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The hormonal suppression of ovarian endometriomas larger than 1 cm is not effective; however, such suppression may improve the symptoms in 40% to 65% of the patients for a period of 6 to 12 months. Aspiration of endometriomas either by transvaginal or transabdominal ultrasound guidance or laparoscopy is no advisable as a first-line surgical treatment. These procedures are followed by a high recurrence rate (28% to 100%) within 1 to 9 months following the aspiration. Hormonal suppression before or after the aspiration does not affect the result. Laparoscopic fenestration and ablation of the endometriotic cyst wall either by laser or electrocautery is a better treatment than aspiration alone. This procedure can be done in a simple setting, eliminating the need for another operation. The symptomatic improvement rate after this procedure is 74% to 91%, the recurrence rate is 8% to 13%, and the pregnancy rate is 45% to 50%. Laparoscopic treatment of ovarian endometrioma by stripping the cyst wall from the remaining ovarian tissue seems to be the best surgical treatment. This procedure is technically more demanding than fenestration, but is associated with prolonged symptomatic improvement, a lower recurrence of pelvic pain, and a lower reoperation rate. The cumulative pregnancy rate is also higher than after fenestration only. The current studies conclude, first, that vaporization of the internal cyst wall does not impair ovarian function in terms of IVF parameters and outcome; second, that theoretical risks of loss of viable ovarian tissue during cystectomy exist but may be avoided by microsurgical laparoscopic technique, taking care to preserve the normal residual ovarian cortex; and, third that, after removal or destruction of endometriomas, IVF outcomes are similar in endometriosis patients when compared to women with tubal factor or idiopathic infertility.

Controversias en el manejo quirúrgico del endometrioma ovárico