A 34-year-old woman with stage IV endometriosis (American Society for Reproductive Medicine) and primary infertility has bilateral endometriomas (right 4 cm, left 3 cm) and a small amount of residual normal ovarian tissue. She is about to undergo IVF. What is the recommended approach to the endometriomas before IVF?

• A Laparoscopic cystectomy of both endometriomas before IVF to improve oocyte retrieval
• B Proceed to IVF directly without surgical intervention to preserve ovarian reserve ✓
• C Medical suppression with GnRH agonist for 3 months before IVF
• D Drain both cysts under ultrasound guidance and proceed with IVF immediately

Explanation

ESHRE guidelines recommend against routine surgical removal of endometriomas before IVF when ovarian reserve is already compromised, as cystectomy risks further reduction of ovarian reserve (diminished AMH and antral follicle count post-surgery). For cysts <3–4 cm in women with reduced reserve, IVF can proceed directly. In this patient with bilateral endometriomas and limited residual ovarian tissue, surgical removal carries a high risk of further reserve reduction. GnRH agonist suppression can be used to improve IVF success rates but is not the primary recommendation for managing endometriomas themselves.

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

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