Ovarian damage following surgery for endometriomas, 20 years later: did awareness improve the situation?

Background: Early reports from the beginning of this century highlighted significant ovarian damage following laparoscopic stripping of endometriomas. During the last 2 decades, the raised awareness of the possible detrimental effects of surgery has boosted the attention of surgeons on sparing ovarian reserve. Giving this increased consciousness on this issue, in this real-life study, we aimed to assess whether the surgically-related damage to the ovaries has been reduced over the years. Materials and methods: Ovarian reserve was assessed by comparing ovarian response during stimulation for IVF in women who previously underwent surgical treatment for unilateral endometriomas. This study design allows intra-patient comparisons, limiting confounders. In addition, this same design was used in the past and allows therefore to compare findings with those obtained 2 decades ago. The primary aim was the frequency of non-response among operated gonads. Results: One hundred seven female patients with unilateral endometrioma surgery who underwent IVF/ICSI cycles were eligible for the study. The mean ± SD diameter of the excised endometriomas was 46 ± 20 mm. Most women underwent cyst stripping while drainage and ablation was used in only three subjects. The median [IQR] number of follicles in the operated and contralateral gonads was 3 [1–5] and 7 [5–9], respectively (p < 0.001). Absence of follicular growth was observed in 19 operated ovaries (18%, 95% CI 12–26%). The magnitude of the damage remained unchanged, if not worse, when compared to what observed 2 decades ago. Conclusions: Ovarian reserve continues to be significantly compromised after surgery for endometriomas. Further research is urgently needed to better understand the underlying mechanisms and to refine surgical techniques aimed at minimizing this damage.