Endometrioma repair prior to IVF is controversial. The ENDOVA trial and ESHRE guidelines (2022) recommend which approach for an isolated, unilateral 5 cm endometrioma in a woman who has not undergone prior ovarian surgery and is planning IVF?

• A Laparoscopic cystectomy is mandatory before IVF to prevent cyst infection during oocyte retrieval
• B Expectant management with direct IVF without cystectomy, to preserve ovarian reserve ✓
• C Drainage and sclerotherapy as an alternative to cystectomy without affecting IVF outcomes
• D GnRH agonist downregulation for 3 months before IVF is sufficient to reduce endometrioma size

Explanation

ESHRE 2022 Endometriosis guideline recommends against routine surgical treatment of endometrioma before IVF when the purpose is to improve IVF outcomes, as cystectomy reduces ovarian reserve (particularly repeat surgery). However, surgery may be considered for endometriomas >4 cm if: there is concern about access to follicles, rapid growth, or suspicion of malignancy. Direct IVF is appropriate for women with endometrioma who have adequate ovarian reserve. The risk of infection during oocyte retrieval from endometrioma aspiration exists but is low with antibiotics. Sclerotherapy (ethanol, tetracycline) has shown efficacy comparable to cystectomy for recurrence prevention without ovarian reserve loss in some studies.

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

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Written and medically reviewed by the StethoPrep medical team.