Optimal Laparoscopic Surgical Technique for Preserving Fertility and Ovarian Reserve in Patients With Endometrioma: A...

This systematic review and Bayesian network meta-analysis aimed to evaluate the comparative efficacy and safety of various laparoscopic techniques for endometrioma management, focusing on their impact on fertility outcomes and ovarian reserve preservation.

A systematic search was conducted in PubMed/MEDLINE, Embase, Cochrane Library, and Scopus, following PRISMA 2020 guidelines.

This systematic review and Bayesian network meta-analysis included only randomized controlled trials, encompassing women between 18 and 45 years, undergoing primary laparoscopic surgery for unilateral or bilateral endometriomas. Eligible interventions included cystectomy with bipolar coagulation, cystectomy alone, cystectomy with suturing, fenestration with bipolar coagulation, drainage with CO₂ laser vaporization, cystectomy with hemostatic sealant, cystectomy with ultrasonic scalpel, and vasopressin-assisted cystectomy with bipolar coagulation. Eleven randomized controlled trials were included (956 participants).

Statistical analyses integrated Bayesian random-effects to compute pooled risk ratios and mean differences, with 95% credible intervals. Surface Under the Cumulative Ranking Curve (SUCRA) rankings were used to rank interventions. For cumulative pregnancy rate within 12 months (ΔAMH at 3, 6, and 12 months), no statistically significant differences were observed across treatment comparisons. However, probabilistic ranking consistently indicated cystectomy with ultrasonic scalpel as the most favorable technique at 6 (SUCRA = 0.711) and 12 months (SUCRA = 0.693), while cystectomy with suturing ranked the least favorable. Regarding reproductive outcomes, drainage with CO₂ laser vaporization showed the most favorable ranking profile for cumulative clinical pregnancy within 12 months. Importantly, the overall ranking probabilities for fertility and ovarian reserve were not supported by statistically significant differences among techniques.

This meta-analysis evaluated different laparoscopic techniques for endometrioma management. While no technique demonstrated statistically significant superiority across all outcomes, the probabilistic rankings identified cystectomy with ultrasonic scalpel as a more favorable approach for ovarian reserve preservation and drainage with CO₂ laser vaporization for pregnancy achievement. These findings highlight the need for careful, individualized patient counseling enabling tailored surgical decisions aligned with individual reproductive goals. Future direct head-to-head trials with standardized long-term follow-up are warranted to definitively guide clinical practice.