Precision in Endometrioma Surgery: Fellowship Training Predicts Ovarian Preservation and Guideline Adherence

Abstract

Study Objective

To evaluate the association between surgeon subspecialty training and ovarian preservation in endometrioma surgery and assess adherence to guideline-based management.

Design

Retrospective multicenter cohort study (2012–2024) with multivariable logistic and ordinal regression.

Setting

Five sites (academic and regional); procedures performed via minimally invasive or abdominal approach, low lithotomy positioning. Ergonomics varied.

Patients or Participants

18–50yo with histologically confirmed endometrioma (N=319), identified using diagnostic and procedural codes and confirmed by chart review. IRB-approved, de-identified data utilized.

Interventions

Demographics, surgeon training, and perioperative details were abstracted, including surgical approach, procedures, blood loss, operative time, complications. Guideline adherence was assessed using a 2-point composite score based on ACOG, ASRM, and ESHRE: 1 point for minimally invasive approach; 1 point for cystectomy. Oophorectomy scored 1 point only if prior endometrioma cystectomy on the same ovary. In bilateral cases with mixed management, scoring was based on the oophorectomy side. Higher scores indicated greater adherence.

Measurements and Primary Results

The cohort included MIGS(148), REI(85), OBGYN(51), GynOnc(34), and UROGYN(1). Ovarian preservation was more common among REI(88.2%) and MIGS(83.8%) vs GynOnc(67.6%) and OBGYN(60.8%). Adherence scores were higher in REI(1.9) and MIGS(1.7) vs GynOnc(1.3) and OBGYN(1.1). MIGS and REI were grouped for analysis based on shared training in endometriosis care and compared to a combined group of OBGYN, GynOnc. MIGS/REI training (aOR 11.65, 95% CI 4.87–27.89), fertility desire(aOR 5.31), and younger age(aOR 0.90/year) predicted ovarian preservation; prior surgery reduced odds(aOR 0.38). MIGS/REI training also predicted higher adherence(OR 1.47), and more frequent ureterolysis(OR 5.13) and endometriosis excision(OR 21.15). There were no significant differences in patient demographics or complications across groups. Model AUC = 0.90. Sensitivity analyses confirmed findings.

Conclusion

MIGS and REI fellowship training are associated with higher rates of ovarian preservation and guideline adherence. These findings illustrate how subspecialty training improves precision in endometriosis care and support the development of training-informed metrics for future progress and AI-driven clinical decision tools.