Surgery versus conservative management of endometriomas in subfertile women. A systematic review.

INTRODUCTION: Endometriomas are present in up to 44% of all women with endometriosis and have a detrimental effect on fertility. However, it is controversial whether endometriomas should be surgically removed before assisted reproduction technology (ART). Our purpose was to evaluate whether surgical stripping of endometriomas in subfertile women improves the chance of a live birth. Secondary outcomes were impact on ovarian reserve and pain. Material and methods We conducted a systematic review and metaanalysis with results reported in accordance to the PRISMA guidelines. Summary of findings table was developed using GRADE. We searched Medline and Embase. Two reviewers performed the screening. RESULTS: Out of 686 manuscripts we included one randomized controlled trial and nine retrospective cohort studies most of low quality. Odds ratio for live birth after surgery (compared with conservative management before in vitro fertilization (IVF)/ intracytoplasmic sperm injection (ICSI)) was 0.87 (95% CI; 0.64-1.18, six studies, I(2) = 3%; ⨁◯◯◯, VERY LOW quality). The mean difference of antral follicle count was -2.09 (95% CI; -4.84 - +0.67, four studies). No difference was observed regarding antral follicle count between the two groups (MD -2.09, 95% CI -4.84 to +0.67, four studies, ⨁◯◯◯, VERY LOW quality). Pain outcome was not reported in the included studies. CONCLUSION: Very low quality evidence suggests no difference in odds ratio of live birth between women who underwent surgery for endometriomas before IVF/ICSI compared to conservative management. Further high quality studies are needed, but due to lack of convincing evidence favoring surgery we recommend considering conservative treatment if the only indication is subfertility. This article is protected by copyright. All rights reserved.