What are the key surgical considerations when treating ovarian endometriosis?

Highlights

• For patients with low ovarian reserve, consider fertility treatments like IVF or egg freezing before proceeding with endometriosis surgery.
• To preserve ovarian function, surgeons should minimize using heat or electrocautery on the ovary, opting for techniques like suturing.
• Completely stripping the endometrioma cyst wall is the standard of care, as this technique significantly lowers the risk of disease recurrence.
• In select cases of very low reserve, partial cyst removal with CO2 laser ablation is an alternative to complete stripping.
• Avoiding repeated ovarian surgeries and considering postoperative suppression are crucial to prevent recurrence and preserve long-term ovarian function.

Expert Insights

Preoperative Strategy: Balancing Fertility and Symptom Control

When managing ovarian endometriomas, the initial and most critical consideration is often the timing of surgery relative to fertility treatments. Experts agree that a thorough preoperative assessment of ovarian reserve is non-negotiable. For patients desiring fertility, the decision to proceed with surgery or assisted reproductive technology first is highly individualized. Dr. Zaraq Khan outlines a common clinical dilemma: "for a patient in her early 40s who will need IVF and has an endometrioma but an already low ovarian reserve, it is usually better to do IVF first: create embryos, freeze them, then perform surgery." This approach safeguards oocytes before a procedure that could further diminish ovarian reserve. Conversely, Dr. Khan notes that a younger patient with robust ovarian reserve and significant pain may benefit more from surgery first to improve quality of life before pursuing conception. Echoing this cautious approach, Dr. Jessica Opoku-Anane recommends considering egg freezing before surgery, particularly if ovarian reserve is low or the patient has undergone multiple previous ovarian procedures.

Intraoperative Principles for Ovarian Preservation

During surgery, the consensus among specialists is to employ meticulous techniques that prioritize the preservation of healthy ovarian tissue. A key principle is the aggressive avoidance of thermal energy on the ovarian cortex. "Avoid using energy sources or electrocautery on the ovarian bed when excising the cyst, because heat and electricity can further reduce ovarian reserve," advises Dr. Khan. Both he and Dr. Opoku-Anane advocate for suturing the ovary for hemostasis rather than using cautery. Dr. Antonio Gargiulo reinforces this, stating that "the opening of the ovary, hemostasis, and closing of the ovary are all done mechanically to avoid delayed thermal damage." Dr. Khan also suggests the use of vasopressin to reduce blood flow, facilitating cyst removal with minimal damage, and strongly cautions that an ovary should rarely be removed simply due to the size of an endometrioma. The inherent difficulty of the procedure is highlighted by Dr. Opoku-Anane, who notes that an endometrioma is often "sticky and hard to separate from normal ovarian tissue," increasing the risk of ovarian damage, especially in cases involving large cysts or bilateral disease.

"An ovary should not be removed simply because of the size of an endometrioma." Dr. Zaraq Khan

The Cystectomy Dilemma: Nuances in Surgical Technique

The standard-of-care technique for endometrioma is cystectomy, or "stripping" the cyst wall from the ovary. However, this procedure presents a clinical paradox. Dr. Antonio Gargiulo explains that while failing to strip the cyst leads to a much higher recurrence rate, the act of stripping itself can negatively impact ovarian reserve. This has led to the development of alternative or modified techniques for specific patient populations. For a patient with very low ovarian reserve who has had a prior cystectomy, Dr. Gargiulo discusses a modified approach: leaving 10–15% of the cyst wall at its deepest point and using CO2 laser superpulse ablation to destroy the remaining endometriotic lining. "The laser has very low depth of penetration, so it only superficially ablates tissue," he notes, a technique that has been shown not to decrease ovarian reserve. However, he cautions that the recurrence risk is likely higher and must be discussed with the patient. Dr. Gargiulo also mentions sclerotherapy—instilling alcohol into the cyst—as a niche procedure with variable results that may be considered in select cases.

"Whenever we do not completely strip the cyst, the patient has a higher chance of recurrence until proven otherwise." Dr. Antonio Gargiulo

Postoperative Management and Long-Term Considerations

Surgical intervention for ovarian endometriosis does not end with closure. A long-term management strategy is critical to prevent disease recurrence and preserve ovarian function. Dr. Zaraq Khan emphasizes the importance of postoperative ovarian suppression to reduce the likelihood of endometrioma recurrence. Perhaps most importantly, he stresses that "avoiding repeated ovarian surgeries is crucial, since multiple procedures can lead to premature ovarian insufficiency or failure." This underscores the need to perform the initial surgery with maximum efficacy and to follow it with a robust medical management plan, viewing the surgical procedure as one key component of a patient’s comprehensive, long-term care plan rather than a definitive cure.

"Avoiding repeated ovarian surgeries is crucial, since multiple procedures can lead to premature ovarian insufficiency or failure." Dr. Zaraq Khan