Invited Lecture by Dr Sujoy Dasgupta in the Webinar on "Update on Endometriosis" organized by AICC RCOG (All India Coordinating Committee of Royal College of Obstetricians and Gynaecologists) East Zone, held in December, 2021

1. Management of Endometrioma:
Current Update
Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (New Delhi)
MRCOG (London)
Advanced ART Course for Clinicians (NUHS, Singapore)
Diploma, Sexual and Reproductive Medicine (University of South Wales, UK)
Consultant: Reproductive Medicine, Genome Fertility Centre, Kolkata
Visiting Consultant, RSV Hospital, Kolkata
Bhagirathi Neotia Women and Child Care centre
Woodlands Multispeciality Hospital, Kolkata
Managing Committee Member, Bengal Obstetric & Gynaecological Society (BOGS)
Secretary, Subfertility and Reproductive Endocrinology Committee, BOGS
Executive Committee Member, Indian Society for Assisted Reproduction (ISAR)- Bengal
Executive Committee Member, Indian Fertility Society (IFS)- West Bengal Chapter
Winner, Prof Geoffrey Chamberlain Award, RCOG World Congress, London, 2019

2. Facts and figures
• Ovarian endometrioma, a subtype of endometriosis,
affects 17–44% of women with endometriosis.
• Also known as ‘chocolate cysts’, contain thick, old
haemorrhage that appears as a brown fluid.
• 30% B/L.
• More frequently located in the left ovary.
• Commonly present with pelvic endometriotic lesions.
• Up to 50% cases are accidently diagnosed during
laparoscopy/ laparotomy.
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3. Diagnosis of Endometrioma
• Clinical examination
• CA-125
• TVS
• MRI
• Laparoscopy

4. Additional tests
• Do not systematically
request second-level
diagnostic investigations
in women with known or
suspected non-occlusive
colorectal endometriosis
or with symptoms
responding to medical
treatment (quality of the
evidence, low; weak
suggestion)
• CA-125 is NOT routine
investigation

5. Patient's age
Pain symptoms
Extent of disease
Patient's
reproductive
plans
Treatment risks
Side effects
Cost
considerations
Every
endometriosis
is different

6. Endometrioma and Subfertility

7. Reduced Fertility in Endometrioma
 Adhesions, tubal blockage and anatomical
distortion
 Chronic pelvic pain → dysparaeunia
 Inflammatory response damaging oocytes, sperms
and fertilization capacities
 Poor embryo quantity and quality
 Poor ovarian reserve
 Inflammation affecting endometrial receptivity
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8. Conservative management for
spontaneous conception
Encourage to try natural conception before seeking fertility
treatment-
1. Young women,
2. Regular menstrual cycles
3. An incidental finding of an ovarian endometrioma
4. Without suspicion of malignancy
•43% spontaneous pregnancy rate during the 6-month follow up
period in the presence of unilateral endometriomas of varying
sizes (diameter 5.3 ±1.7 cm)
•Similar ovulation rates in the affected ovary to the healthy ovary
(49.7% versus 50.3%)
*Benaglia et al., 2009; Leone Roberti Maggiore et al., 2015; RCOG, 2017

9. For women with a naturally or abnormally reduced
ovarian reserve
• conservative management for fertility should be weighed
against the potential benefits of surgery or fertility
treatment

10. Medical Management
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• Do not offer
hormonal
treatment to
women with
endometriosis who
are trying to
conceive, because
it does not improve
spontaneous
pregnancy rates.

11. Surgical treatment for spontaneous conception
• It may improve spontaneous pregnancy rates by restoring the
pelvic anatomy
• It is still controversial if cumulative pregnancy rate is more after
surgery but time to achieve the first pregnancy in infertile
patients was significantly shorter
• Management should be individualised and based upon clinical
factors, including pain symptoms, size of the cysts and concerns
over potential malignancy.
• Consideration should be given to surgical treatment being
undertaken by a gynaecologist with specific expertise in
endometriosis and fertility, in order to minimise the impact on the
ovarian reserve
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12. Laparoscopy for endometrioma
Cystectomy
• first line choice for
conservative treatment of
endometriotic cysts.
• The removed tissue helps in
histopathological
characterization.
• Recurrence rate with or
without medication- 5-20%.
Fenestration,
Drainage & Ablation of Cyst Wall
• Careful and skilled method
allows the preservation of
ovarian follicular reserve
• Recurrence rate- 2-30%.

