CLINICAL PERSPECTIVE
The Case for Ovarian Preservation in Young Women with Endometrioma
Cystectomy has been the default for three decades. A decade of higher-quality data now suggests that for young patients who want children, ablative techniques may be the better choice—quietly, consistently, and with numbers that are difficult to ignore.
READING TIME · 11 minutes | EVIDENCE BASE · 6 RCTs, 4 meta-analyses, 2022 ESHRE guidance | ESSI · New York
A 29-year-old nulliparous woman arrives for preoperative counseling with a 4-centimetre unilateral endometrioma and a serum AMH of 2.4 ng/mL. She wants surgery for pain. She also wants children—just not yet. What do you offer her? For most of the last two decades, the answer has been straightforward: laparoscopic cystectomy with the stripping technique. That answer is increasingly hard to defend on fertility grounds, and the published data now tell a more uncomfortable story than many surgeons acknowledge during consent.
The problem is not that cystectomy fails to remove disease. It removes disease well, with the lowest recurrence rates of any technique. The problem is what comes out with the cyst. Endometriomas are pseudocysts. There is no true cleavage plane between the endometriotic cyst wall and the ovarian cortex, and a decade of histological work has shown that primordial follicles are inadvertently stripped away alongside the capsule—even in the hands of the most experienced fertility surgeons. Adding bipolar coagulation for hemostasis compounds the injury through thermal damage to the adjacent cortex. For a 29-year-old with reproductive intentions, this is not an abstract concern. It is arithmetic.
01 / THE RESERVE COST
What cystectomy actually does to AMH.
The most cited contemporary synthesis is the 2024 updated meta-analysis by Paik and Jee, which pooled six randomized controlled trials and five prospective cohort studies comparing cystectomy with ablation. The headline finding is simple and now reproducible across multiple syntheses: the drop in serum anti-Müllerian hormone after surgery is roughly two and a half times larger after cystectomy than after ablation.
Source: Paik H, Jee BC. Reprod Sci. 2024;31(7):1924–1935. Intergroup difference favoring ablation: +0.38 ng/mL, 95% CI 0.13 to 0.63, p = 0.003.
The subgroup analyses are where the conversation should shift from population-level effects to patient-level counseling. The advantage for ablation is most pronounced in three scenarios that describe exactly the young, fertility-motivated patient we most want to protect: follow-up beyond three months, bilateral disease, and the laser ablation technique specifically. Put differently, the worse the situation—more cyst, more ovary at risk—the larger the reserve penalty of stripping.
The laterality effect is the most clinically useful piece. Raffi’s classic 2012 meta-analysis quantified the AMH decline at roughly 30% for unilateral cystectomy and 44% for bilateral cystectomy. Younis’s more recent prospective data pushed those estimates higher: a 39% reserve decline at 9–12 months after unilateral surgery and a 57% decline after bilateral. These are not transient, post-inflammatory dips. Multiple meta-analyses now report that the drop persists at 18 months and is not recovering—it is structural.
Sources: Raffi F et al., J Clin Endocrinol Metab. 2012;97:3146–3154. Younis JS et al., Front Endocrinol. 2022;13:996531.
The population we most want to protect—young, bilateral, fertility-motivated—is also the population most penalized by stripping.
02 / THE FOLLICULAR WIPEOUT
A statistic more people should be quoting.
The most striking recent contribution to this literature comes from Hurni and the Dexeus Mujer group in Barcelona, published in Reproductive BioMedicine Online in late 2025. This was a 176-patient retrospective cohort of young women (18–40) with unilateral endometriomas, half managed by plasma energy ablation (PEA) and half by conventional cystectomy (CC), followed to 48 months.
The recurrence rates were nearly identical—23.7% for ablation versus 26.6% for cystectomy—which undermines the most common objection to ablative approaches. But the ovarian reserve data told a different story. Among ovaries that underwent cystectomy, more than one in three had an antral follicle count of zero in the operated ovary after surgery. Among ovaries managed with plasma energy ablation, one in ninety. It is difficult to overstate this difference.
Source: Hurni Y et al. Reprod Biomed Online. 2025. N = 176. Difference p < 0.001.
The same study reported a mean AMH reduction of 0.3 ng/mL after plasma ablation versus 0.9 ng/mL after cystectomy. AFC in the operated ovary increased by 2.0 follicles after ablation (the cyst was no longer displacing parenchyma) while decreased by 1.0 follicles after cystectomy.
