1. Surgery versus conservative management of endometriomas in subfertile women.
A systematic review
JACOB BRINK LAURSEN1, JEPPE B. SCHROLL2, KIRSTEN T. MACKLON3 & MARTIN RUDNICKI4
1Department of Obstetrics and Gynecology, Zealand University Hospital, Copenhagen University, Roskilde, 2Department of Obstetrics and Gynecology, Herlev University Hospital, Herlev, 3The Fertility Clinic, section 4071, Copenhagen University Hospital Rigshospitalet, Copenhagen, and 4Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
ACTA Obstetricia et Gynecologica Scandinavica Journal Club
-Gynecology-
June 2017
Edited by Francesco D’Antonio

2. Background
The cause for sub-fertility associated with endometriosis is assumedly multi-factorial, possibly involving components such as inflammatory factors, adhesions involving the internal genitalia but also the presence of endometriomas.
The influence of endometriomas on fertility and in vitro fertilization (IVF) has still to be ascertained.
Current clinical practice in the management of endometriomas is laparoscopic removal. Alternatively, endometriomas can be removed by several other methods, such as stripping, excision, ablation or drainage.
Beyond the inherent complications to surgery and regardless of the operating technique, damage to the ovary is inevitable.

3. Aim of the study
To evaluate whether surgical stripping of endometriomas in subfertile women improves the chance of a live birth and whether it affects ovarian reserve and pain.

4. Methodology Study design: Systematic review.
Medical databases: Medline and Embase.
Inclusion criteria: Women of fertile age who wished to be pregnant, and those who were eligible for ART and who had one or more ultrasonically identified endometriomas.The intervention group was women who had undergone excision/stripping of endometriomas before ART (IVF or ICSI). The control group was women with endometriomas followed with conservative management or direct referral to ART (IVF or ICSI).
Primary outcome: Live birth, defined as total number of live births among the total number of women in the respective studies included.
Secondary outcomes: Clinical pregnancy (defined as all pregnancies among all women in the respective studies diagnosed by ultrasound in week 7 with the presence of a beating heart), ovarian reserve as measured by anti-Mullerian hormone (AMH) and antral follicle count (AFC), and pain as reported by visual analog scale (VAS) or similar, or as part of a quality of life evaluation.

5. Methodology
Systematic review protocol: Only randomized controlled trials (RCTs) and observational studies were considered for inclusion. Reviews, conference abstracts and case reports were excluded. Only studies with an intervention group and a control group where both groups had endometriomas were included.
Statistical analiyis: Meta-analyses were performed using a fixed effects model. Statistical heterogeneity was evaluated by the measure of I2 . In the case of high heterogeneity (I 2 > 50%) the random effects model was applied. Odds ratio (OR) as effect measure for dichotomous data and mean difference for continuous outcomes were used to compute data.

6. Results (1) 10 studies were included. Only one study was an RCT.
The studies were of low quality with a high risk of bias. Only three studies were adjusted for confounders

7. Results (2)

8. Results (3)
No difference in the rate of live birth between women who underwent surgery for endometriomas before IVF/ICSI compared with conservative management.
No difference in the rate of clinical pregnancy.
No study that reported pain or quality of life for the two different interventions. Was found

9. Limitations Small number of included studies.
Different outcomes’ measures.
Differences in study design.
Low quality of the included studies.

10. Conclusion
There is no evidence in favor of surgical removal of endometriomas in women prior to ART if the indication is solely optimizing fertility.
On the contrary, surgery poses a risk of complications including adverse effects on ovarian reserve.
Physicians should take this into account when counseling their patients.
However, the quality of evidence is very low and high quality studies are needed.