13. Which Surgery
(RCOG 2017, NICE 2017)
Compared with drainage and coagulation,
Cystectomy is associated with
• an overall lower recurrence risk
• higher spontaneous postoperative pregnancy rate,
• particularly if the cyst is ≥3 cm in diameter.
• (OR 5.24, 95% CI 1.92–14.27; n = 88; two trials)
[Cochrane Database Syst Rev 2008;(2):CD004992]
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14. ESHRE, 2013
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Endometrioma is a false cyst and its cyst wall is the
same as the ovarian cortex. Therefore unsafe removal
of pseudocyst may damage the ovary and interfere
with future fertility.
• clinicians should perform excision of the
endometrioma capsule, instead of drainage
and electrocoagulation of the endometrioma
wall, to increase spontaneous pregnancy
rates and reduces risk of recurrence

15. Problems with surgical management
• 3-10% chances of damaging the surrounding
organs- bladder, bowel, ureter, nerves
• A reported reduction in the ovarian reserve
(more with repeated Sx)
• A small added risk of requiring an oophorectomy
• Complete excision of endometriotic tissue may
not be possible.
• May not reverse the inflammatory and
biomolecular changes shown to influence
fertilisation and implantation.
*Vercellini et al., 2009; Lebovic, 2016

16. Adjuvant hormone therapies
• In infertile women with endometriosis, the GDG
recommends clinicians NOT to prescribe
adjunctive hormonal treatment BEFORE
surgery to improve spontaneous pregnancy rates,
as suitable evidence is lacking.
• In infertile women with endometriosis, clinicians
should NOT prescribe adjunctive hormonal
treatment AFTER surgery to improve
spontaneous pregnancy rates

17. Ultrasound-guided Aspiration
• Transvaginal USG-guided drainage without surgery does not
seem to be effective.
• a high recurrence rate
• To decrease recurrence rate, aspiration is combined with in situ
injection of tetracycline/ethanol/methotrexate
• Disadvantages:
 Complications: infection, abscess formation, and pain
 inability to rule out any malignancy
 risk of pelvic adhesion
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18. IUI in Endometrioma
(ESHRE, 2013)
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• In infertile women with AFS/ASRM stage I/II
endometriosis,
• clinicians may perform IUI with COS,
instead of expectant management or IUI
alone, as it increases live birth rates
• clinicians may consider performing IUI with
COS within 6 months after surgical
treatment, since pregnancy rates are similar to
those achieved in unexplained infertility

19. Limitations of IUI in endometriosis
• Hughes, 1997- Meta-analysis- IUI success is halved in
stage I/II endometriosis
• Gandhi et al., 2014- No difference between expectant
management and IUI
• Dmowski et al., 2002- first-cycle chance of pregnancy with
IVF is significantly higher than the cumulative
pregnancy rate after 6 IUI cycles
• IVF, but not IUI, can be expected to overcome the
detrimental effects of a pelvic inflammatory milieu.
• Van der Houwen et al., 2014; D’Hooghe et al., 2006- the risk of
endometriosis recurrence appears to be increased by
IUI (more than IVF)

21. IVF in Endometrioma
(ESHRE, 2013)
22
• The GDG recommends the use of ART for
infertility associated with endometriosis,
especially if tubal function is compromised or
if there is male factor infertility, and/or other
treatments have failed.
• In women with endometrioma, clinicians may
use antibiotic prophylaxis at the time of
oocyte retrieval, although the risk of ovarian
abscess following follicle aspiration is low
•

22. Complications during and after OPU
(RCOG, 2017)
• Technical difficulties during oocyte retrieval is low,
• No data to suggest that surgery will prevent adhesion
reformation and facilitate oocyte retrieval effectively.
• Risks of infection from an endometrioma (0–1.9%)
• Progression of pelvic endometriosis and ovarian
endometriomas- ?
• Follicular fluid contamination (2.8–6.1%)
• The risk of missing an occult malignancy? (1-2%-
lifetime probability)
*Koch et al., 2012; RCOG, 2017
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23. Endometrioma and IVF Outcome
1. Lower serum AMH
2. Inadequate ovarian response to gonadotropin
3. Total stimulation dosage of gonadotropin used was
comparable.
4. Lower number of oocytes retrieved (mean difference –0.23;
95% CI 0.37–0.1)
5. Higher cancellation rate (OR 2.83; 95% CI 1.32–6.06)
6. live birth (OR 0.98; 95% CI 0.71–1.36), pregnancy (OR
1.17; 95% CI 0.87–1.58) and miscarriage rates (OR 1.7;
95% CI 0.86–3.35) were similar
*Maneschi et al., 1993; Sanchez et al., 2014; Coccia et al., 2014; Somigliana et al., 2014;
Hamdan et al., 2015; Goodman et al., 2016; Ferrero et al., 2017

24. Endometrioma vs other areas of
endometriosis
IVF outcomes (live birth, pregnancy, miscarriage
and cycle cancellation rates, and mean number of
oocytes retrieved) were similar
[Hum Reprod Update 2015]
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25. Medical treatment before ART
(ESHRE, 2013)
26

26. Surrey ES. "Endometriosis-Related Infertility: The Role of the Assisted
Reproductive Technologies", BioMed Research International, 2015

27. Georgiou EX, Melo P, Baker PE, Sallam HN, Arici A, Garcia‐Velasco JA, Abou‐Setta AM,
Becker C, Granne IE. Long‐term GnRH agonist therapy before in vitro fertilisation (IVF) for
improving fertility outcomes in women with endometriosis. Cochrane Database of Systematic
Reviews 2019, Issue 11. Art. No.: CD013240. DOI: 10.1002/14651858.CD013240.pub2
• In light of the paucity and very low quality of
existing data, particularly for the primary
outcomes examined, further high‐quality
trials are required to definitively determine
the impact of long‐term GnRH agonist therapy
on IVF/ICSI outcomes, not only compared to
no pretreatment, but also compared to other
proposed alternatives to endometriosis
management

