DOI: 10.1111/tog.

12705 2021;23:28–37
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Does ovarian cystectomy pose a risk to ovarian reserve

and fertility?
Neerujah Balachandren iBSc MBBS MRCOG,a* Ephia Yasmin MBBS MD MRCOG,b
Dimitrios Mavrelos BA MBBS MD MRCOG,b Ertan Saridogan PhD FRCOGc
a
Specialty Registrar/Research Fellow in Reproductive Medicine, Reproductive Medicine Unit, University College London Hospital,
London NW1 2BU, UK
b
Consultant Obstetrician and Gynaecologist and Sub-Specialist in Reproductive Medicine and Surgery, Reproductive Medicine Unit,
University College London Hospital, London NW1 2BU, UK
c
Consultant in Reproductive Medicine and Minimal Access Surgery, Reproductive Medicine Unit, University College London Hospital,
London NW1 2BU, UK
*Correspondence: Neerujah Balachandren. Email: n.balachandren@nhs.net

Accepted on 6 April 2020. Published online 3 December 2020.

Key content Learning objectives

 The impact of benign ovarian cysts on a woman’s fertility is  To understand what factors need to be considered before making a
dependent on the nature, size, number, bilaterality and risk of decision to perform an ovarian cystectomy.
recurrence of the cyst(s).  To be aware of different surgical techniques and their impact on
 Children and adolescents presenting with pathological ovarian fertility outcomes.
cysts require a multidisciplinary team approach and, where  To take anatomical considerations into account to minimise
possible, fertility sparing treatment should be offered. damage to healthy ovarian tissue.
 Laparoscopic detorsion has the potential to preserve ovarian
Ethical issues
reserve and should remain the optimal treatment for ovarian  The UK’s National Health Service does not routinely fund oocyte
torsion in girls and premenopausal women.
 Surgery for bilateral endometriomas has been shown to increase
freezing for benign conditions.
the risk of developing premature ovarian insufficiency. Keywords: endometriomas / fertility / ovarian cystectomy / ovarian
 It is important to consider performing ovarian reserve assessments cysts / ovarian reserve assessments
before any ovarian surgery in women who have not completed
their family.

Please cite this paper as: Balachandren N, Yasmin E, Mavrelos D, Saridogan E. Does ovarian cystectomy pose a risk to ovarian reserve and fertility?
The Obstetrician & Gynaecologist 2021;23:28–37. https://doi.org/10.1111/tog.12705

Introduction Functional ovarian cysts and their effects

on fertility
Ovarian cystectomy is a common procedure for the
management of benign ovarian cysts in premenopausal The ovary has two main functions: folliculogenesis and
women.1,2 The procedure is usually performed to prevent steroidogenesis. The process of folliculogenesis – that is, the
cyst complications such as pain, rupture or torsion, or when progression of primordial follicles into large pre-ovulatory
there is concern of malignancy, while preserving fertility in follicles – makes the ovary intrinsically prone to developing
those of reproductive age.3 It is not, however, easy to functional cysts. Functional ovarian cysts have been described
determine the effect of the cyst or a cystectomy on a as nonpathological follicular cysts that failed to ovulate, a
woman’s future fertility. This will depend on specific persistent corpus luteum cyst, or other unspecified ovarian
characteristics of the cyst(s); for example, the nature, size, cysts measuring more than 20 mm in diameter.4 They are the
number, bilaterality and risk of recurrence.3 The scope of most common ovarian cysts in adults and children and
this Review article is to understand how these factors account for 46–53% of all adnexal pathologies.5 They almost
can affect the decision to perform a cystectomy, as well as always regress spontaneously within one to three menstrual
determine when and how a cystectomy can be performed cycles, so should not require any surgical or hormonal
to reduce the risk of damage to a woman’s reproduc- interventions.6 With the exception of luteal cysts and
tive potential. persistent functional cysts, functional ovarian cysts are

28 ª 2020 Royal College of Obstetricians and Gynaecologists

 Balachandren et al.

