WHEN AND HOW IS SURGERY REQUIRED FOR LARGE ENDOMETRIOMA PRIOR TO IN VITRO FERTILIZATION (IVF): A SURVEY OF PRACTICES.

Abstract

Introduction: Proper management of large endometriomas in patients scheduled for IVF continues to be a matter of debate. While small endometriomas are no longer an absolute indication for surgery, the large ones present unique challenges, potentially impacting ovarian response and follicle accessibility. This study aims to evaluate current practices among gynecologists in managing large endometriomas before IVF.

Methodology: An online survey with 18 questions was distributed to gynecologists through various professional societies. The survey addressed their clinical experience, type of practice, threshold size for surgery, surgical techniques used, hormonal treatment protocols, and the timing of ovarian stimulation post-surgery. Data were collected anonymously and analyzed using SPSS 29.0.2.0.

Results: Of the 111 respondents, 73% practiced in academic settings, and 61% had over 15 years of experience. Laparoscopic cystectomy was the most common procedure (48.2%). The median threshold size for surgery was 50 mm (IQR 40-60). Despite the same median threshold, surgeons performing laparoscopic surgery as their main clinical activity had a significantly different distribution of thresholds (IQR 40-60 vs. 47-89, p = 0.006), with a tendency to recommend surgery for smaller endometriomas. Techniques like CO2 laser ablation and plasma energy were less commonly used. Notably, 40.5% of participants indicated they would change their practice if a CO2 laser or plasma energy device were available in their surgical armamentarium. Most participants (67.9%) adjusted their strategy based on pre-operative AMH levels. The average timing for IVF stimulation post-surgery was 6 weeks(IQR 4-8) with no difference across different experiences.

Conclusion: Managing large endometriomas before IVF involves balancing surgical benefits with risks to ovarian reserve. The survey highlights significant variability in practices, with a median surgical threshold size of 50 mm. Laparoscopic cystectomy, while common, is associated with ovarian tissue loss, whereas emerging techniques like CO2 laser ablation show promise in preserving ovarian reserve. The need for up-to-date evidence-based guidelines is essential to standardize practices and optimize outcomes for IVF patients.