What Are Endometriomas?
Endometriomas, or "chocolate cysts", are cysts that form in the ovaries when endometriosis tissue grows there. They are filled with old blood and can range from small to quite large. Endometriomas are found in up to 40% of women with endometriosis and can affect fertility by damaging healthy ovarian tissue, reducing your egg supply, and sometimes making it harder for fertility doctors to access your ovaries during fertility treatments like IVF.
If you have an endometrioma and are hoping to become pregnant, one of the most important decisions you and your doctor will make is whether, and how, to treat it surgically.
Why does the Surgical Approach Matter for Fertility?
Your ovaries contain a limited number of eggs, and this supply naturally decreases over time. Doctors measure your "ovarian reserve" using blood tests (Anti Müllerian Hormone- AMH) and ultrasound (antral follicle count- AFC). Some surgical techniques remove more healthy ovarian tissue than others, which can reduce your egg supply. At the same time, leaving an endometrioma untreated carries its own risks.
There is no single "best" approach for every woman. The right choice depends on your symptoms, the size and location of the cyst, whether one or both ovaries are affected, your current egg supply, and your fertility plans.
The Main Treatment Options
1. Excision (Cystectomy)- "Stripping" the Cyst Out
This is the most commonly performed and most widely studied technique. The surgeon peels the cyst wall away from the ovary and removes it entirely.
Advantages:
- Lowest recurrence rate.
- Provides a tissue sample that can be examined under a microscope to confirm endometriosis diagnosis and rule out rare but serious conditions
- May improve pain symptoms including painful periods and pain during intercourse
Disadvantages:
- Is associated with damage to egg supply. Studies show a 35-54% drop in AMH levels after surgery, and this decline persists over 18 months
- Some healthy ovarian tissue may be inevitably removed along with the cyst wall
We use advanced surgical techniques to preserve the normal ovarian tissue and completely remove endometriomas. These include the use of special agents to limit bleeding and separate the cyst from the surrounding normal ovarian tissue so that only the cyst is removed, and avoiding energy use during cystectomy. These techniques have been scientifically proven to preserve normal ovarian tissue and function.
2. Ablation- Destroying the Cyst Lining
Instead of removing the cyst, the surgeon drains it and then destroys the inner lining using laser, electrical energy, or plasma energy.
Advantages:
- Preserves more egg supply- AMH drops by about 0.4 ng/mL compared to about 1.1 ng/mL with cystectomy
- Pregnancy rates appear similar to cystectomy
Disadvantages:
- Traditional ablation techniques have a higher recurrence rate (about 1.5 times higher than cystectomy)
- No tissue sample is obtained for microscopic examination
A technique called plasma energy ablation (PEA) may offer good results, but evidence is limited. In one study, PEA had a recurrence rate similar to cystectomy (about 24% vs. 27% at 4 years) while preserving more egg supply.
3. Sclerotherapy- A Non-Surgical Alternative
Sclerotherapy involves draining the cyst through a needle (during laparoscopic surgery or guided by ultrasound) and then injecting a substance, usually ethanol (medical-grade alcohol), to destroy the cyst lining. It can be done without general anesthesia in some cases.
Advantages:
- Minimal impact on egg supply. One study showed only a 15% AMH decline compared to 40% with cystectomy 12 months after the procedure
- Studies suggest women who undergo sclerotherapy before IVF may have more eggs retrieved and higher pregnancy rates
- Less invasive than traditional surgery
Disadvantages:
- Relatively new technique with less long-term data
- Does not provide a tissue sample for microscopic examination
- Not yet widely available at all centers
Importantly, the strength of this evidence is low, and more studies are needed to confirm these results.
4. Expectant Management- Watching and Waiting
For some women, the best option may be no surgery at all, particularly if the endometrioma is not causing significant symptoms and IVF is planned.
Advantages:
- Avoids any surgery-related loss of eggs
- Studies comparing surgery versus no surgery before IVF show similar live birth rates
- Avoids surgical risks and recovery time
Disadvantages:
- The cyst may grow or cause new symptoms
- Large cysts can make it difficult for doctors to reach your ovaries during egg retrieval
- There is a small risk of cyst rupture or other complications
- Does not provide a tissue diagnosis
How Do Fertility Outcomes Compare?
One of the most important findings from the research is that pregnancy and live birth rates are broadly similar across all approaches. The key difference is in how much each technique affects your egg supply:
- Cystectomy causes the greatest decline in egg supply but has the lowest recurrence
- Ablation and sclerotherapy preserve more eggs but may have higher recurrence
- Expectant management may preserves eggs but does not address the cyst itself
- When IVF is planned, surgery before IVF does not appear to improve live birth rates
Special Considerations
- If your egg supply is already low, your doctor may recommend freezing eggs or embryos before any surgery
- Larger endometriomas, usually considered >4 cm, generally warrant treatment to confirm the diagnosis, improve access during fertility treatments, and prevent complications
The Bottom Line
There is no one-size-fits-all answer for managing endometriomas when fertility is a priority. Each approach involves trade-offs between preserving your egg supply, reducing the chance the cyst comes back, and confirming the diagnosis. The good news is that pregnancy rates appear similar regardless of the approach chosen. What matters most is selecting the strategy that is right for your individual situation.
Work closely with your reproductive specialist or gynecologist to develop a plan that considers your symptoms, your egg supply, the size and number of cysts, and your timeline for becoming pregnant.