Este necesară prezervarea fertilităţii înaintea tratamentului chirurgical al endometriozei?

 Is fertility preservation a necessity before endometriosis surgical treatment?

First published: 22 martie 2021

Editorial Group: MEDICHUB MEDIA

DOI: 10.26416/Gine.31.1.2021.4329


Endometriosis is a common cause of infertility. Personalized counselling regarding fertility preservation should be of­fered particularly to young women with high risk of recur­rence of endometriosis or to those with bilateral en­do­me­trio­mas. The surgical treatment of ovarian en­do­me­trio­sis consists in cystectomy. The methods used for preserving fertility in women with endometriosis are oocyte or embryo cryopreservation. In this study, we re­viewed the literature in order to investigate if fertility pre­ser­va­tion is necessary before the surgical treatment of endometriomas. We concluded that more clinical data and economic analyses are needed in order to recommend fer­ti­li­ty preservation as a routine procedure for all women before undergoing surgical treatment for endometriosis.

fertility preservation, endometriosis, oocyte cryopreservation, embryo cryopreservation


Endometrioza este o cauză frecventă a infertilităţii. Con­si­lie­rea per­so­nalizată privind conservarea fertilităţii ar trebui pre­zen­ta­tă în special femeilor tinere cu risc crescut de recurenţă a endometriozei sau celor cu endometrioame bilaterale. Tratamentul chirurgical al endometriozei ova­rie­ne constă în chistectomie. Metodele utilizate pentru con­ser­varea fertilităţii la femeile cu endometrioză sunt reprezentate de crio­con­ser­varea de ovocite sau embrioni. În acest articol, am realizat revizuirea literaturii cu privire la conservarea fer­ti­li­tă­ţii preoperatoriu în cazul chirurgiei pentru endo­me­trioa­me. Concluziile arată că sunt necesare mai multe date cli­ni­ce şi analize economice pentru a recomanda con­ser­va­rea fertilităţii ca procedură de rutină înaintea intervenţiei chi­rur­gi­ca­le pentru endometrioză.


Endometriosis is defined by the presence of endometrial glands and stroma outside the uterus, and is mostly found on the pelvic peritoneum, ovaries, rectovaginal septum and ureters. Endometrial implants rarely appear in the bladder, pericardium or pleura(1). Endometriosis affects about 10% of women of reproductive age(2). Thus, infertility is common in women with endometriosis and has two leading causes: the disease itself and iatrogenicity due to reduced ovarian reserve after surgical treatment(3,4).

Women with endometriosis – especially young women with high risk of recurrence of endometriosis or those with bilateral endometriomas – should be counselled regarding fertility preservation(3).

Originally, methods for preserving fertility were proposed to women who undergo gonadotoxic treatments such as oncologic treatment and consists of: oocyte cryopreservation, embryo cryopreservation or ovarian tissue cryopreservation(5).

In this article, we will investigate if fertility preservation is necessary before the surgical treatment for endometriosis, and if it is necessary, in which patients.

A narrative literature review was conducted in the PubMed database, in order to select full-length articles published in peer-reviewed journals up to the 14th of September 2020. The keywords along with respective combinations included in the search strategy were: fertility preservation, severe endometriosis, surgical treatment.

We found a total number of 139 relevant articles, published between 1984 and 2020. We selected only full-text articles, with studies including population of adult females, published in this period in the literature.

Preoperative fertility preservation

It is well known that the surgical treatment for stage I or II endometriosis improves fertility, in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) outcome(6,7).

There are no randomized control trials to prove the same outcome in moderate or severe endometriosis. Literature data show that it is recommended to remove large endometriomas prior to attempting spontaneous conception, as part of the treatment of ovarian endometriosis(8).

The surgical technique used for endometriomas is cystectomy(8). It is usually preferred due to the lower risk of recurrence of the disease, but recent studies show that CO2 laser and plasma energy produce less thermal injury and improve ovarian reserve when compared to ablation using electrosurgery or even cystectomy(9-12).