A second analysis—the Candiani randomized trial of one-step CO₂ laser vaporization versus stripping—found a similar pattern at three months: AFC in the operated ovary climbed from 3.6 to 8.6 after laser, while only rising from 4.1 to 6.3 after excision.
Source: Candiani M et al. Hum Reprod. 2018;33(12):2205–2211. RCT, n = 60. Laser group: significant AFC increase (p < 0.01).
03 / THE ABLATIVE TOOLKIT
Not all “ablation” is the same.
One reason this debate has been slower to resolve than it should have been is that older reviews lumped very different energy sources into a single bucket labelled “ablation” or “fenestration and coagulation”. Bipolar electrocautery applied to the inner cyst wall—the dominant technique in the 1990s and early 2000s—is genuinely inferior: it produces deep, uncontrolled thermal damage to the underlying cortex and is associated with both high recurrence and significant reserve loss.
The modern ablative techniques of interest are something different. Their shared feature is shallow, precise energy delivery that destroys endometriotic epithelium without cooking the ovary beneath it.
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CO₂ fibre laser: 10,600 nm photothermal absorption by water; very shallow penetration (~0.1 mm). It holds the largest RCT base, is reproducible regardless of surgeon seniority, and demonstrates favourable IVF ovarian responsiveness.
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Argon plasma coagulation: Ionised argon carries monopolar current in a controlled arc to tissue; coagulation ~0.8 mm. It provides precise hemostasis with minimal lateral spread, and early histological data show no parenchymal damage.
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Plasma energy (PlasmaJet): Pure neutral argon plasma; vaporizes and coagulates without electrical current through tissue; maximum depth ~2 mm. Excellent in bilateral or recurrent disease, preserving AFC with equivalent recurrence at 48 months.
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(For contrast, bipolar coagulation carries a ~4 mm thermal spread).
04 / THE PREGNANCY QUESTION
Does preserving reserve translate to babies?
This is where the skeptics have historically pushed back—correctly—because AMH is a surrogate. What matters clinically is pregnancy. The evidence here is now genuinely reassuring.
Across the modern comparative studies, pregnancy rates after ablation are not inferior to cystectomy. The Paik and Jee 2024 meta-analysis reported an odds ratio of 1.18 for pregnancy favouring ablation, which was not statistically significant. The Ferrari 2025 Italian cohort reported a 5-year pregnancy rate of 65.5% after CO₂ laser vaporization, with 55.6% of those conceptions occurring spontaneously.
Sources: Candiani M et al. J Minim Invasive Gynecol. 2021;28(1):34–41. Ferrari SM et al. J Minim Invasive Gynecol. 2025;32(2):171–176. Bafort C et al. Reprod Biomed Online. 2022;45(1):101–108.
A retrospective IVF case-control study of women who had undergone plasma energy ablation before ART produced perhaps the most interesting finding: despite retrieving fewer oocytes, the ablation cases had superior implantation, pregnancy, delivery, and cumulative live birth rates per transfer compared with matched controls. The interpretation offered by the authors—that surgery reduces inflammatory and oxidative stress in the ovarian microenvironment without the parenchymal cost of stripping—is speculative but coherent with everything else in the literature.
05 / THE RECURRENCE TRADE-OFF
Honest about what ablation costs.
Nothing in this argument requires pretending ablation is superior on every endpoint. It isn’t. The Paik and Jee meta-analysis found a higher overall recurrence rate after ablation (RR 1.51, 95% CI 1.08–2.12) and a higher one-year recurrence (RR 2.36). Those are meaningful numbers and patients deserve to hear them during consent. The question is whether, for a young woman with fertility intentions, a modestly higher probability of a second surgery is a better trade than a significantly higher probability of diminished reserve or iatrogenic premature ovarian insufficiency.
Source: Hurni Y et al. Reprod Biomed Online. 2025. Log-rank p = 0.866; surgical technique was not independently associated with recurrence risk in adjusted Cox regression.
It also matters that the most contemporary data—Hurni’s 2025 cohort with 48-month follow-up—does not replicate that recurrence penalty. In unilateral disease managed at a specialist centre, the curves converged. The older meta-analyses may be picking up an era when bipolar “ablation” was the dominant non-excisional technique, not modern plasma, argon, and CO₂ laser practice. At minimum, the recurrence gap is narrower than the reserve gap, and far narrower than it used to be.
