A 34-year-old with known endometriosis and a 6 cm right endometrioma has a serum CA-125 of 72 U/mL. She wishes to conceive. According to ESHRE 2022 endometriosis guidelines, what is the recommended surgical approach?

• A Aspiration and sclerotherapy is the first-line treatment to preserve ovarian reserve
• B IVF should be attempted first without surgery as surgery reduces ovarian reserve
• C Laparoscopic cystectomy (stripping technique) is preferred over aspiration due to lower recurrence and better IVF outcomes ✓
• D Total laparoscopic hysterectomy with bilateral salpingo-oophorectomy is recommended for Stage IV endometriosis

Explanation

ESHRE 2022 guidelines recommend laparoscopic excision (cystectomy/stripping) of endometriomas >3 cm before IVF as it reduces endometrioma-related symptoms, improves access for oocyte retrieval, and lowers IVF cancellation rates — despite a recognised risk of reducing ovarian reserve. Aspiration alone is not recommended as primary treatment due to high recurrence (~80% at 2 years). Sclerotherapy with ethanol is an alternative in recurrent disease or limited reserve. Hysterectomy is not appropriate in a woman wishing fertility. ESHRE also emphasises shared decision-making about the 15% risk of reducing AMH with cystectomy.

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

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