simply by-products of ovulation, so – in theory – they should regular vascular network similar to that of the normal
not have any effect on fertility. Luteal cysts are thought to ovarian cortex.17 One small study also looked at IVF
result from failure of the ovulatory follicle to rupture.7 The outcomes in six patients with dermoid cysts with a mean
unruptured follicle undergoes luteinisation under the action size of 2.4 cm and showed no difference in the number of
of luteinising hormone (LH); it still produces normal levels eggs collected.18 Overall, the presence of a dermoid cyst
of progesterone and has the same duration of luteal phase.8 appears to have very little or no effect on fertility. However,
Luteal cysts are observed in 10% of natural menstrual cycles dermoid cysts frequently occur bilaterally and have a
in fertile women, but are thought to occur more frequently in relatively high recurrence rate.1 These factors, along with
the infertile population.8 Qublan and colleagues8 found that their ability to grow to relatively large sizes, can lead to
luteal cysts occurred in 25% of intrauterine insemination repeated surgery, bilateral procedures and relatively large
(IUI) cycles in women with unexplained infertility. cystectomies; all of which can have an adverse effect on
Persistent functional cysts are sometimes seen in women fertility. One study showed a statistically significant reduction
undergoing controlled ovarian stimulation (COS), or in in AMH following surgery for cysts over 5 cm in diameter.19
those with extensive peri-ovarian adhesions. Women with Therefore, operating early, while the cyst is still small, may
low ovarian reserve and those on a gonadotrophin-releasing prevent the need for a large cystectomy and thus lower the
hormone agonist (GnRHa) cycle are at increased risk of effect on the ovarian reserve.
developing functional cysts.9 The incidence of persistent
functional cysts in those undergoing COS ranges between 8%
Endometriomas and their effects on
and 53%.10 The effect of functional cysts on in vitro
fertility
fertilisation (IVF) success remains contentious. Although
some studies suggest very poor outcome of cycles where Endometriomas, or ovarian endometriotic cysts, are reported
functional cysts were detected, including high cancellation, in 17–44% of women with endometriosis and are a marker of
decreased follicular recruitment and low pregnancy rates,11,12 more severe, deeper disease.20 Furthermore, 28% of
others have failed to report a difference in any outcome.13 endometriomas are bilateral.21 The risk of recurrence of
The first line of treatment is usually prolonged endometriomas in the same ovary or contralateral ovary
downregulation with either a progesterone-only pill or the following surgery is high, with cumulative rates of 12–30%
combined contraceptive pill and, as a last resort, ultrasound after 2–5 years of follow-up.22 Exacoustos and colleagues23
guided or laparoscopic drainage. reported that 81% had recurrence in the treated ovary, 11%
on the contralateral untreated ovary and 8% in both the
treated and untreated ovaries. Overall, most recurrence
Dermoid cysts and their effects on fertility
occurs in the treated ovary, suggesting that the recurring
A dermoid cyst is a benign type of germ cell tumour arising cysts seem to grow from residual loci.23 The mean monthly
from totipotent ovarian cells. They are the most common rate of growth of endometriomas following postoperative
pathological cysts in premenopausal women.14 They are recurrence was about 0.48 cm in those not using any
bilateral in 10–20% of cases and grow at a rate of 1.7–1.8 mm hormonal therapies.22
per year.3 The recurrence rate following cystectomy is The effects of endometriosis and endometriomas on
3–4%.14 Few studies have looked at the effects of dermoid fertility have been extensively studied. Overall, their
cysts on ovarian function and fertility, and none have shown presence has a detrimental effect. Several causes have been
a negative effect. Kim and colleagues15 compared the anti- implicated, including chronic inflammation affecting quality
m€ullerian hormone (AMH) levels in women with unilateral of oocytes and impaired ovarian function resulting in
and bilateral dermoid cysts with those of controls and found defective folliculogenesis and fertilisation; poor embryo
no significant difference. The mean size of the dermoid cysts quality secondary to an altered follicular environment,
in their study was 6.3  0.3 cm.15 Schubert and colleagues16 resulting in embryos with reduced implantation capacity;
histologically assessed the ovarian cortex surrounding poor ovarian reserve with a significant reduction in the
dermoid cysts, serous cysts and endometriomas taken at primordial follicle cohort secondary to fibrosis from
cystectomy. The follicular density was higher in dermoid increased tissue oxidative stress;24 and anatomical
cysts than in endometriotic and serous cysts. There was also a distortion and tubal damage or occlusion secondary to
clear limit between the dermoid cyst and the ovarian cortex, pelvic adhesions.
thus the ovarian cortex seemed to be stretched but not The evidence for poorer oocyte and embryo quality in
damaged by the dermoid cyst.16 Maneschi and colleagues17 patients with endometriosis and endometriomas remains
also studied the ovarian cortical tissue surrounding benign patchy and inconclusive; most studies have only evaluated
cysts removed at cystectomy. The cortical tissue surrounding this indirectly. Two such studies found higher rates of
dermoid cysts showed normal morphological patterns and a miscarriage in patients with endometriosis/endometriomas

ª 2020 Royal College of Obstetricians and Gynaecologists 29

 Ovarian cystectomy and fertility

than in healthy controls following spontaneous and at laparoscopy, persistent haemorrhagic cysts can be
conception.25,26 Sanchez and colleagues27 performed a mistaken for endometriomas, and diagnosis can only be
systematic review of the literature to evaluate the effect of confirmed by histology. Like other functional cysts,
endometriosis on oocyte quality from a clinical and haemorrhagic cysts are unlikely to have any effect on
biological perspective. They found that oocytes retrieved fertility, thus cystectomy for a haemorrhagic cyst is more
from women affected by endometriosis are more likely to fail likely to have an adverse effect.
in vitro maturation and showed altered morphology and a
lower cytoplasmic mitochondrial content than in women
Other benign ovarian cysts and their
with other causes of infertility.27 A meta-analysis of 36
effects on fertility
published studies involving women with all stages of
endometriosis found that clinical pregnancy rate was Ovarian cystadenomas are common benign epithelial
significantly lower for endometriosis patients (odds ratio neoplasms, of which serous and mucinous are two of the
[OR] 0.78; 95% confidence interval [CI] 0.65–0.94).28 most common types seen.36,37 Serous cystadenomas are more
Another meta-analysis showed live birth rates were not prevalent in menopausal women, while the mucinous type
statistically different, although women with endometriosis mainly occurs during the third to sixth decade.38 Mucinous
had lower clinical pregnancy rates.29 Similarly, a third meta- cystadenomas are usually unilateral, but they can grow large
analysis looking specifically at the effects of endometriomas in size – on average between 15 and 30 cm.39,40 To the best of
on IVF outcomes included 30 retrospective and three our knowledge, nothing has been reported in the literature
randomised controlled trials (RCTs). This analysis found about the effect of a mucinous cystadenoma on fertility.
similar live birth rates and clinical pregnancy rates, but a However, owing to the relatively large sizes of these cysts,
lower mean number of eggs retrieved and higher cancellation there is a greater chance of oophorectomy. In addition,
rates in women with endometriomas compared with surgical spill of mucinous material can lead to pelvic
no endometriomas.30 adhesions and subsequent infertility.
With regard to effects on ovarian reserve, two prospective
studies demonstrated lower AMH levels and antral follicle
Benign ovarian cysts in children and
counts (AFC) in women with endometriomas compared with
adolescents
age-matched controls.31,32 In a systematic review and meta-
analysis looking at the effect of surgery for endometriomas, Malignant ovarian cysts are uncommon in children and
pooled analysis of preoperative AFC showed that the mean adolescents. Despite this, oophorectomy is frequently
AFC for the ovary with the endometrioma was lower than performed in this age group. One study found that 75% of
that for the contralateral one (mean difference 2.79, 95% CI oophorectomies in children and adolescents had been carried
7.10 to 1.51), but statistical significance was not reached out for benign ovarian cysts.41 Functional ovarian cysts
(p = 0.20).33 On histological studies, Schubert et al.16 account for about 45% of all paediatric adnexal
showed that endometriotic cysts had lower follicular abnormalities5 and usually resolve spontaneously.
density than dermoid and serous cysts. Endometriotic cysts Teratomas constitute about half of all ovarian neoplasms in
also showed invasion of the surrounding cortex resulting in children42 and 1% of these are malignant immature
fibrosis and the surrounding cortical tissue had abnormal teratomas.43 Since laparoscopic cystectomy has become the
morphological patterns and irregular vascular networks.16,17 accepted practice for the management of mature cystic
Endometriomas were also thought to negatively affect teratomas in adults, the same approach should apply to
ovulation, with one study showing lower ovulation rates in children and adolescents.43 With greater use of preoperative
ovaries containing endometriomas greater than 10 mm in investigations, including pelvic imaging and tumour markers,
diameter compared with the healthy contralateral ovary.34 along with a multidisciplinary team approach and
However, more recently, Maggiore and colleagues35 conservative surgery, we should be able to better protect
conducted a larger prospective study involving 244 women, the future fertility of these young girls.
all of whom had a unilateral endometrioma greater than
20mm in diameter, and performed ultrasound monitoring
Ovarian torsion and its effect on fertility
for ovulation over six cycles. No difference was found in the
ovulation rates between the affected ovary and healthy ovary Ovarian torsion is a rare gynaecological emergency.
(50.3% versus 49.7%, p = 0.919).34 Approximately 3% of all emergency gynaecological
A haemorrhagic cyst is the result of bleeding into a surgeries are for ovarian torsion.44,45 One study conducted
follicular or corpus luteum cyst. Like other functional cysts, over a 24-month period found the cumulative incidence of
most will resolve spontaneously, but occasionally they can ovarian torsion in women with ovarian tumours was 0.3%.46
become trapped by pelvic adhesions. On ultrasound imaging Torsion usually involves the ovary and fallopian tube and is

