Endometriosis is a common gynecological disease affecting 10–15% of women of reproductive age. One of its most severe and clinically complex forms is ovarian endometriosis, or endometrioma. The disease is associated not only with chronic pelvic pain and impaired quality of life, but also directly with infertility and a reduction in ovarian reserve [1; 2]. Current literature indicates that endometrioma itself may damage ovarian tissue, reduce the reserve of surrounding healthy follicles, and lead to a decrease in anti-Müllerian hormone (AMH) levels [2; 9].
Surgical treatment, particularly laparoscopic cystectomy, remains the main method of disease control. However, the traditional “stripping” technique and hemostasis performed using bipolar coagulation may further reduce ovarian reserve due to removal of the healthy ovarian cortical layer and thermal injury [1; 4; 5]. Therefore, in modern gynecology, a personalized approach aimed at balancing surgical radicality with preservation of reproductive function has become highly relevant [3; 6].
Individualization of treatment tactics, taking into account the patient’s age, fertility plans, unilateral or bilateral localization of the disease, cyst size, history of previous ovarian surgery, and baseline AMH and AFC values, is the key prerequisite for effective protection of ovarian reserve [3; 6; 11].
To substantiate a personalized clinical and surgical approach aimed at preserving ovarian reserve after surgical treatment in reproductive-age women with ovarian endometriosis, and to develop a perioperative assessment algorithm and clinical criteria for selecting the method of hemostasis.
Materials and Methods
The study was conducted in the format of a prospective-retrospective clinical observation. Women of reproductive age with confirmed ovarian endometriosis who required surgical treatment were included in the study. The diagnosis was confirmed based on clinical examination, pelvic ultrasound examination, magnetic resonance imaging (MRI) when necessary, intraoperative visualization, and histological examination findings.
Before surgery, ovarian reserve was comprehensively assessed in all patients. This assessment included measurement of serum anti-Müllerian hormone (AMH), determination of antral follicle count (AFC) by transvaginal ultrasound, evaluation of menstrual function, and analysis of reproductive history. In addition, the patient’s age, disease duration, history of infertility, previous ovarian surgeries, and prior hormonal therapy were taken into account.
Surgical treatment was performed laparoscopically in accordance with the principle of tissue-sparing removal. The main intraoperative priority was to preserve the healthy ovarian cortex as much as possible. The method of hemostasis was selected individually for each patient. Preference was given to techniques associated with minimal thermal injury, such as suturing and the use of hemostatic sealants. Bipolar coagulation was used only under strict indications and in a minimal volume.
Postoperative dynamic follow-up was performed at 3, 6, and 12 months. At each follow-up stage, AMH and AFC were reassessed, and menstrual and reproductive function were evaluated. A p-value of <0.05 was accepted as the threshold for statistical significance.
Results and Discussion
In the postoperative period, a certain decrease in AMH levels was observed in all monitored patients. However, the degree of decrease varied significantly depending on the patients’ baseline clinical profile and the surgical tactics used [11]. The greatest decrease was observed in patients with initially low ovarian reserve, large cysts, and extended resection. In contrast, in the group where tissue-sparing techniques were used, the decrease in AMH was moderate, and partial recovery over time was observed in some women [11].
These findings are fully consistent with international literature: bilateral endometrioma, repeated surgeries, and extensive loss of ovarian tissue are identified as the main predictive factors for postoperative decline in ovarian reserve [2; 6]. A contemporary critical appraisal conducted by Younis and Taylor in 2024 once again confirmed that cystectomy performed using the “stripping” technique leads to a statistically significant decrease in AMH levels [2].
The second important finding of the study concerned the method of hemostasis and tissue-handling technique. It was established that minimal use of electrocoagulation and careful dissection of endometrioid tissue help preserve functional ovarian tissue [11]. This conclusion is consistent with meta-analytic evidence showing that bipolar coagulation has a more negative effect on ovarian reserve compared with suturing or hemostatic sealants [4; 5].
Within the discussion, the balance between surgical radicality and preservation of reproductive potential is of particular importance. Although complete removal of an endometrioma may reduce recurrence rates and improve certain reproductive outcomes, it may also lead to inadvertent removal of healthy ovarian cortex and a decrease in future fertility [1; 2]. Therefore, the goal of modern surgery should not be radicality alone, but rather “function-preserving radicality” adapted to the patient’s age, ovarian reserve, and reproductive plans [6].
Preoperative assessment of ovarian reserve is considered a mandatory element based on current evidence. Since AMH is more sensitive than AFC in detecting the effect of surgical intervention, it is regarded as the most informative biomarker for perioperative decision-making and patient counseling [2]. In women with bilateral disease, a history of previous ovarian surgery, low baseline AMH levels, or urgent fertility plans, the threshold for extended resection should be higher, and fertility preservation strategies should be discussed before surgical intervention [3; 6].
The role of hemostasis requires particular emphasis. Ovarian damage occurs not only due to excision, but also as a result of thermal exposure during the hemostasis stage [5; 11]. Therefore, the choice between bipolar coagulation, suturing, hemostatic sealants, or other methods must be made individually and based on the principle of maximal preservation of the ovarian cortex [4].
The timing of surgical intervention is also clinically important. The ESHRE 2022 guideline does not recommend routine surgery for endometrioma before assisted reproductive technologies with the aim of increasing live birth rates. Decision-making should take into account pain symptoms, surgical access to follicles, suspicion of malignancy, and the status of ovarian reserve [3]. This recommendation supports the concept of individualized management rather than a universal operative strategy [3; 11].
1. Ovarian endometriosis negatively affects ovarian reserve both due to the disease process itself and due to possible complications of surgical treatment [1; 2].
2. The risk of postoperative decline in ovarian reserve is higher in women with bilateral endometriomas, previous ovarian surgeries, low baseline AMH levels, and extensive surgical dissection [6; 11].
3. A personalized approach should include preoperative assessment of AMH and AFC, consideration of reproductive plans, careful selection of surgical technique, and minimization of thermal injury during hemostasis [3–5].
4. Bipolar coagulation may cause greater damage to ovarian reserve compared with suturing or hemostatic sealants; therefore, its use should be limited, and preference should be given to alternative tissue-sparing methods [4; 5].
5. Dynamic follow-up at 3, 6, and 12 months after surgery is clinically justified for monitoring ovarian reserve and developing a subsequent fertility management plan [11].
6. Modern management of women with ovarian endometriosis should be based not on standardized routine surgery for all patients, but on the principle of individualized decision-making [3; 6].
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