06 / WHERE THE GUIDELINES HAVE LANDED
Quietly, a paradigm shift.
The 2022 ESHRE guideline on endometriosis marked a more significant shift in practice than most clinicians registered at the time. Two changes are directly relevant. First, the decision to operate on an endometrioma should not be driven by cyst diameter alone—a departure from decades of “anything over 3 cm gets taken out.” Second, routine cystectomy prior to assisted reproductive technology is no longer recommended; surgery before IVF should be reserved for pain, suspected malignancy, or anatomical difficulty with oocyte retrieval.
The 2025 German S2k guideline, the 2023 SEUD consensus, and the 2024 NICE update have all moved in the same direction: toward conservatism, toward reserve preservation, and toward individualized consent that explicitly puts the long-term reproductive cost of excision on the table. The World Endometriosis Society’s position is similar. There is, at this point, no internationally authoritative body still recommending cystectomy as a one-size-fits-all default for reproductive-age women with endometrioma. The decision is no longer between surgery and no surgery—it is between which kind of surgery, for which patient, at which moment in her reproductive life.
07 / THE IDEAL CANDIDATE
Who most clearly benefits from an ablative approach.
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Women under 35 with clear fertility intentions within the next 5–10 years.
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Bilateral endometriomas, where the reserve cost of stripping compounds.
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Prior ovarian surgery—recurrent endometrioma with residual reserve to protect.
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Preoperative AMH in the low-normal range (< 2.0 ng/mL) or borderline diminished.
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Small-to-medium endometriomas (3–6 cm) with clear cyst wall access.
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Patients for whom a second surgery, if needed, is acceptable but oocyte loss is not.
08 / WHAT THIS MEANS AT THE BEDSIDE
The consent conversation has to change.
None of this replaces surgical judgement. Cystectomy remains entirely appropriate when pain is the primary indication, when malignancy cannot be confidently excluded, when the endometrioma is large and anatomically complex, or when the patient has already completed her family. For patients who want the technique with the lowest probability of requiring a second operation and who accept the reserve cost, cystectomy is a reasonable choice.
What has changed is the default. The default can no longer be stripping every endometrioma in every reproductive-age woman and treating the AMH decline as an acceptable incidental cost of good surgery. For the 29-year-old in the opening scenario, the better conversation sounds something like this: we can take the entire cyst out, and the recurrence risk is low, but roughly one in three similar ovaries end up with no measurable follicles afterward; or we can vaporize the cyst wall using laser, plasma, or argon energy, preserve your reserve, achieve similar pregnancy outcomes, and accept a modestly higher chance you’ll need a follow-up procedure. That is a choice a patient can actually make. Offering only the first half of it isn’t informed consent—it is momentum.
EXPERT COMMENTARY
A conversation with Dr. Andrea Vidali
Reproductive endocrinologist and reproductive immunologist. Founder, Endometriosis Surgical Specialists International (ESSI), a multisite surgical boutique. Director, BRI Center for Immunological Diagnosis and Treatment & Advanced Endometriosis Robotic Surgery. Twenty-five years of practice in New York and New Jersey.
Q: As someone who is both a reproductive endocrinologist and a surgeon, what’s your honest reaction to this body of evidence? A: Relief, mostly. For twenty-five years I have watched women come through my office who had their endometrioma stripped somewhere else at 28 or 30, and by the time they reach me at 34 their AMH is 0.6 and we are talking about donor eggs. The histology was telling us why this was happening long before the AMH data caught up, but the surgical community was slow to accept it because cystectomy is technically satisfying and gives the surgeon a specimen to hand to pathology. A clean ablated ovary looks, on the monitor, like you didn’t do much—even though you did more to preserve her future than stripping ever would. What the Paik meta-analysis, the Hurni cohort, and the Candiani randomized data now show collectively is that the ovarian reserve penalty of stripping is real, is large, is reproducible, and—critically—is not offset by meaningfully better clinical outcomes for the fertility-seeking patient. I don’t think it is intellectually honest to keep offering cystectomy as the default to a 29-year-old with pregnancy intentions without putting those numbers on the table.