30 ª 2020 Royal College of Obstetricians and Gynaecologists

 Balachandren et al.

more commonly seen with benign cysts greater than 5 cm did not show morphological characteristics seen in normal
in diameter.45 ovarian tissue.35
Conservative management, which involves laparoscopic Several other studies have also demonstrated a reduction
unwinding of the twisted ovary, is the treatment of choice in in the ovarian reserve following cystectomy for
prepubescent girls and women of reproductive age, endometriomas. The literature includes a meta-analysis of
regardless of the colour of the ovary at the time of seven published studies, which showed a 30% decrease in
surgery.47,48 When an ovary undergoes torsion and postoperative AMH levels, and a systematic review also
detorsion, it results in haemorrhage, congestion and demonstrating a decline in ovarian reserve following
apoptosis secondary to ischaemia, which can affect the surgery.3,53,54 Two prospective longitudinal studies showed
ovarian reserve.49 One retrospective study found that partial recovery of AMH levels 3 months after surgery to
detorsion of the ischaemic ovary preserved ovarian about 65% of the preoperative level in both endometriotic
function in 91.3% of patients; this was demonstrated by and non-endometriotic cysts.55,56 Similar findings of reduced
follicular development on ultrasound, normal ovary at ovarian reserve were seen in studies assessing ovarian reserve
subsequent laparotomy for other indications and successful following cystectomy for non-endometriotic cysts, primarily
fertilisation of oocytes retrieved from the ischaemic ovary dermoid cysts.55,57,58
following controlled ovarian stimulation.50 To our In contrast, Muzii et al.33 analysed data from 13
knowledge, only one study has assessed ovarian reserve publications reporting AFC levels before and after
post-detorsion and found no difference in the AFC between endometrioma surgery. They showed that ovarian reserve,
the affected and contralateral ovary 3 months after surgery.49 as assessed by AFC, did not change significantly. The
Similarly, they found no difference in the AMH level differences between the changes of these two surrogate
taken preoperatively on the day of detorsion and at 1 and markers (AMH and AFC) can probably be explained by the
3 months postoperatively.49 Thus, compared with fact that AFC assessment is likely to be less reliable in the
oophorectomy, laparoscopic detorsion has the potential to presence of endometriomas and that the preoperative AFC
preserve the ovarian reserve and should remain the optimal underestimates the value; this may then obscure the
treatment in girls and premenopausal women. In cases where postoperative reduction in AFC.59
torsion has occurred in the presence of an ovarian cyst, an The size of the cyst being removed is another important
elective cystectomy 2–3 weeks later is advised to allow time factor when determining the effect on ovarian reserve and
for the congestion and oedema to resolve.51 future fertility. Using histological measurements of
endometrioma cystectomy specimens, Roman et al.60 found
an average loss of 200 µm of ovarian tissue per centimetre
Ovarian cystectomy and its effect on
increase in endometrioma diameter. Several other studies
ovarian reserve
also demonstrated a more significant decline in ovarian
There are several ways to perform ovarian cystectomy, but, in reserve following removal of endometriomas greater than 5–
principle, it involves incising the ovarian cortex to identify 7 cm in diameter.32,61,62 There is also a higher risk of
the cyst capsule, removing the cyst wall, with or without oophorectomy when performing large cystectomies.
draining the cyst, and finally applying haemostatic Clinicians frequently advise patients to delay surgery until a
measures.20 The size and nature of the cyst being removed, cyst reaches a particular size, when there is a significant risk
bilaterality and/or repeated surgery, method of cystectomy, of ovarian torsion. It may be wiser to proceed with surgery
method of haemostasis and – of course – the skill and when the cyst is small; especially in those with mucinous
experience of the surgeon are all important factors that will cystadenomas, which have a propensity to grow into
determine how much of an effect, if any, the cystectomy will large cysts.63
have on the ovarian reserve. Bilateral cystectomy can also lead to a greater decline in the
Stripping and removing the cyst wall and the thermal ovarian reserve than with unilateral surgery.3,64 In particular,
damage provoked by coagulation can lead to loss of healthy women having surgery for bilateral endometriomas have
ovarian tissue and subsequent reduction in the follicle been shown to have an increased risk of developing
density. Muzii et al.52 histologically analysed excised premature ovarian insufficiency.21,65
specimens following laparoscopic excision of ovarian cysts
using the stripping technique. The primary outcome in this
Ovarian cystectomy and spontaneous
study was to evaluate the presence and nature of ovarian
conception
tissue adjacent to the cyst wall. Fifty-four percent of ovarian
tissue was inadvertently excised along with the cyst wall in Higher rates of spontaneous conception have been shown in
those with endometriotic cysts, compared with 6% in those infertile women who had surgical treatment for
with non-endometriotic cysts.35 The excised ovarian tissue endometriomas.66 Maggiore and colleagues35 looked at