Prior to the surgical treatment, a clear assessment of ovarian lesions is required. Ovarian sparing surgical techniques are mandatory, and these interventions should be performed by skilled gynecologists. All of these measures are taken to prevent further damage to the ovary either by excess excision of healthy ovarian tissue or by deep coagulation that might lower the circulation from the hilum and, therefore, lower the ovarian reserve(4,13).

During cystectomy, a consistent amount of ovarian tissues is removed and the number of ovarian follicles decreases due to ovarian vascularization damage by electrosurgical coagulation for haemostasis purposes(14,15)

Anti-Müllerian hormone (AMH) levels are the best current available measure to estimate ovarian reserve(16). Studies have shown that AMH levels decreases up to 30% after excision of unilateral endometrioma and up to 44% after bilateral endometriomas(17,18). However, AMH is a poor predicator of spontaneous fertility(19).

Antral follicle counting (AFC) is another marker of ovarian reserve and it correlates with AMH levels. AFC can be difficult to determine in the presence of endometriomas and is less reproducible than AMH(20,21).

Llarena et al. presented in a study the benefits of the surgical treatment of endometriomas. They consist in facilitating oocyte retrieval and prevention of spillage of endometrioma contents into oocyte(22).

In 2015, Hamdan et al. published a meta-analysis of the surgical treatment for endometriomas prior to IVF and concluded that untreated patients had a higher rate of cycle cancelation and a lower mean number of oocytes retrieved(23). Furthermore, two other meta-analyses could not demonstrate a statistical difference in pregnancy rate when comparing surgically untreated and treated endometriomas prior to IVF(24,25).

However, there are some studies that reveal a major impairment in the ovarian reserve especially after the surgical treatment of bilateral endometriomas(26-28).

In 2015, a study conducted by Rizk et al. concluded that surgery is recommended as first-line treatment in women affected with minimal or mild endometriosis, as well as for patients with moderate and severe endometriosis(29).

Another retrospective study, with the same outcome, compared pregnancy rates in women with advanced endometriosis who underwent repeat surgery versus IVF. It showed a cumulative pregnancy rate of 70% after two IVF cycles, compared to 24% in 9 months of spontaneous trial after repeat surgery(30). In a similar way, an additional decrease of AMH levels and AFC was observed after the surgical treatment for recurrent endometriomas rather than after the initial surgery(31,32).

To minimize the negative effects of surgery on the ovarian reserve, some authors suggested a combined treatment for endometriomas: laparoscopic cyst drainage and biopsy to confirm the diagnosis of endometriosis, followed by a 12-week treatment with a gonadotropin receptor hormone (GnRH) agonist – this being used to reduce the cyst volume and its mitotic activity, followed by laparoscopic ablation of the cyst wall using CO2 laser(33). A major disadvantage of this approach is the need for multiple laparoscopies. Despite this disadvantage, a randomized controlled study was conducted by Tsolakidis et al. and reported a significant decrease in postoperative AMH decline with this three-stage approach(34).

A series of studies were conducted in order to evaluate pregnancy rate after laparoscopic cystectomy versus combined excision/ablation(35).

According to ESHRE guidelines, in women with ovarian endometrioma receiving surgery for infertility, the standard surgical management is excision, because it is proven that it increases the rate of spontaneous postoperative pregnancy(36,37).

The American Society for Reproductive Medicine suggests that for a 4 cm or larger endometrioma, surgery can be used for histological diagnosis, to ease the access to follicles during oocyte retrieval and to improve ovarian response(38).

Fertility preservation (FP) procedures should be taken into consideration for women with endometriosis. It is well known that infertility is commonly found in women suffering from endometriosis, particularly in patients with unoperated bilateral endometriomas and in those who already had surgery for unilateral endometriomas and require surgical treatment for contralateral recurrence(39). However, to improve pregnancy rates, surgical and medical treatment for endometriosis should be done before assisted reproduction technology(5,41).

Bedoschi et al. recommended that women at reproductive age with risk of severe endometriosis or even surgery should be counselled regarding fertility preservation(5). If oocyte cryopreservation becomes widely used in women with endometriosis, more studies will be needed in this population. More so, the reproductive potential of the ovarian tissue must be assessed, as it might be compromised due to endometriomas(4,42).