Q: Why has this shift been so slow to reach the bedside in the United States? A: Three reasons, in order of importance. First, most of the comparative data comes from European high-volume endometriosis centres—Milan, Barcelona, Rouen, Leuven—and American practice has been slow to accept European surgical literature as fully relevant to U.S. patients. Second, ablative techniques require specific energy platforms—CO₂ fibre laser, PlasmaJet, argon—that most community OR suites don’t stock, and a surgeon who doesn’t have the tool reaches for the one they do. Third, and most quietly, cystectomy is what residents are still being taught. Training inertia in surgery is enormous. There is also a fourth reason that nobody likes to say out loud: ablation looks less impressive on an operative report. You don’t send anything to pathology. An insurance reviewer may question why you didn’t “remove” the cyst. None of that is a good reason, but it shapes practice.
Q: ESSI uses argon plasma coagulation routinely for endometrioma. Walk us through why. A: Argon plasma coagulation has a particular property we care about enormously: the depth of coagulation is predictable and shallow—roughly 0.8 millimetres—because the argon gas carries the current in a controlled, non-contact arc rather than conducting through tissue like monopolar electrosurgery does. You are effectively painting the cyst wall with thermal energy and stopping before you reach the ovarian cortex. The recent APC-ENDO histological pilot confirmed what we see clinically: no detectable damage to the surrounding parenchyma, and complete ablation of the endometriotic epithelium at that depth. The second advantage is hemostasis. An endometrioma bed bleeds. The traditional answer has been bipolar coagulation, which is the single most destructive thing you can do to an ovarian cortex short of resecting it. Argon delivers hemostasis at a controlled depth, without the thermal spread of bipolar. For a patient in whom we are doing everything possible to protect reserve, that distinction matters on every single oozing surface we touch. At ESSI we combine argon for the cyst wall with meticulous cold excision of any deep infiltrating disease elsewhere, and when it is appropriate we use CO₂ fibre laser or plasma energy instead of or alongside argon. The point isn’t brand loyalty to one tool. It’s matching the energy profile to the tissue.
Q: You are also a reproductive immunologist. Does the choice of surgical energy matter from an immune-environment standpoint? A: It matters a great deal, and this is the part of the picture that isn’t captured in AMH numbers. An endometrioma is not an inert cyst. It is a reservoir of iron, free radicals, and pro-inflammatory cytokines—TNF-α, IL-6, IL-15—that drive local follicular atresia and contribute to the implantation-hostile environment many of our patients carry. When you operate well, you remove that reservoir. When you operate badly, you add thermal necrosis, devascularization, and a new inflammatory signal that may take months to resolve. Bipolar coagulation of the ovarian bed is, from an immunological standpoint, additive injury. You are not just removing endometriotic epithelium—you are laying down a wider band of necrotic tissue that the immune system then has to clear, often in an ovary that is already primed to over-respond. Shallow ablative energy—argon, CO₂ laser, plasma—produces a smaller necrotic footprint, less cytokine release, and a faster return to a normal follicular microenvironment. That is almost certainly part of why the Roman IVF data showed superior implantation and live birth rates after plasma ablation compared with matched controls, despite fewer oocytes retrieved. The oocytes were in a better immunological neighbourhood.
Q: How do you counsel the patient with bilateral endometriomas—the scenario where the reserve cost compounds? A: Bilateral disease is where the conversation changes most sharply from the textbook answer. If a 30-year-old comes in with 4-centimetre endometriomas on both ovaries and she hasn’t built her family, I am not stripping both ovaries. The Younis data—a 57% AMH decline at 9 to 12 months after bilateral cystectomy—is simply not a trade I am willing to make without an extraordinarily compelling indication. What we offer that patient is ablation of both cyst walls, removal of any accompanying deep infiltrating disease, and—critically—a pre-operative fertility-preservation conversation. In many of these cases we coordinate oocyte vitrification before surgery if the preoperative AMH is already borderline, which is something a reproductive endocrinologist is positioned to do in a way that a pure surgeon usually isn’t. That integrated workflow is why we built ESSI the way we did: the patient doesn’t have to bounce between a surgeon who only operates and an REI who only stimulates. Both decisions happen in the same conversation.
