When and How Is Surgery Required for Large Endometrioma prior to in vitro Fertilization: A Survey of Practices

The aim of the study was to evaluate current practices among gynecologists in managing large endometriomas before in vitro fertilization (IVF).

A cross-sectional online survey was conducted. Participants/Materials: The survey was distributed to an estimated 410 gynecologists, with 111 specialists completing the survey (response rate: 27.8%). Among respondents, 73% practiced in academic settings, and 61% had more than 15 years of clinical experience.

Gynecologists involved in IVF treatments or endometrioma surgery were recruited via email through professional societies across multiple countries.

An online survey consisting of 18 questions covering clinical experience, surgical thresholds, techniques, hormonal protocols, and timing of ovarian stimulation post-surgery was distributed through professional societies. Responses were collected anonymously and analyzed using SPSS version 29.0.2.0.

Laparoscopic cystectomy was the most common procedure (48.2%). The median threshold size for surgery was 50 mm (interquartile range [IQR] 40-60). Despite the same median threshold, surgeons performing laparoscopic surgery as their main clinical activity had a significantly different distribution of thresholds (IQR 40-60 vs. 47-89, p = 0.006), with a tendency to recommend surgery for smaller endometriomas. Techniques like CO₂ laser ablation and plasma energy were less commonly used. Notably, 40.5% of participants indicated they would change their practice if a CO₂ laser or plasma energy device were available in their surgical armamentarium. Most participants (67.9%) adjusted their strategy based on preoperative anti-Müllerian hormone levels. The average timing for IVF stimulation post-surgery was 6 weeks (IQR 4-8) with no difference across different experiences.

The survey-based design may introduce response bias and reflect only the opinions of those who chose to participate. Additionally, the study may not capture regional or institutional differences comprehensively.

Managing large endometriomas before IVF involves balancing surgical benefits with risks to ovarian reserve. The survey highlights significant variability in practices, with a median surgical threshold size of 50 mm. Laparoscopic cystectomy, while common, is associated with ovarian tissue loss, whereas emerging techniques like CO₂ laser ablation show promise in preserving ovarian reserve. The need for up-to-date evidence-based guidelines is essential to standardize practices and optimize outcomes for IVF patients.