Some reports have demonstrated that ovarian tissue cryopreservation aiming future transplantation and ovarian tissue fresh transplantation are valuable techniques(43-45). Age, history or planned surgeries, the success rates of fertility preservation technologies, as well as ovarian reserve are all factors to be considered when counselling patients regarding fertility preservation. Thus, this approach should be highly individualized(4,22,39).

The quality of banked oocytes is likely higher in younger women and the risk of endometriosis recurrence is also higher(39,46). Studies demonstrate that age influences the live birth rate per warmed vitrified oocyte(47). Doyle et al. proved in their study that the estimated efficiencies per warmed oocyte by age group were as follows: 7.4% for women aged <30 years old at the time of oocyte cryopreservation; 7% for women aged 30-34 years old; 6.5% for women aged 35-37 years old; and 5.2% for women aged ≥38 years old(47). With this piece of information as a basis, Streuli et al. recommend preserving 15-20 oocytes if the patient is younger than 38 years old, or 25-30 oocytes for the 38-40 years old range(48).


Firstly, fertility preservation should be an option to be taken into consideration before the surgical treatment in women with bilateral endometriomas, in women with unilateral endometrioma with history of surgery for contralateral endometrioma, history of multiple surgeries or at risk for multiple surgeries.

Secondly, age is also a criterion. Women older than 37 years of age with any stage of endometriosis should consider fertility preservation.

Thirdly, for patients with endometriosis, oocyte or embryo cryopreservation are the preferred methods.

Conflict of interests: The authors declare no conflict of interests.