ª 2020 Royal College of Obstetricians and Gynaecologists 31

 Ovarian cystectomy and fertility

spontaneous pregnancy rates of women who tried to conceive

Table 1. Clinical variables to be considered when deciding whether or
spontaneously for 1 year, with known rectovaginal not to perform surgery in women with endometriomas selected for IVF
endometriosis with or without endometriomas and treated
with expectant or surgical management. The crude and Favours Favours expectant
Characteristics surgery management
cumulative spontaneous pregnancy rate was higher in those
treated surgically (30.4% and 34.5% versus 11.7% and 18.0%,
respectively).35 It must be emphasised that these data apply Previous interventions for None ≥1
to women with a history of infertility; it would be difficult to endometriosis
recommend routine surgical treatment of endometriomas to
Ovarian reservea Intact Damaged
improve chances of spontaneous conception in those without
proven infertility. Even in the infertile woman with an Pain symptoms Present Absent
endometrioma, the potential benefit of improving her
Bilaterality Monolateral Bilateral disease
chances of spontaneous conception through surgical
disease
management must be balanced with the risk of reducing
her ovarian reserve and worsening the pelvic anatomy. The Sonographic feature of Present Absent
European Society of Human Reproduction and Embryology malignancyb
(ESHRE) Guideline Group for the management of women
Growth Rapid growth Stable
with endometriosis recommends clinicians to counsel
women about the risk of a reduction in the ovarian reserve, a
Ovarian reserve is estimated based on serum markers or previous
along with the possible loss of the entire ovary – in particular hyperstimulation cycles. bSonographic feature of malignancy refers
for those who have had previous ovarian surgery.66 to solid components, locularity, echogeniety, regularity of shape,
wall, septa, location and presence of peritoneal fluid. Republished
with permission.70
Ovarian cystectomy and IVF outcomes
Cystectomy for endometriomas prior to IVF treatment is not
routinely recommended because it has not been shown to better preservation of ovarian reserve when using laser
improve IVF outcomes.67 A Cochrane review assessed the ablation or plasma energy rather than cystectomy,72–74
effectiveness of surgery versus no treatment for women with although recurrence rates at 1 year post-laser ablation
an endometrioma prior to undergoing assisted reproductive were higher.75
technology (ART).67 They included two trials comparing Following cystectomy, haemostasis can be achieved using
surgery (aspiration and cystectomy) with expectant diathermy, suturing or haemostatic sealants. A systematic
management and found no evidence of benefit for clinical review and meta-analysis of 12 published controlled trials
pregnancy rates.68,69 In fact, one study showed a decreased showed that laparoscopic suturing was superior to bipolar
ovarian response to gonadotrophins following cystectomy coagulation when comparing AMH and AFC – even
for endometriomas.68 12 months after surgery.76 When comparing bipolar with
Surgery should be considered under some clinical haemostatic sealants, the results favoured the use of
circumstances. Garcia-Velasco and Somigliana70 created the haemostatic agents.76
following table (Table 1) to help guide clinicians on the
clinical variables to be considered when deciding whether or
Recommendations for ovarian cystectomy
not to perform surgery in women with endometriomas
selected for IVF. 1. Perform ovarian reserve assessments
For women who have not completed their family, ovarian
reserve assessments should be carried out before any
Effect of surgical technique on fertility
cystectomy in the following situations:
outcomes
 those requiring repeat surgery on the same or
Apart from cyst excision, several other surgical techniques contralateral ovary
exist, including drainage and bipolar coagulation or ablation  women diagnosed with severe endometriosis and
using plasma or laser energy. A systematic review of two bilateral endometriomas
RCTs revealed cystectomy to be superior to drainage and  those with coexistent aetiologies for subfertility, including
bipolar coagulation in terms of spontaneous pregnancy rates, low sperm parameters in the male partner
lower risk of recurrence and pain symptoms among subfertile  women of advanced reproductive age
patients with endometriomas greater than 3 cm in  women with coexistent risk factors for premature
diameter.71 Several comparative studies have also showed ovarian insufficiency.

32 ª 2020 Royal College of Obstetricians and Gynaecologists

 Balachandren et al.

These patients are more likely to need ART to help them in the Pouch of Douglas, which can be difficult to visualise
conceive in the future and/or are at increased risk of on ultrasound.
premature ovarian failure. Ovarian cystectomy can reduce a
woman’s ovarian reserve, which can hinder the chance of 4. Obtain appropriate consent
success with IVF treatment.77 The patient should be fully informed of all possible risks
Ovarian reserve assessments provide an indirect measure associated with the surgical procedure, including reduction
of oocyte quantity but are poor predictors of oocyte quality78 in ovarian reserve and risk of oophorectomy.
and should not be used to predict spontaneous conception in
ovulatory couples.79 The accuracy of ovarian reserve 5. Refer the woman to a centre of expertise
assessments in the presence of ovarian cysts has not been If the surgery cannot be performed or completed safely, the
well studied. AFC and serum AMH have been shown to be patient should be referred to a centre of expertise.
lower in the presence of endometriomas, but they did not
appear to be affected by the presence of other types of
Anatomical consideration during
cysts.31,32,80 The reduced AFC associated with
cystectomy
endometriomas could be associated with an inability to
visualise the antral follicles on ultrasound scan in the The ovary receives its blood supply from two sources: the
presence of an endometrioma.81 This theory is further ovarian artery and an anastomosis between the ovarian artery
supported by Lima et al.,82 who analysed the number of and the ascending branch of the uterine artery/tubal artery.
oocytes retrieved during IVF or intracytoplasmic sperm The ovarian artery approaches the ovary through the
injection (ICSI) cycles in women with a unilateral infundibulopelvic ligament, while the uterine/tubal artery is
endometrioma. Although the AFC was reduced in the found within the ovarian ligament. These intra-ovarian
ovaries with an endometrioma, the median number of vessels are found in the anterolateral aspect of the ovary, at
oocytes retrieved was similar (p = 0.60) between ovaries with the insertion of the mesovarium.
an endometrioma (2.0; interquartile range [IQR] 0.5–5.0)
and the contralateral ovaries (2.0; IQR 0.0–4.0).73
Surgical recommendations
2. Discuss fertility preservation options Non-endometriotic cysts
If the ovarian reserve is already compromised or there is a 1. Make an incision on the anti-mesenteric surface of ovarian
considerable risk of premature ovarian insufficiency, fertility cortex (Figure 1a).
preservation should be discussed prior to cystectomy. For 2. Identify the plane between the cyst wall and the ovarian
postpubertal females, egg or embryo storage following cortex; develop this plane further (Figure 1b).
ovarian stimulation is an established technique that allows 3. Enucleate the cyst or cyst wall (if the contents are spilled
subsequent IVF and embryo transfer.83 However, ovarian or aspirated) by a combination of blunt and sharp
stimulation may be unsuccessful if the ovarian reserve is dissection, traction and countertraction.
already compromised. The disadvantages of fertility 4. Achieve haemostasis by targeted coagulation of blood
preservation before cystectomy include delay in surgery, vessels (Figure 1c) or suturing (Figure 1d). Avoid
visceral injury during egg collection, pelvic infection indiscriminate use of diathermy and consider using
from accidental puncture of the cyst84 and a theoretical haemostatic sealants instead of excessive diathermy.
increase in the risk of torsion of the hyperstimulated
ovary. Endometriotic cysts
In the UK, NHS funding is not routinely available for The European Society of Gastrointestinal Endoscopy (ESGE)/
oocyte or embryo cryopreservation for benign conditions. ESHRE/World Endometriosis Society (WES) Working Party
However, if there is a considerable risk of permanent on the surgical techniques for ovarian endometriomas
infertility, such as previous oophorectomy or repeat surgery recommends the following approaches:18
for severe endometriosis, individual funding requests can be 1. Mobilise the ovary and drain the cyst (Figure 2a and 2b).
made to the relevant clinical commissioning group. 2. Make an incision to reveal the cleavage plane (Figure 2c),
either on the edge of the cyst opening or a central incision,
3. Perform pelvic ultrasound scan and a bimanual which divides the cyst into two halves. Incision should be
examination away from the blood vessels in the hilum/mesovarium.
Assess the type, size, number and location (unilateral or Use of cold cut at the edge of the cyst opening may assist
bilateral) of the ovarian cysts before surgery using pelvic in identifying the cleavage plane.
ultrasound and bimanual examination. Bimanual 3. To aid dissection and identification of the cyst wall, saline
examination can help identify deep endometriotic nodules or diluted synthetic vasopressin (0.1–1 unit/ml) may be

