A 34-year-old woman with Stage IV (revised ASRM) endometriosis involving bilateral ovarian endometriomas (4 cm and 3.5 cm) and deep infiltrating endometriosis (DIE) of the rectovaginal septum desires fertility. Her AMH is 1.8 ng/mL. What is the MOST appropriate management approach according to current ESHRE guidelines?

• A Laparoscopic cystectomy of both endometriomas followed by IVF if spontaneous conception fails within 6 months
• B Medical suppression with GnRH analogue for 3 months followed by IVF
• C Direct IVF without surgical intervention to preserve ovarian reserve ✓
• D Bilateral endometrioma cystectomy with complete DIE excision followed by immediate IVF

Explanation

ESHRE 2022 endometriosis guidelines state that in women with endometriomas who desire fertility, surgical cystectomy may further reduce ovarian reserve (AMH, AFC) and should be balanced against this risk. For women proceeding to IVF, ESHRE does not recommend routine endometrioma surgery before IVF solely to improve IVF outcomes, as evidence does not consistently show improved live birth rates. Direct IVF is preferred to preserve ovarian reserve, particularly when AMH is already borderline. GnRH agonist pre-treatment for 3 months before IVF in endometriosis is supported by some evidence (Sallam meta-analysis), but this represents an adjunct, not a replacement for IVF timing decisions. DIE excision before IVF has limited evidence for improving outcomes.

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

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Written and medically reviewed by the StethoPrep medical team.