IVF outcomes after transvaginal sclerotherapy for ovarian endometrioma: a systematic review and meta-analysis

To evaluate whether pre-IVF/ICSI transvaginal ethanol sclerotherapy for ovarian endometrioma improves reproductive outcomes compared with expectant management, and to assess whether prior cystectomy modifies treatment effect.

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, major clinical trial registries, PubMed, and Google Scholar were searched from 1980 to November 2025 without language restriction.

Eligible studies included women with ovarian endometrioma undergoing IVF/ICSI, comparing those who received sclerotherapy with those managed expectantly. Eligible study designs included randomized controlled trials (RCTs) and observational cohorts. Following the screening of 742 records, six studies met the inclusion criteria: one RCT, one prospective comparative study, and four retrospective cohorts.

Six studies (one RCT, four retrospective cohorts, and one prospective comparative study) were included. The primary patient-level live birth analysis (2 studies, 124 patients) showed no statistically significant difference between sclerotherapy and expectant management (OR 2.20, 95% CI 0.66-7.32, p=0.20). The primary patient-level analysis for clinical pregnancy (4 studies, 221 patients) demonstrated that sclerotherapy was associated with a significantly higher clinical pregnancy rate (OR 2.14, 95% CI 1.21-3.79, p=0.009). At the cycle level, sclerotherapy yielded significantly more total oocytes (MD 2.20, 95% CI 0.06-4.34, p=0.04) and total embryos (MD 0.56, 95% CI 0.07-1.05, p=0.02), whereas the increase in mature oocytes was non-significant (MD 1.56, 95% CI -0.14-3.26, p=0.07). According to the GRADE framework, the certainty of evidence for all outcomes was Very Low.

Low-certainty evidence suggests that pre-IVF ethanol sclerotherapy for ovarian endometrioma may be associated with improved clinical pregnancy compared with expectant management, with benefits evident regardless of prior cystectomy history. While a positive trend in live births was observed, this finding was not statistically significant at the patient level, highlighting the fragility of the current evidence. These clinical enhancements are supported by overall improvements in oocyte and embryo yields. Sclerotherapy serves as a valuable, fertility-preserving alternative to repeat surgery for selected patients.