ª 2020 Royal College of Obstetricians and Gynaecologists 33

 Ovarian cystectomy and fertility

(a) (b)

(c) (d)

Figure 1. Ovarian cystectomy. (a) Reveal cleavage plane. (b) Dissect the cyst wall from the ovarian parenchyma. (c,d) Achieve haemostasis by
targeted coagulation and/or suturing and then reconstruct the ovary.

(a) (b)

(c) (d)

(e) (f)

(g)

Figure 2. Ovarian cystectomy of an endometrioma. (a) Right ovarian endometrioma and adherent right ovary. (b) Drainage of endometrioma
after mobilising the ovary. (c) Exposure of the plan between the cyst wall and ovarian cortex. (d) Vasopressin injection under the cyst capsule. (e)
Dissect cyst capsule from the ovarian parenchyma. (f) Cyst capsule after complete removal. (g) Precise spot bipolar diathermy to achieve
haemostasis.

34 ª 2020 Royal College of Obstetricians and Gynaecologists

 Balachandren et al.

injected under the cyst capsule (Figure 2d). This has the ART in the future, including the male partner’s sperm
additional advantage of reducing bleeding during parameters.3
cyst removal. Performing ovarian reserve assessments would be
4. Once the cleavage plane is identified, use gentle traction recommended in all women having repeated surgery on the
and countertraction to dissect the cyst capsule from the ovaries, as well as in those with severe endometriosis, or if
ovarian parenchyma (Figure 2e and 2f). Avoid excessive there is a high chance of needing ART to conceive. Regardless
force to separate a highly adherent cyst from the ovary. of whether or not a cystectomy is performed, it is imperative
This is likely to tear the ovarian tissue, causing excessive that the risk to fertility and ovarian function is discussed with
bleeding and the need for coagulation or diathermy, which all patients. The lack of routine NHS funding for oocyte
will further damage normal ovarian tissue. cryopreservation for benign conditions should not deter
5. Precise spot bipolar coagulation will prevent unnecessary clinicians from discussing fertility preservation options when
damage to healthy tissue and avoids blind or excessive there is a significant risk of injury to a woman’s
diathermy (Figure 2g). reproductive potential.
6. Ensure final haemostasis after complete removal of the
cyst capsule. Bipolar coagulation, suturing or intra- Disclosure of interests
ovarian haemostatic sealant agents may also be used for EY is an Associate Editor of The Obstetrician & Gynaecologist;
this purpose. It is important to avoid damaging the major she was excluded from editorial discussions regarding the
blood supply at the hilum coming in from the ovarian and paper and had no involvement in the decision to publish.
infundibulopelvic ligaments at this stage.
7. After removal of large cysts, reconstruct the ovary and Contribution to authorship
achieve haemostasis with monofilament sutures. For small NB and ES conceived the topic. NB planned the scope of the
cysts, suturing is often not required because the ovarian article, researched and wrote the initial draft. EY, DM and ES
opening usually approximates spontaneously. If a suture is reviewed and revised the manuscript. All authors approved
used, it should ideally be placed inside the ovary, as the the final version.
exposed suture may be prone to adhesion formation.

