Should patients undergo endometrioma surgery before IVF/ICSI? a retrospective study with propensity score matching

Does surgical management of ovarian endometriomas improve in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI)?

This retrospective study analyzed 1,456 IVF/ICSI cycles from June 2017 to September 2022, comparing 530 control cycles with 926 endometriosis (EMS) cycles. The EMS group comprised pre-EMS (non-operated endometriomas, N = 272) and post-EMS (operated endometriomas, N = 654) subgroups. Propensity score matching (PSM) balanced female age, antral follicle count (AFC), body mass index (BMI), anti-Müllerian hormone (AMH), follicle stimulating hormone (FSH), and estradiol levels. Receiver operating characteristic (ROC) analyses identified potential predictors of high-quality D3 embryos and live birth.

After PSM, the EMS group showed significantly lower normal fertilization rates, D3 embryo rates, and ovarian sensitivity index (OSI) compared to the control group (P < 0.05), but comparable oocyte yield, fertilization outcomes, and embryo parameters. Subgroup analysis showed that advanced-stage post-EMS cases had fewer retrieved oocytes and embryos, along with lower OSI, than the pre-EMS group after PSM. LBRs were similar between the EMS and control groups, irrespective of prior endometrioma surgery. ROC analysis identified AMH (cutoff 1.17 ng/mL; AUC 0.703, 95% CI 0.654-0.752) and AFC (cutoff 7.5; AUC 0.670, 95% CI 0.621-0.720) as predictors of high-quality day-3 embryos in EMS patients. In post-EMS patients, AMH (cutoff value 1.175; AUC 0.703, 95% CI 0.647-0.759) and AFC (cutoff 6.5; AUC 0.667, 95% CI 0.608-0.725) were predictive. AMH, AFC, age, and endometrioma size did not predict live birth.

Advanced-stage Endometriosis negatively impacts oocyte quantity and ovarian response, but endometrioma surgery may not improve these outcomes or LBRs. Following exclusion of malignancy, asymptomatic endometriosis patients with AMH ≤ 1.17 ng/mL or AFC ≤ 7 should not routinely undergo cystectomy.