Q: Is there still a place for cystectomy in your practice? A: Absolutely, and I want to be careful not to overstate the argument. I still do cystectomies. The indications are clear: a cyst large enough or complex enough to raise malignancy concern, where histology is mandatory; a patient who has completed childbearing and wants the lowest possible recurrence risk; a cyst that is so anatomically unfavourable to ablation that ablation would be incomplete; and occasionally a patient who, after a genuine informed-consent conversation, prefers the excisional option and accepts the reserve trade-off. The point isn’t that cystectomy is wrong. The point is that it is one option among several, and the default should stop being cystectomy for everyone. For a young woman who wants children, the default at ESSI is fertility-sparing ablation unless there is a specific reason to do otherwise.
Q: You have extended this fertility-preserving philosophy to adenomyosis, using microwave ablation. Can you walk us through that? A: Adenomyosis is the endometrioma problem moved to the myometrium, and until recently our options were equally binary and equally unsatisfying: hysterectomy, which ends the reproductive conversation; or adenomyomectomy—a true excisional debulking—which leaves behind a uterine scar with a reported rupture rate in subsequent pregnancies of 4 to 6 percent. Neither of those is a good answer for a 32-year-old who hasn’t carried a pregnancy yet. Microwave ablation—specifically ultrasound-guided percutaneous microwave ablation—gives us a third option. A microwave antenna is placed into the adenomyotic lesion under real-time ultrasound, and the tissue is thermally necrosed in a controlled volume. The uterus is preserved, the junctional zone is normalized, the inflammatory load falls, and the catastrophic rupture risk of excisional adenomyomectomy is essentially eliminated. The published rupture rate after microwave ablation for adenomyosis is close to zero. The pattern is the same as the endometrioma story: shallow, precise, targeted energy delivery outperforms aggressive excision when fertility is the priority.
This is the organizing principle of how we practice at ESSI. Wherever the newest ablative technology has a plausible fertility-preservation advantage—argon for the ovary, microwave for the uterus, CO₂ laser for the peritoneum—we have adopted it, refined it, and incorporated it into our standard workflow. I would argue, without much hesitation, that ESSI is the most technologically advanced center for fertility-sparing endometriosis and adenomyosis surgery currently operating in the United States. That is not a marketing claim; it is a reflection of the fact that we have made a deliberate choice to bring each of these energy platforms into the same practice rather than specialize in one.
Q: If a referring physician or a patient took one thing from this review, what should it be? A: That “we can just take the cyst out” is no longer an adequate consent conversation for a young woman who wants children. The evidence is now strong enough that the surgeon has an affirmative obligation to discuss the reserve cost of stripping, the comparative data on ablative techniques, and the fertility-preservation options that may be worth considering before surgery. The concrete number I would ask every referring physician to remember is the Hurni 2025 figure: 33.7 percent of cystectomized ovaries left without a single antral follicle in the operated ovary, versus 1.1 percent with plasma ablation. Once you have said that number out loud to a patient, you cannot unsay it. And once she has heard it, the conversation is different.
Q: Where is ESSI going next? A: Three directions. First, we are continuing to build the integrated surgical–immunological–reproductive endocrinology workflow—because endometriosis is not a surgical problem or a fertility problem or an immune problem. It is all three, and patients are badly served by fragmented care. Second, we are expanding our use of shallow-energy ablative platforms, including argon and microwave, and tracking our own outcomes so we can contribute comparative data to the literature rather than just citing it. Third, we are investing in the diagnostic side—particularly in identifying silent endometriosis in women with recurrent pregnancy loss and unexplained implantation failure, where the disease is often the missing variable and where a well-executed ablative procedure may be the single most effective intervention in an otherwise failed IVF career.
The larger arc, I think, is that endometriosis surgery is finally moving from an era of technically aggressive excision toward an era of precision tissue preservation. Our job is to stay at the front of that transition and to make sure patients have access to it now, rather than waiting the fifteen years it typically takes for the field to catch up with its own evidence.
SELECTED REFERENCES
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Hurni Y, La Torre F, Barbany-Freixa N, Platón-Galofré C, Coll S, García-Martínez S, Cabrera S, Barri-Soldevila PN. Plasma energy ablation versus cystectomy in fertility-sparing surgery for endometriomas: impact on recurrence and ovarian reserve. Reproductive BioMedicine Online. 2025.
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Candiani M, Ottolina J, Posadzka E, et al. Assessment of ovarian reserve after cystectomy versus ‘one-step’ laser vaporization in the treatment of ovarian endometrioma: a small randomized clinical trial. Human Reproduction. 2018 Dec 1;33(12):2205–2211.
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