References
Two-step approach for large
1 Westhoff C, Clark CJ. Benign ovarian cysts in England and Wales and in the
endometriomas United States. Br J Obstet Gynaecol 1992;99:329–32.
After opening and draining the endometrioma as described 2 Mimoun C, Fritel X, Fauconnier A, Deffieux X, Dumont A, Huchon C.
Epidemiology of presumed benign ovarian tumors. J Gynecol Obstet Biol
previously, the cyst wall is inspected and a biopsy taken. Reprod (Paris) 2013;42:722–9.
GnRHa therapy is then given for 3 months to reduce the 3 Legendre G, Catala L, Moriniere C, Lacoeuille C, Boussion F, Sentilhes L, et al.
Relationship between ovarian cysts and infertility: what surgery and when?
thickness of the cyst wall through atrophy and reduction in
Fertil Steril 2014;101:608–14.
stromal vascularisation.85 The surgery is completed with a 4 Baerwald AR, Pierson RA. Ovarian follicular development during the use of
second laparoscopy in the form of cystectomy, CO2 oral contraception: a review. J Obstet Gynaecol Can 2004;26:19–24.
5 Spinelli C, Di Giacomo M, Cei M, Mucci N. Functional ovarian lesions in
vaporisation, bipolar diathermy or plasma ablation of the
children and adolescents: when to remove them. Gynecol Endocrinol
cyst wall lining.20 Although women have to undergo two 2009;2:294–8.
invasive procedures, the potential benefit is that this may 6 Grimes DA, Jones LB, Lopez LM, Schulz KF. Oral contraceptives for functional
facilitate the management of larger ovarian endometriomas, ovarian cysts. Cochrane Database Syst Rev 2014;(4):CD006134.
7 Vermesh M, Kletzky OA, Davajan V, Israel R. Monitoring techniques to
reduce recurrence rates and limit the damage to the predict and detect ovulation. Fertil Steril 1987;47:259–64.
ovarian reserve.20 8 Qublan H, Amarin Z, Nawasreh M, Diab F, Malkawi S, Al–Ahmad N, et al.
Luteinized unruptured follicle syndrome: incidence and recurrence rate in
infertile women with unexplained infertility undergoing intrauterine
Conclusion insemination. Hum Reprod 2006;21:2110–3.
9 Keltz MD, Jones EE, Duleba AJ, Polcz T, Kennedy K, Olive DL. Baseline cyst
formation after luteal phase gonadotropin-releasing hormone agonist
The management of benign ovarian cysts in women of
administration is linked to poor in vitro fertilization outcome. Fertil Steril
reproductive age, children and adolescents is complex. Those 1995;64:568–72.
experiencing considerable pain related to the cyst and who 10 Qublan HS, Amarin Z, Tahat YA, Smadi AZ, Kilani M. Ovarian cyst formation
are unsuitable for hormonal therapy will often require following GnRH agonist administration in IVF cycles: incidence and impact.
Hum Reprod 2006;21:640–4.
surgery. Before an ovarian cystectomy, the surgeon should 11 Keltz MD, Jones EE, Duleba AJ, Polcz T, Kennedy K, Olive DL. Baseline cyst
carefully consider the age of the patient, the nature of the formation after luteal phase gonadotropin-releasing hormone agonist
administration is linked to poor in vitro fertilization outcome. Fertil Steril
cyst, rate of growth, risk of recurrence, surgical history and
1995;64:568–72.
future fertility plans. They should also assess other causes of 12 Biljan MM, Lapensee L, Mahutte NG, Bissonnette F, Hemmings R, Tan SL.
subfertility that would increase the likelihood of needing Effects of functional ovarian cysts detected on the 7th day of gonadotropin-