  1. Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM. Williams Gynecology 3rd ed. 2016;10:230-44.
  2. Viganò P, Parazzini F, Somigliana E, Vercellini P. Endometriosis: epidemiology and aetiological factors. Best Pract Res Clin Obstet Gynaecol. 2004;18(2):177-200.
  3. Llarena NC, Falcone T, Flyckt RL. Fertility preservation in women with endometriosis. Clin Med Insights Reprod Health. 2019;13:1179558119873386.
  4. Gica N, Panaitescu AM, Iancu G, Botezatu R, Peltecu G, Gică C. The role of biological markers in predicting infertility associated with non-obstructive endometriosis. Ginekol Pol. 2020;91(4):189-92.
  5. Bedoschi G, Turan V, Oktay K. Fertility preservation options in women with endometriosis. Minerva Ginecol. 2013;65:99-103.
  6. Opøien HK, Fedorcsak P, Byholm T, Tanbo T. Complete surgical removal of minimal and mild endometriosis improves outcome of subsequent IVF/ICSI treatment. Reprod Biomed Online. 2011;23(3):389-95.
  7. Chang FH, Chou HH, Soong YK, Chang MY, Lee CL, Lai YM. Efficacy of isotopic 13CO2 laser laparoscopic evaporation in the treatment of infertile patients with minimal and mild endometriosis: a life table cumulative pregnancy rates study. J Am Assoc Gynecol Laparosc. 1997;4(2):219–23.
  8. Donnez J, Squifflet J, Jadoul P, Lousse JC, Dolmans MM, Donnez O. Fertility preservation in women with ovarian endometriosis. Front Biosci (Elite Ed). 2012;4:1654-62. 
  9. Muzii L, Di Tucci C, Di Feliciantonio M, Galati G, Verrelli L, Donato VD, Marchetti C, Panici PB. Management of endometriomas. Semin Reprod Med. 2017;35(1):25–30. 
  10. Candiani M, Ottolina J, Posadzka E, et al. Assessment of ovarian reserve after cystectomy versus “one-step” laser vaporization in the treatment of ovarian endometrioma: a small randomized clinical trial. Hum Reprod. 2018;33(12):2205-11.
  11. Pedroso J, Gutierrez M, Volker KW. Comparative thermal effects of J-plasma, monopolar, argon and laser electrosurgery in a porcine tissue model. Surg Technol Int. 2019;34:35-39.
  12. Carmona F, Martinez-Zamora MA, Rabanal A, Martinez-Roman S, Balasch J. Ovarian cystectomy versus laser vaporization in the treatment of ovarian endometriomas: a randomized clinical trial with a five-year follow-up. Fertil Steril. 2011;96(1):251–54.
  13. Muzii L, Marana R, Angioli R, Bianchi A, Cucinella G, Vignali M, et al. Histologic analysis of specimens from laparoscopic endometrioma excision performed by different surgeons: does the surgeon matter? Fertil Steril. 2011;95(6):2116–9.
  14. Garcia-Velasco JA, Somigliana E. Management of endometriomas in women requiring IVF: to touch or not to touch. Hum Reprod. 2009;24(3):496-501.
  15. Somigliana E, Benaglia L, Vigano P, Candiani M, Vercellini P, Fedele L. Surgical measures for endometriosis-related infertility: a plea for research. Placenta. 2011;32 Suppl 3:S238-S42.
  16. Broer SL, Broekmans FJ, Laven JS, Fauser BC. Anti-Müllerian hormone: ovarian reserve testing and its potential clinical implications. Hum Reprod Update. 2014;20(5):688-701.
  17. Kitajima M, Dolmans MM, Donnez O, Masuzaki H, Soares M, Donnez J. Enhanced follicular recruitment and atresia in cortex derived from ovaries with endometriomas. Fertil Steril. 2014;101(4):1031-7.
  18. Falcone T, Flyckt R. Clinical management of endometriosis. Obstet Gynecol. 2018;131(3):557-71.
  19. Steiner AZ, Pritchard D, Stanczyk FZ, et al. Association between biomarkers of ovarian reserve and infertility among older women of reproductive age. JAMA. 2017;318(14):1367-76.
  20. van Disseldorp J, Lambalk CB, Kwee J, Looman CW, Eijkemans MJ, Fauser BC, Broekmans FJ. Comparison of inter- and intracycle variability of anti-Mullerian hormone and antral follicle counts. Hum Reprod. 2010;25(1):221–7.
  21. Fanchin R, Taieb J, Lozano DH, Ducot B, Frydman R, Bouyer J. High reproducibility of serum anti-Mullerian hormone measurements suggests a multi-staged follicular secretion and strengthens its role in the assessment of ovarian follicular status. Hum Reprod. 2005;20(4):923-7.
  22. Llarena N, Flyckt R. Strategies to preserve and optimize fertility for patients with endometriosis. J Endometr Pelvic Pain Disord. 2017;9(2):98-104.
  23. Hamdan M, Dunselman G, Li TC, Cheong Y. The impact of endometrioma on IVF/ICSI outcomes: a systematic review and meta-analysis. Hum Reprod Update. 2015;21(6):809-25.
  24. Tsoumpou I, Kyrgiou M, Gelbaya TA, Nardo LG. The effect of surgical treatment for endometrioma on in vitro fertilization outcomes: a systematic review and meta-analysis. Fertil Steril. 2009;92(1):75-87.
