles in the ovaries, i.e., ovarian reserve reduction. Indeed, the most common side effect of cystectomy is damage to healthy ovarian tissue. Reduction of the deleterious effects of surgery on ovarian reserve is a major concern to all reproductive surgeons. The issue of reducing the deleterious effect of surgery on ovarian reserve is many times over important in adolescent girls; therefore, it is given a place in this textbook. In this chapter, we will review the pathophysiology, evaluation, and prevalence of the decrease in ovarian reserve after surgical treatment of endometriomas and the recommended surgical technique for cyst excision and ablation. Several surgical innovative techniques have been developed in recent years aiming to reduce ovarian damage, and these techniques will be presented and discussed. Simple drainage of the endometrioma alone has been shown to have a high rate of recurrence of symptoms (Donnez et al., Fertil Steril 62(1):63–66, 1994; Vercellini et al., J Reprod Med 37(7):577–580, 1992); therefore, this procedure is not recommended and will not be discussed.