ª 2020 Royal College of Obstetricians and Gynaecologists 35

 Ovarian cystectomy and fertility

releasing hormone analog administration on the outcome of IVF treatment. 34 Benaglia L, Somigliana E, Vercellini P, Abbiati A, Ragni G, Fedele L.
Fertil Steril 2000;74:941–5. Endometriotic ovarian cysts negatively affect the rate of spontaneous
13 Sampaio M, Serra V, Miro F, Calatayud C, Castellvi RM, Pellicer A. ovulation. Hum Reprod 2009;24:2183–6.
Development of ovarian cysts during gonadotrophin releasing hormone 35 Leone Roberti Maggiore U, Scala C, Tafi E, Racca A, Biscaldi E, Vellone VG,
agonists (GnRHa) administration. Hum Reprod 1991;6:194–7. et al. Spontaneous fertility after expectant or surgical management of
14 O’Neill KE, Cooper AR. The approach to ovarian dermoids in adolescents rectovaginal endometriosis in women with or without ovarian
and young women. J Pediatr Adolesc Gynecol 2011;24:176–80. endometrioma: a retrospective analysis. Fertil Steril 2017;107:969–76.e5.
15 Kim JY, Jee BC, Suh CS, Kim SH. Preoperative serum anti-mullerian hormone 36 Seidman JD, Mehrotra A. Benign ovarian serous tumors: a re-evaluation and
level in women with ovarian endometrioma and mature cystic teratoma. proposed reclassification of serous “cystadenomas” and
Yonsei Med J 2013;54:921–6. “cystadenofibromas”. Gynecol Oncol 2005;96:395–401.
16 Schubert B, Canis M, Darcha C, Artonne C, Pouly J-L, Dechelotte P, et al. 37 El-Agwany AS. Recurrent bilateral mucinous cystadenoma: laparoscopic
Human ovarian tissue from cortex surrounding benign cysts: a model to ovarian cystectomy with review of literature. Indian J Surg Oncol
study ovarian tissue cryopreservation. Hum Reprod 2005;20:1786–92. 2018;9:146–9.
17 Maneschi F, Marasa L, Incandela S, Mazzarese M, Zupi E. Ovarian cortex 38 Saba L, Acharya UR, Guerriero S, Suri JS, editors. Ovarian neoplasm imaging.
surrounding benign neoplasms: a histologic study. Am J Obstet Gynecol New York, NY: Springer US; 2014.
1993;169:388–93. 39 Cowan RA, Haber EN, Faucz FR, Stratakis CA, Gomez-Lobo V. Mucinous
18 Caspi B, Weissman A, Zalel Y, Barash A, Tulandi T, Shoham Z. Ovarian cystadenoma in children and adolescents. J Pediatr Adolesc Gynecol
stimulation and in vitro fertilization in women with mature cystic teratomas. 2017;30:495–8.
Obstet Gynecol 1998;92:979–81. 40 Posabella A, Galetti K, Engelberger S, Giovannacci L, Gyr T, Rosso R. A huge
19 Henes M, Engler T, Taran F-A, Brucker S, Rall K, Janz B, et al. Ovarian cyst mucinous cystadenoma of ovarian: a rare case report and review of the
removal influences ovarian reserve dependent on histology, size and type of literature. Rare Tumors 2014;6:5225.
operation. Womens Health (Lond) 2018;14:1745506518778992. 41 Hernon M, McKenna J, Busby G, Sanders C, Garden A. The histology and
20 Saridogan E, Becker CM, Feki A, Grimbizis GF, Hummelshoj L, Keckstein J, management of ovarian cysts found in children and adolescents presenting
et al. Recommendations for the surgical treatment of endometriosis-part 1: to a children’s hospital from 1991 to 2007: a call for more paediatric
ovarian endometrioma. Gynecol Surg 2017;14:27. gynaecologists. BJOG 2010;117:181–4.
21 Coccia ME, Rizzello F, Mariani G, Bulletti C, Palagiano A, Scarselli G. Ovarian 42 Azizkhan RG, Caty MG. Teratomas in childhood. Curr Opin Pediatr
surgery for bilateral endometriomas influences age at menopause. Hum 1996;8:287–92.
Reprod 2011;26:3000–7. 43 Templeman CL, Hertweck SP, Scheetz JP, Perlman SE, Fallat ME. The
22 Seracchioli R, Mabrouk M, Frasca C, Manuzzi L, Montanari G, Keramyda A, management of mature cystic teratomas in children and adolescents: a
et al. Long-term cyclic and continuous oral contraceptive therapy and retrospective analysis. Hum Reprod 2000;15:2669–72.
endometrioma recurrence: a randomized controlled trial. Fertil Steril 44 Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 1985;152:456–61.
2010;93:52–6. 45 Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med
23 Exacoustos C, Zupi E, Amadio A, Amoroso C, Szabolcs B, Romanini ME, 2001;38:156–9.
et al. Recurrence of endometriomas after laparoscopic removal: sonographic 46 Froyman W, Landolfo C, De Cock B, Wynants L, Sladkevicius P, Testa AC,
and clinical follow-up and indication for second surgery. J Minim Invasive et al. Risk of complications in patients with conservatively managed ovarian
Gynecol 2006;13:281–8. tumours (IOTA5): a 2-year interim analysis of a multicentre, prospective,
24 The effect of surgery for endometriomas on fertility: Scientific Impact Paper cohort study. Lancet Oncol 2019;20:448–58.
No. 55. BJOG 2018;125:e19–28. 47 Damigos E, Johns J, Ross J. An update on the diagnosis and management of
25 Hjordt Hansen MV, Dalsgaard T, Hartwell D, Skovlund CW, Lidegaard O. ovarian torsion. Obstet Gynaecol 2012;14:229–36.
Reproductive prognosis in endometriosis. A national cohort study. Acta 48 Ben-Rafael Z, Bider D, Mashiach S. Laparoscopic unwinding of twisted
Obstet Gynecol Scand 2014;93:483–9. ischemic hemorrhagic adnexum after in vitro fertilization. Fertil Steril
26 Vercellini P, Parazzini F, Pietropaolo G, Cipriani S, Frattaruolo MP, Fedele 1990;53:569–71.
L. Pregnancy outcome in women with peritoneal, ovarian and 49 Yasa C, Dural O, Bastu E, Zorlu M, Demir O, Ugurlucan FG. Impact of
rectovaginal endometriosis: a retrospective cohort study. BJOG laparoscopic ovarian detorsion on ovarian reserve. J Obstet Gynaecol Res
2012;119:1538–43. 2017;43:298–302.
27 Sanchez AM, Vanni VS, Bartiromo L, Papaleo E, Zilberberg E, Candiani M, 50 Oelsner G, Cohen SB, Soriano D, Admon D, Mashiach S, Carp H. Minimal
et al. Is the oocyte quality affected by endometriosis? A review of the surgery for the twisted ischaemic adnexa can preserve ovarian function.
literature. J Ovarian Res 2017;10:43. Hum Reprod 2003;18:2599–602.
28 Hamdan M, Dunselman G, Li TC, Cheong Y. The impact of endometrioma 51 Oelsner G, Shashar D. Adnexal torsion. Clin Obstet Gynecol
on IVF/ICSI outcomes: a systematic review and meta-analysis. Hum Reprod 2006;49:459–63.
Update 2015;21:809–25. 52 Muzii L, Bianchi A, Croce C, Manci N, Panici PB. Laparoscopic excision of
29 Harb HM, Gallos ID, Chu J, Harb M, Coomarasamy A. The effect of ovarian cysts: is the stripping technique a tissue-sparing procedure? Fertil
endometriosis on in vitro fertilisation outcome: a systematic review and Steril 2002;77:609–14.
meta-analysis. BJOG 2013;120:1308–20. 53 Raffi F, Metwally M, Amer S. The impact of excision of ovarian
30 Hamdan M, Omar SZ, Dunselman G, Cheong Y. Influence of endometriosis endometrioma on ovarian reserve: a systematic review and meta-analysis.
on assisted reproductive technology outcomes: a systematic review and J Clin Endocrinol Metab 2012;97:3146–54.
meta-analysis. Obstet Gynecol 2015;125:79–88. 54 Somigliana E, Berlanda N, Benaglia L, Vigano P, Vercellini P, Fedele L.
31 Uncu G, Kasapoglu I, Ozerkan K, Seyhan A, Oral Yilmaztepe A, Ata B. Surgical excision of endometriomas and ovarian reserve: a systematic review
Prospective assessment of the impact of endometriomas and their removal on serum antimullerian hormone level modifications. Fertil Steril
on ovarian reserve and determinants of the rate of decline in ovarian reserve. 2012;98:1531–8.
Hum Reprod 2013;28:2140–5. 55 Chang HJ, Han SH, Lee JR, Jee BC, Lee BI, Suh CS, et al. Impact of
32 Chen Y, Pei H, Chang Y, Chen M, Wang H, Xie H, et al. The impact of laparoscopic cystectomy on ovarian reserve: serial changes of serum anti-
endometrioma and laparoscopic cystectomy on ovarian reserve and the Mullerian hormone levels. Fertil Steril 2010;94:343–9.
exploration of related factors assessed by serum anti-Mullerian hormone: a 56 Amooee S, Gharib M, Ravanfar P. Comparison of anti-mullerian hormone
prospective cohort study. J Ovarian Res 2014;7:108. level in non-endometriotic benign ovarian cyst before and after laparoscopic
33 Muzii L, Di Tucci C, Di Feliciantonio M, Marchetti C, Perniola G, Panici PB. cystectomy. Iran J Reprod Med 2015;13:149–54.
The effect of surgery for endometrioma on ovarian reserve evaluated by 57 Somigliana E, Ragni G, Infantino M, Benedetti F, Arnoldi M, Crosignani PG.
antral follicle count: a systematic review and meta-analysis. Hum Reprod Does laparoscopic removal of nonendometriotic benign ovarian cysts affect
2014;29:2190–8. ovarian reserve? Acta Obstet Gynecol Scand 2006;85:74–7.

36 ª 2020 Royal College of Obstetricians and Gynaecologists

 Balachandren et al.

