A Conversation with Dr. Andrea Vidali: The Case for Ovarian Preservation

The founder of Endometriosis Surgical Specialists International (ESSI) on what the published evidence is now obligating American surgeons to do differently—and what most of them still aren’t.

Dr. Andrea Vidali is double-board-certified in Obstetrics & Gynecology and in Reproductive Endocrinology & Infertility. As a reproductive immunologist and the founder of ESSI, he has spent twenty-five years building a practice dedicated to advanced endometriosis care. In this commentary, Dr. Vidali responds to the latest literature regarding ovarian preservation in young women with endometriomas.

The Problem with Standard American Practice

When asked about his reaction to the current evidence on endometrioma surgery, Dr. Vidali expressed relief that the data is finally in print, but frustration that it took so long. The histology, AMH data, antral follicle counts, and pregnancy outcomes have all shown that cystectomy removes healthy ovarian cortex alongside the cyst wall.

Despite this, American practice has been extraordinarily slow to adjust.

“I spend a meaningful fraction of my consultations seeing young women in their early thirties whose AMH is already below 1.0 because a general gynecologist, or even a fellowship-trained minimally invasive surgeon, stripped both of their ovaries in a twenty-minute procedure somewhere and told them the cyst ‘was successfully removed,'” says Dr. Vidali. While the cyst is removed, the reproductive capacity of that ovary has often been stripped to an empty shell.

Dr. Vidali points out that laparoscopic cystectomy with bipolar hemostasis—the default technique in most American hospitals—produces a documented 30 to 57 percent drop in AMH. He attributes this ongoing issue to four main factors:

• Training inertia: Residents are taught stripping techniques simply because that is what their attendings were taught.

• Equipment limitations: Most community operating rooms lack capital investments like CO₂ fibre lasers or argon plasma coagulation, forcing surgeons to rely on bipolar graspers.

• Surgical volume: Generalist models, where an OB/GYN performs a few cystectomies a month alongside other procedures, are structurally incompatible with the tissue-sparing precision required for this disease.

• Financial incentives: There is no financial incentive in the American system to do a harder, longer operation; spending ninety extra minutes vaporizing a cyst wall pays the same as ripping it out in fifteen minutes.

The ESSI Approach: Precision Energy and Immunology

To combat iatrogenic ovarian damage, ESSI routinely utilizes argon plasma coagulation (APC). APC provides a predictable and shallow depth of coagulation (roughly 0.8 millimetres) because the argon gas carries the current in a controlled, non-contact arc.

“You are effectively painting the cyst wall with thermal energy, and the energy stops before it reaches the ovarian cortex,” Dr. Vidali explains. This avoids the deep thermal necrosis caused by traditional bipolar forceps, which can create a zone of thermal damage extending four millimetres or more into healthy tissue.

From an immunological standpoint, the choice of surgical energy matters enormously. Bipolar coagulation adds additive injury, laying down a wider band of necrotic tissue that the immune system must clear. Conversely, shallow ablative energy like argon or CO₂ laser produces a smaller necrotic footprint, a smaller cytokine release, and a faster return to a normal follicular environment.

Navigating Bilateral Disease and Adenomyosis

For patients with bilateral endometriomas, Dr. Vidali is unyielding. “If a thirty-year-old comes in with four-centimetre endometriomas on both ovaries and she hasn’t built her family, I am not stripping both ovaries,” he states, citing data that shows a 57 percent AMH decline following bilateral cystectomy. Instead, ESSI offers ablation of both cyst walls, removal of deep infiltrating disease, and preoperative oocyte vitrification coordinated by their integrated reproductive endocrinology team.

ESSI also extends this fertility-preserving philosophy to adenomyosis using ultrasound-guided percutaneous microwave ablation. This procedure thermally necroses the tissue in a controlled volume, preserving the uterus and shrinking the adenomyotic mass. Crucially, it essentially eliminates the catastrophic uterine rupture risk associated with excisional adenomyomectomy.

When is Cystectomy Still Appropriate?

Dr. Vidali clarifies that the default procedure must change, but cystectomy still has a place. Indications for cystectomy include:

• Cysts with a real malignancy concern where histological analysis of the entire wall is mandatory.

• Patients who have completed childbearing and desire the lowest possible recurrence risk.

• Cysts that are anatomically unfavourable to ablation.

• Patients who explicitly prefer the excisional option and accept the reserve trade-off after informed consent.

Advice for Patients Facing Surgery

Dr. Vidali advises patients to take four specific steps before agreeing to endometrioma surgery:

• Get a preoperative AMH: Know your baseline ovarian reserve before the operation, not after.

• Ask about the energy source: If the surgeon plans to use “bipolar” without mentioning CO₂ laser, argon, or plasma energy, you are being offered twenty-year-old technology for a twenty-first-century problem.

• Ask about personal recurrence and reserve rates: Demand the recurrence rate and reserve cost of the specific operation in that specific surgeon’s hands.

• Discuss fertility preservation: Preoperative oocyte vitrification should be considered for any woman under 35 with bilateral disease, a preoperative AMH under 2.0 ng/mL, or a history of prior ovarian surgery.

“Endometriosis and adenomyosis are tractable diseases when treated with the right technology and the right surgical philosophy,” concludes Dr. Vidali. “Understand that the choice of who operates on you—and with what—may be the single most consequential medical decision you make in your reproductive life”.

Editor’s note: This commentary reflects the clinical opinions of Dr. Andrea Vidali and is informed by peer-reviewed evidence. It is not a substitute for individualized medical advice. Patients considering surgical treatment should consult a specialist.