Early stage management of ovarian endometrioma to prevent infertility

Abstract

There are now convincing data showing that cystectomy of the endometrioma is not only no cure of infertility, but may harm follicle reserve. The question arises why is cystectomy for an endometrioma, in contrast with other -benign cysts, a risk for follicle reserve and how can ovarian damage be prevented. Surgical specimens of ovaries with endometrioma in situ show in the majority of cases manifestly a combined -extra-ovarian and intra-ovarian pathology with the cortex invaginated to form a pseudocyst. The extra-ovarian pathology includes endometrial lining of the cortex, bleeding and adhesions with surrounding tissues. The intra-ovarian pathology is characterized by microscopic stromal implants, fibrosis, smooth muscle metaplasia and -arteriosclerosis, all affecting follicle reserve in the endometrioma bed. Clinically, ovarioscopy allows differential diagnosis (e.g. luteal cyst) and evaluation of the degree of fibrosis and darkening of the cortical wall. Transvaginal colour Doppler sonography can demonstrate the presence and extent of devascularisation in the endometrioma bed. Given this reality, surgery should be based on evaluation of the pathology of the endometrioma bed, but not on the mere size of the chocolate cyst. The main clinical problem is indeed the delayed diagnosis and consequently advanced irreversible cortical damage. Therefore, the sooner endometriomas are diagnosed, the better, because it increases the chances that vascularisation of the endometrioma bed is preserved. Finally, ablation, but not excision is the treatment of choice. The diagnosis of endometriosis is traditionally based on laparoscopy, but in a sexually active adolescent transvaginal endoscopy can be proposed.

Keywords: Endometrioma; diagnosis; fertility; follicle reserve; surgery; vascularisation.

Fig. 1. THL provides a direct access to the fossa ovarica beneficial for minimal invasive diagnosis and treatment.

a: active and vascularized endometriotic lesion upon the ovarian surface and presence of vesicle on the parietal peritoneum. b: endometriosis with fixed adhesions of ovary with pelvic sidewall. c: invaginating ovarian cyst with endometrial like tissue and neo-angiogenesis. d: invaginated cyst after coagulation with bipolar probe; remark the white colour of the base of the cyst comparable with the ovarian surface.