Direct IVF versus prior laparoscopic cystectomy for ovarian endometrioma ≥4 cm: cumulative live birth rate and implications for fertility preservation - a retrospective cohort study.

BACKGROUND

Current guidelines recommend laparoscopic cystectomy for ovarian endometrioma (OMA) ≥4 cm before fertility treatment, yet cystectomy inevitably damages ovarian reserve. While recent large-scale studies have confirmed that cystectomy reduces antimüllerian hormone (AMH) levels and oocyte yield, whether this translates into impaired cumulative live birth rate (CLBR)-the most clinically relevant IVF outcome-remains inadequately addressed.

METHODS

This retrospective cohort study included 394 infertile patients with OMA undergoing their first IVF cycle at a single tertiary center (January 2016-December 2022). Patients were stratified into Group A (non-surgical OMA <4 cm, n=116), Group B (non-surgical OMA ≥4 cm, n=47), and Group C (surgical OMA ≥4 cm, n=231). The primary outcome was CLBR. Multivariable logistic regression (primary analysis of CLBR), propensity score matching (PSM), and inverse probability of treatment weighting (IPTW) were employed. Multiple linear regression was used as an exploratory analysis of oocyte yield.

RESULTS

In non-surgically managed patients, OMA size did not independently predict CLBR (Group B vs. A: OR = 1.06, P = 0.882). Among patients with OMA ≥4 cm, prior cystectomy was associated with significantly lower AMH (1.98 vs. 3.16 ng/mL, P = 0.001), fewer retrieved oocytes (median 7 vs. 11, P = 0.001), and impaired embryological outcomes. However, CLBR did not differ significantly between surgical and non-surgical management (52.4% vs. 59.6%, P = 0.370; adjusted OR = 0.77, 95% CI: 0.38-1.56, P = 0.469). PSM (OR = 0.67, P = 0.374) and IPTW (OR = 0.77, P = 0.448) confirmed these findings. Patient age (OR = 0.92, P = 0.030) and number of transferred embryos (OR = 2.21, P = 0.014) were the only independent predictors of CLBR.

CONCLUSIONS

Pre-IVF laparoscopic cystectomy for OMA ≥4 cm significantly compromises ovarian reserve and IVF efficiency and this study did not detect a significant improvement in CLBR, although the comparison was underpowered to exclude clinically meaningful differences. Direct IVF may warrant consideration as an alternative strategy for patients without absolute surgical indications. When surgery is planned, preoperative fertility preservation should be considered. These findings require validation in prospective randomized trials.