Excisional surgery versus ablative surgery for ovarian endometriomata

Endometriomata are benign growths of the ovary. Evidence suggests that surgery to remove the endometrioma provides better results than draining and destroying the lining of the cyst with regard to the recurrence of the cyst, pain symptoms and also the chance of a spontaneous pregnancy in women who were previously subfertile. Surgery to excise the cyst should be the favoured surgical approach. Evidence that one technique is favoured in women who desire to conceive and who seek in vitro fertilization (IVF) treatment is however lacking. An additional randomised trial demonstrated that in women trying to conceive the ovarian response to stimulation, as part of fertility treatment, is better in women who have undergone surgery to remove the cyst rather than draining and destroying the endometrioma. The subsequent likelihood of pregnancy was not affected.

Further research is required in this field to assess quality of life after surgery, clarify the effect of surgery on fertility with IVF treatment and to study the effect of surgery on ovarian function.

Authors' conclusions: 

There is good evidence that excisional surgery for endometriomata provides a more favourable outcome than drainage and ablation with regard to the recurrence of the endometrioma, recurrence of pain symptoms, and subsequent spontaneous pregnancy in women who were previously subfertile. Consequently this approach should be the favoured surgical approach. However in women who may subsequently undergo fertility treatment, insufficient evidence exists to determine the favoured surgical approach.

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Background: 

Endometriomata are endometriotic deposits within the ovary. The surgical management of these blood filled cysts is controversial. The laparoscopic approach to the management of endometriomata is favoured over a laparotomy approach as it offers the advantage of a shorter hospital stay, faster patient recovery and decreased hospital costs. Currently the commonest procedures for the treatment of ovarian endometriomata are either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall.

Objectives: 

The objective of this review was to determine the most effective technique for treating an ovarian endometrioma, either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall, measuring the outcomes improvement in pain symptoms and fertility. The primary endpoints assessed were the relief of pain and, in women desiring to conceive, the subsequent pregnancy rate (either spontaneous or as part of fertility treatment). Secondary outcomes assessed were the recurrence of the endometrioma and the recurrence of symptoms.

Search strategy: 

The review authors searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of trials (to 31st August 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 3), MEDLINE (1966 to August 2009), EMBASE (1980 to August 2009) and reference lists of articles; and handsearched relevant journals and conference proceedings and contacted leaders in the field of endoscopic surgery throughout the world.The Cochrane Menstrual Disorders and Subfertility Group Specialised Register is based on regular searches of MEDLINE, EMBASE, CINHAL and CENTRAL.

Selection criteria: 

Randomised controlled trials of excision of the cyst capsule versus drainage and electrocoagulation of the cyst in the management of ovarian endometriomata.

Data collection and analysis: 

Review authors assessed eligibility and trial quality.

Main results: 

Two randomised studies of the laparoscopic management of ovarian endometriomata, size greater than 3 cm, for the primary symptom of pain were included. For the primary outcome measures laparoscopic excision of the cyst wall of the endometrioma was associated with a reduced recurrence rate of the symptoms of dysmenorrhoea (painful periods) (odds ratio (OR) 0.15, 95% CI 0.06 to 0.38), dyspareunia (OR 0.08, 95% CI 0.01 to 0.51) and non-menstrual pelvic pain (OR 0.10, 95% CI 0.02 to 0.56). In those women subsequently attempting to conceive excision of the cyst wall was also associated with a subsequent increased spontaneous pregnancy rate in women who had documented prior subfertility (OR 5.21, 95% CI 2.04 to13.29) compared to women who underwent laparoscopic ablation of the endometrioma. For the secondary outcome measures laparoscopic excision of the cyst wall was associated with a reduced rate of recurrence of the endometrioma (OR 0.41, 95% CI 0.18 to 0.93) and with a reduced requirement for further surgery (OR 0.21, 95% CI 0.05 to 0.79) compared with surgery to ablate the endometrioma. A further randomised study was identified that demonstrated an increased ovarian follicular response to gonadotrophin stimulation for women who had undergone excisional surgery when compared to ablative surgery (mean difference (MD) 0.6, 95% CI 0.04 to1.16). There is insufficient evidence to support excisional surgery over ablative surgery with respect to the chances of pregnancy after controlled ovarian stimulation and intra-uterine insemination (OR 1.40, 95% CI 0.47 to 4.15).

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