A 31-year-old with Stage III endometriosis (revised ASRM classification) and primary infertility for 2 years undergoes laparoscopy. She has bilateral endometriomas (4 cm right, 3 cm left) and dense cul-de-sac adhesions. Ovarian reserve is normal (AMH 2.8 ng/mL). Which management strategy is supported by current ESHRE 2022 guidelines for endometriosis-associated infertility in this scenario?

• A Surgical cystectomy of endometriomas + adhesiolysis at the time of diagnostic laparoscopy, then attempt natural conception for 6–12 months before IVF ✓
• B Medical suppression with GnRH agonist for 3 months before IVF
• C Immediate IVF without surgical intervention as surgery reduces ovarian reserve
• D Laparoscopic surgical resection followed immediately by in vitro fertilisation (IVF) without natural conception period

Explanation

ESHRE 2022 endometriosis guidelines recommend surgical cystectomy for endometriomas > 3 cm before IVF or natural conception attempts, not only to confirm histology and improve access to follicles at oocyte retrieval, but because large endometriomas reduce oocyte quality and fertilisation rates. Following surgical resection of endometriomas and adhesiolysis in a 31-year-old with normal ovarian reserve, a trial of natural conception for 6–12 months is appropriate before IVF. Immediate IVF post-surgery is preferred only if ovarian reserve is markedly impaired, age is advanced, or male factor/tubal factor coexists. GnRH agonist pre-IVF improves pregnancy rates in endometriosis but does not replace surgical management of large cysts.

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

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Written and medically reviewed by the StethoPrep medical team.