28. Muller V, Kogan I, Yarmolinskaya M, Niauri D, Gzgzyan A, Aylamazyan E.
(2017). Dienogest treatment after ovarian endometrioma removal in infertile
women prior to IVF, Gynecological Endocrinology, 33:sup1, 18-21,

29. Tamura, H., Yoshida, H., Kikuchi, H. et al. The clinical outcome of Dienogest treatment
followed by in vitro fertilization and embryo transfer in infertile women with endometriosis. J
Ovarian Res 12, 123 (2019).
• No significant difference in the implantation and
miscarriage rates between the groups
• The cumulative pregnancy rate and live birth rate were
lower in the DNG group than in the control group.

30. GnRH Ago in IVF for endometriosis
1. Ultra-long protocol
2. Antagonist protocol → OPU → Freeze all →
GnRH Ago (3-6) → FET
Antagonist protocol may not be inferior to
agonist protocol (ESHRE, 2013)

31. Human Reproduction, Volume 27,
Issue 3, 1 March 2012
Systems Biology in Reproductive
Medicine, Volume 60, 2014
Letrozole improves the
marker of Endometrial Receptivity
Letrozole improves
Integrin expression in IVF
Letrozole improves
Integrin, LIF & L- Selectin
expression in natural cycle
Window of uterine receptivity remains open for an extended period
at lower estrogen levels but rapidly closes at higher levels
PNAS March 4, 2003 100 (5) 2963-296

32. Surgical treatment prior to IVF
• Surgically-treated endometriomas compared to those with intact
endometriomas, both having IVF
• similar live birth (OR 0.9; 95% CI 0.63–1.28), clinical pregnancy
(OR 0.97; 95% CI 0.78–1.2) and miscarriage rates (OR 1.32; 95%
CI 0.66–2.65)
• number of oocytes retrieved and the cancellation rates were
comparable,
• lower AFC
• required higher doses of gonadotropins for ovarian stimulation.
• Women who had undergone surgical management for a unilateral
endometrioma had a lower number of oocytes retrieved from the
surgically-treated ovary (mean difference –2.59; 95% CI –4.13 to –
1.05) when compared with the contralateral normal ovary
• The potential physiological compensation by the normal ovary [Hum
Reprod Update 2015]
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33. ESHRE, 2013
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In infertile women with endometrioma > 3 cm
only to consider cystectomy prior to ART to
improve
1. endometriosis-associated pain or
2. the accessibility of follicles.

34. RCOG Scientific Impact Paper (2017)
Directly ART
• Asymptomatic women,
• women of advanced
reproductive age,
• those with reduced
ovarian reserve,
• B/L endometriomas,
• a history of prior ovarian
surgery
Surgery before IVF
• Highly symptomatic
women,
• with an intact ovarian
reserve,
• unilateral and large cysts,
• cysts with suspicious
radiological and clinical
features.
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35. Endometrioma and Pain

36. Hormonal therapies
•can reduce pain and has no permanent negative effect on
subsequent fertility.
•No overwhelming evidence to support particular treatments
over other- Continuous COCP, Progesterone, GnRH agonists
 Medical treatments do NOT eliminate the extra-uterine
tissue growth, they just reduce the symptoms.

37. Surgical Management
• When performing surgery in women with ovarian
endometrioma (≥3 cm),
• cystectomy instead of drainage and
coagulation, as cystectomy reduces
endometriosis-associated pain
• Clinicians can consider performing cystectomy
rather than CO2 laser vaporization- because of
a lower recurrence rate of the endometrioma
• Possible difficulties in removal of very small
endometriomas should be kept in mind due to
lack of a clear surgical plane.

38. Preoperative Hormone therapies
• In clinical practice, surgeons prescribe preoperative
medical treatment with GnRH analogues as this can
facilitate surgery due to reduced inflammation,
vascularisation of endometriosis lesions and
adhesions. However, there are no controlled studies
supporting this.
• From a patient perspective, medical treatment should
be offered before surgery to women with painful
symptoms in the waiting period before the surgery
can be performed, with the purpose of reducing pain
before, not after, surgery.

39. Postoperative hormonal therapies
Short Term (<6 months)
 Do not prescribe
adjunctive
hormonal
treatment after
surgery, as it does
not improve the
outcome of
surgery for pain
Long term (>6 months)- Sec
Prevention
 role for prevention of recurrence of
disease and painful symptoms in
women surgically treated for
endometriosis.
 there are limited data
 After cystectomy for ovarian
endometrioma in women not
immediately seeking conception,
prescribe hormonal contraceptives

40. Conclusion
• Medical management can reduce pain
• Medical therapy does NOT improve the chance of
conception (except: GnRH Ago in IVF)
• Laparoscopy confirms the severity of
endometriosis
• Laparoscopy improves pain
• Laparoscopy improves chance of natural
conception
• Laparoscopy does NOT improve the success of
IVF
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