Optimal management of large endometriomas (≥ 4 cm) before IVF: ethanol sclerotherapy, cystectomy, or no intervention?

The optimal management strategy for large (≥ 4 cm) endometriomas prior to in vitro fertilization (IVF) remains uncertain. This study aimed to compare the cumulative live birth rate (CLBR) among three approaches: no intervention, ethanol sclerotherapy (EST), and laparoscopic cystectomy.

This retrospective cohort study included 90 infertile women undergoing their first IVF cycle at a university-based infertility center between 2020 and 2023. Patients were grouped based on endometrioma management: IVF with no intervention (OMA in situ group, N = 39), IVF after EST (EST group, N = 20), or IVF after cystectomy (Cystectomy group, N = 31). The primary outcome was CLBR per initiated cycle. Secondary outcomes included oocyte and embryo yield, fertilization and implantation rates, and cycle cancellation rate. Statistical analysis included one-way ANOVA and chi-square tests, with significance set at P < 0.05.

The EST group demonstrated a significantly higher CLBR (65%) compared to the OMA in situ (30.8%) and cystectomy (29%) groups (P = 0.017). Oocyte yield was higher in the EST group (10.1 ± 3.9) than in the OMA in situ (5.7 ± 4.3) and cystectomy (4.2 ± 3.5) groups (P < 0.001). Fertilization and implantation rates were similar across groups, but the number of good-quality embryos was higher following EST. The cycle cancellation rate was greatest in the cystectomy group (35.5%). Fresh embryo transfer pregnancy rates were higher in the EST and cystectomy groups compared to no intervention (66.7% and 55% vs. 32.4%, respectively; P = 0.044). Ovarian reserve was better preserved in the EST group, with no significant change in AMH levels post-procedure.

Ethanol sclerotherapy prior to IVF improves cumulative live birth outcomes compared to both no intervention and cystectomy in patients with large endometriomas. It enhances oocyte yield, reduces cycle cancellations, and preserves ovarian reserve, supporting its use as a favorable management strategy in IVF planning.

This study was approved by the Institutional Review Board of Ankara University School of Medicine (Approval ID i018525, Date 17 February 2025) and is retrospectively registered.