Is surgery for endometriomas ever indicated?

Endometriomas can be managed through various approaches, including careful observation, medical suppressive therapy, or surgical intervention. Malignancy is rarely a concern in women of reproductive age, making pain relief and the management of infertility the primary foci of treatment. Pain is seldom due to endometriomas per se, and is most often associated with deep endometriotic lesions, usually involving the parametria and the bowel. Patients with infertility are better served with assisted reproductive technology (ART), as endometriomas do not appear to affect oocyte developmental potential or implantation rate. In addition, endometriomas do not increase the complications associated with ART. On the other hand, surgery is associated with decreased ovarian reserve, a considerable risk of recurrence, and tubal obstruction that may inflict irreversible harm. Moreover, surgical complications may delay further fertility-promoting treatment. It is argued that, unless it is performed for acute indications such as cyst rupture or infection, there are remnant indications for surgery, mainly the presence of hydrosalpinx and the size and location of endometriomas, that may impede oocyte retrieval. Surgery for endometriomas does not adhere to the three fundamental principles of surgical indications: preserving life, alleviating suffering, and correcting deformities or dysfunction.