  25. Benschop L, Farquhar C, van der Poel N, Heineman MJ. Interventions for women with endometrioma prior to assisted reproductive technology. Cochrane Database Syst Rev. 2010;11:CD008571.
  26. Seyhan A, Ata B, Uncu G. The impact of endometriosis and its treatment on ovarian reserve. Semin Reprod Med. 2015;33(6):422–8.
  27. Goodman LR, Goldberg JM, Flyckt RL, Gupta M, Harwalker J, Falcone T. Effect of surgery on ovarian reserve in women with endometriomas, endometriosis and controls. Am J Obstet Gynecol. 2016;215(5):589.e1-589.e6.
  28. Li CZ, Liu B, Wen ZQ, Sun Q. The impact of electrocoagulation on ovarian reserve after laparoscopic excision of ovarian cysts: a prospective clinical study of 191 patients. Fertil Steril. 2009;92(4):1428-35.
  29. Rizk B, Turki R, Lotfy H, Ranganathan S, Zahed H, Freeman AR, Shilbayeh Z, Sassy M, Shalaby M, Malik R. Surgery for endometriosis-associated infertility: do we exaggerate the magnitude of effect ? Facts Views Vis Obgyn. 2015;7(2):109-18.
  30. Pagidas K, Falcone T, Hemmings R, Miron P. Comparison of reoperation for moderate (stage III) and severe (stage IV) endometriosis-related infertility with in vitro fertilization-embryo transfer. Fertil Steril. 1996;65(4):791-5.
  31. Muzii L, Achilli C, Lecce F, et al. Second surgery for recurrent endometriomas is more harmful to healthy ovarian tissue and ovarian reserve than first surgery. Fertil Steril. 2015;103(3):738-43.
  32. Ferrero S, Scala C, Racca A, et al. Second surgery for recurrent unilateral endometriomas and impact on ovarian reserve: a case-control study. Fertil Steril. 2015;103(5):1236-43.
  33. Donnez J, Nisolle M, Gillet N, Smets M, Bassil S, Casanas-Roux F. Large ovarian endometriomas. Hum Reprod. 1996;11(3):641-6.
  34. Tsolakidis D, Pados G, Vavilis D, et al. The impact on ovarian reserve after laparoscopic ovarian cystectomy versus three-stage management in patients with endometriomas: a prospective randomized study. Fertil Steril. 2010;94(1):71-7.
  35. Donnez J, Lousse JC, Jadoul P, Donnez O, Squifflet J. Laparoscopic management of endometriomas using a combined technique of excisional (cystectomy) and ablative surgery. Fertil Steril. 2010;94(1):28-32.
  36. Hart RJ, Hickey M, Maouris P, Buckett W. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst Rev. 2008;(2):CD004992.
  37. Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014;29(3):400-12.
  38. The practice committee of the American Society for Reproductive. Endometriosis and infertility: a committee opinion. Fertil Steril. 2012;98(3):591-8.
  39. Somigliana E, Vigano P, Filippi F, et al. Fertility preservation in women with endometriosis: for all, for some, for none? Hum Reprod. 2015;30(6):1280-6.
  40. Elizur SE, Chian RC, Holzer HE, Gidoni Y, Tulandi T, Tan SL. Cryopreservation of oocytes in a young woman with severe and symptomatic endometriosis: a new indication for fertility preservation. Fertil Steril. 2009;91(1):293.e1-293.e2933.
  41. Barnhart K, Dunsmoor-Su R, Coutifaris C. Effect of endometriosis on in vitro fertilization. Fertil Steril. 2002;77(6):1148-55.
  42. Carrillo L, Seidman DS, Cittadini E, Meirow D. The role of fertility preservation in patients with endometriosis. J Assist Reprod Genet. 2016;33(3):317-23.
  43. Oktay K, Oktem O. Ovarian cryopreservation and transplantation for fertility preservation for medical indications: report of an ongoing experience. Fertil Steril. 2010;93(3):762-8.
  44. Akar M, Oktay K. Restoration of ovarian endocrine function by ovarian transplantation. Trends Endocrinol Metab. 2005;16(8):374-80.
  45. Donnez J, Squifflet J, Dolmans MM, Martinez-Madrid B, Jadoul P, Van Langendonckt A. Orthotopic transplantation of fresh ovarian cortex: a report of two cases. Fertil Steril. 2005;84(4):1018e1-1018e3.
  46. Brosens I, Gordts S, Benagiano G. Endometriosis in adolescents is a hidden, progressive and severe disease that deserves attention, not just compassion. Hum Reprod. 2013;28(8):2026-31.
  47. Doyle JO, Richter KS, Lim J, Stillman RJ, Graham JR, Tucker MJ. Successful elective and medically indicated oocyte vitrification and warming for autologous in vitro fertilization, with predicted birth probabilities for fertility preservation according to number of cryopreserved oocytes and age at retrieval. Fertil Steril. 2016;105(2):459-66.
  48. Streuli I, Benard J, Hugon-Rodin J, Chapron C, Santulli P, Pluchino N. Shedding light on the fertility preservation debate in women with endometriosis: a SWOT analysis. Eur J Obstet Gynecol Reprod Biol. 2018;229:172-8.

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