58 Sarmadi S, Ahmadi FS, Ejtemaei Mehr S, Ghaseminejad A, Mohammad K, 72 Tsolakidis D, Pados G, Vavilis D, Athanatos D, Tsalikis T, Giannakou A, et al.
Nekuie S, et al. Histopathologic and sonographic analysis of laparoscopic The impact on ovarian reserve after laparoscopic ovarian cystectomy versus
removal ovarian nonendometriotic cyst: the evaluating effects on ovarian three-stage management in patients with endometriomas: a prospective
reserve. Acta Med Iran 2014;52:341–4. randomized study. Fertil Steril 2010;94:71–7.
59 Ata B, Urman B. Endometrioma excision and ovarian reserve; do 73 Candiani M, Ottolina J, Posadzka E, Ferrari S, Castellano LM, Tandoi I, et al.
assessments by antral follicle count and anti-Mullerian hormone yield Assessment of ovarian reserve after cystectomy versus ’one-step’ laser
contradictory results? Hum Reprod 2014;29:2852–4. vaporization in the treatment of ovarian endometrioma: a small randomized
60 Roman H, Tarta O, Pura I, Opris I, Bourdel N, Marpeau L, et al. Direct clinical trial. Hum Reprod 2018;33:2205–11.
proportional relationship between endometrioma size and ovarian 74 Roman H, Auber M, Mokdad C, Martin C, Diguet A, Marpeau L, et al.
parenchyma inadvertently removed during cystectomy, and its implication Ovarian endometrioma ablation using plasma energy versus cystectomy:
on the management of enlarged endometriomas. Hum Reprod a step toward better preservation of the ovarian parenchyma in women
2010;25:1428–32. wishing to conceive. Fertil Steril 2011;96:1396–400.
61 Henes M, Engler T, Taran FA, Brucker S, Rall K, Janz B, et al. Ovarian cyst 75 Carmona F, Martinez-Zamora MA, Rabanal A, Martinez-Roman S, Balasch J.
removal influences ovarian reserve dependent on histology, size and type of Ovarian cystectomy versus laser vaporization in the treatment of ovarian
operation. Womens Health (Lond) 2018;14:1745506518778992. endometriomas: a randomized clinical trial with a five-year follow-up. Fertil
62 Mehdizadeh Kashi A, Chaichian S, Ariana S, Fazaeli M, Moradi Y, Rashidi M, Steril 2011;96:251–4.
et al. The impact of laparoscopic cystectomy on ovarian reserve in patients 76 Baracat CMF, Abdalla-Ribeiro HSA, Araujo R, Bernando WM, Ribeiro PA. The
with unilateral and bilateral endometrioma. Int J Gynecol Obstet impact on ovarian reserve of different hemostasis methods in laparoscopic
2017;136:200–4. cystectomy: a systematic review and meta-analysis. Rev Bras Ginecol Obstet
63 Farahani L, Morgan S, Datta S. Reprint of: Benign ovarian cysts. Obstet 2019;41:400–8.
Gynaecol Reprod Med 2017;27:226–30. 77 Leijdekkers JA, Eijkemans MJC, van Tilborg TC, Oudshoorn SC, McLernon DJ,
64 Hirokawa W, Iwase A, Goto M, Takikawa S, Nagatomo Y, Nakahara T, et al. Bhattacharya S, et al. Predicting the cumulative chance of live birth over
The post-operative decline in serum anti-Mullerian hormone correlates with multiple complete cycles of in vitro fertilization: an external validation study.
the bilaterality and severity of endometriosis. Hum Reprod Hum Reprod 2018;33:1684–95.
2011;26:904–10. 78 Tal R, Seifer DB. Ovarian reserve testing: a user’s guide. Am J Obstet Gynecol
65 Busacca M, Riparini J, Somigliana E, Oggioni G, Izzo S, Vignali M, et al. 2017;217:129–40.
Postsurgical ovarian failure after laparoscopic excision of bilateral 79 Haadsma ML, Groen H, Fidler V, Bukman A, Roeloffzen EMA, Groenewoud
endometriomas. Am J Obstet Gynecol 2006;195:421–5. ER, et al. The predictive value of ovarian reserve tests for spontaneous
66 Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe T, De Bie pregnancy in subfertile ovulatory women. Hum Reprod 2008;23:
B, et al. ESHRE guideline: management of women with endometriosis. Hum 1800–7.
Reprod 2014;29(3):400–12. 80 Almog B, Shehata F, Sheizaf B, Tulandi T. Effect of different types of ovarian
67 Benschop L, Farquhar C, van der Poel N, Heineman MJ. Interventions for cyst on antral follicle count. Fertil Steril 2010;94:2338–9.
women with endometrioma prior to assisted reproductive technology. 81 Cranney R, Condous G, Reid S. An update on the diagnosis, surgical
Cochrane Database Syst Rev 2010;(11):Cd008571. management, and fertility outcomes for women with endometrioma. Acta
68 Demirol A, Guven S, Baykal C, Gurgan T. Effect of endometrioma cystectomy Obstet Gynecol Scand 2017;96:633–43.
on IVF outcome: a prospective randomized study. Reprod Biomed Online 82 Lima ML, Martins WP, Coelho Neto MA, Nastri CO, Ferriani RA, Navarro PA.
2006;12:639–43. Assessment of ovarian reserve by antral follicle count in ovaries with
69 Alborzi S, Ravanbakhsh R, Parsanezhad ME, Alborzi M, Alborzi S, Dehbashi endometrioma. Ultrasound Obstet Gynecol 2015;46:239–42.
S. A comparison of follicular response of ovaries to ovulation induction after 83 Balachandren N, Davies M. Fertility, ovarian reserve and cancer. Maturitas
laparoscopic ovarian cystectomy or fenestration and coagulation versus 2017;105:64–8.
normal ovaries in patients with endometrioma. Fertil Steril 2007;88:507–9. 84 Moini A, Riazi K, Amid V, Ashrafi M, Tehraninejad E, Madani T, et al.
70 Garcia-Velasco JA, Somigliana E. Management of endometriomas in women Endometriosis may contribute to oocyte retrieval-induced pelvic
requiring IVF: to touch or not to touch. Hum Reprod 2009;24:496–501. inflammatory disease: report of eight cases. J Assist Reprod Genet
71 Hart RJ, Hickey M, Maouris P, Buckett W. Excisional surgery versus ablative 2005;22:307–9.
surgery for ovarian endometriomata. Cochrane Database Syst Rev 2008;(2): 85 Donnez J, Nisolle M, Gillet N, Smets M, Bassil S, Casanas-Roux F. Large
Cd004992. ovarian endometriomas. Hum Reprod 1996;11:641–6.

ª 2020 Royal College of Obstetricians and Gynaecologists 37