The Effect of Surgery on Endometriomas on Fertility (2025 Second Edition)

Endometriosis is a condition where the lining of the uterus (womb) is found in other locations in the body such as, but not limited to, the ovaries, bowel and bladder. It is a common condition that can affect up to one in 10 women and can be found in between three to five in 10 women who have been diagnosed with subfertility.

Women with endometriosis often present with painful periods, heavy periods, pain while opening their bowels or passing urine, pain during sexual intercourse and difficulty in conceiving. A proportion of those with endometriosis remain asymptomatic of the disease. Care should be tailored to each individual.

The significant improvement in diagnostic technology has increased the detection rate of endometriosis. People with ovarian endometriosis, also known as an ovarian endometrioma, can be diagnosed using a transvaginal (internal) or transabdominal (via the tummy) ultrasound scan. Detection rates of up to 90% have been reported for routine ultrasound scans.

Ovarian endometriomas can impact fertility outcomes, and for these people a multidisciplinary approach to care is required. The presence of an ovarian endometrioma and endometriosis is known to have a negative impact on the ovarian reserve (egg count and quality) and overall, chance of successful conception. Women with known endometriosis should therefore be counselled about the various options available for fertility preservation.

The treatment for ovarian endometrioma(s) in those wanting to conceive can be broadly divided into two categories, expectant (watch-and-wait approach), and surgical which most commonly involves-keyhole surgery.

Expectant management avoids the risks of surgery, along with no further surgically related reduction in ovarian reserve. It also reduces the delay from diagnosis to starting fertility treatment. The disadvantages of this approach, however, would be the persistence of pain symptoms, and ongoing difficulty with accessing the ovaries during assisted fertility treatment such as in vitro fertilisation.

Surgical treatment for ovarian endometrioma(s) in the context of women trying to conceive is often approached with caution. Surgery has been shown to reduce the ovarian reserve further, and clinicians would attempt to limit the degree of impact by reducing the amount of surgical stress to an ovary. The benefits of this approach, however, would be an improvement in symptoms and access to the ovaries for fertility treatment.