A 32-year-old nulliparous woman with stage III endometriosis (revised ASRM classification) is trying to conceive naturally without success for 18 months. Bilateral ovarian endometriomas of 4 cm are present. What is the MOST appropriate management to improve fertility outcomes?

• A Laparoscopic cystectomy of endometriomas followed by ovarian stimulation for IVF ✓
• B GnRH agonist therapy for 6 months to suppress endometriosis before natural conception attempts
• C Proceed directly to IVF without surgical intervention due to risk of reducing ovarian reserve with cystectomy
• D Combined oral contraceptive pill for 3 months then natural conception attempts

Explanation

For endometriomas ≥4 cm causing infertility in women who have tried natural conception for >12 months, laparoscopic cystectomy (not drainage and coagulation) is preferred as it improves access to oocytes, reduces endometrioma fluid contamination of follicular aspirates, and may improve response to ovarian stimulation. Following cystectomy, IVF is the next step given stage III endometriosis. GnRH agonists alone do not improve live birth rates for endometriosis-associated infertility. The risk of reduced ovarian reserve with cystectomy is real but is weighed against benefits of IVF optimization.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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Written and medically reviewed by the StethoPrep medical team.