Laparoscopic Chocolate Cyst (Endometrioma) Surgery

A Selective Surgical Approach that Preserves Ovarian Reserve

Assoc. Prof. Dr. Cengiz Andan explains:

Chocolate cysts (endometriomas) are a type of ovarian cyst, seen especially in women of reproductive age, that can impact fertility. These cysts form when tissue similar to the uterine lining (endometrium) implants within the ovary, bleeds every month, and accumulates a dark brown fluid inside. They get their name from this appearance: they have contents with a chocolate-like consistency.

However, the most critical issue in this disease is to intervene at the right time and in the right way, while preserving the ovarian reserve.

Is Surgery Always Necessary?

No. Current scientific data clearly indicates that chocolate cysts should not always be removed. Especially in women of reproductive age, any surgical intervention can also affect healthy ovarian tissue and may lead to a loss of reserve (ACOG, 2022; ESHRE, 2022).

Therefore, we perform a detailed evaluation based on the following criteria before surgery:

• Is the cyst larger than 8 cm?

• Is there a feeling of fullness or bloating in the lower abdomen caused by the cyst?

• Is it causing recurrent and severe pain?

• Does it obstruct IVF (In Vitro Fertilization) treatment?

• Do the cyst’s contents and structure suggest potential malignancy?

• What is the level of ovarian reserve? (Measured by tests like AMH, AFC)

If one or more of these criteria are present, surgery is carefully considered.

Why is Ovarian Reserve Important?

Ovarian reserve is the primary indicator determining the number and quality of a woman’s eggs (oocytes).

During laparoscopic surgery for chocolate cysts, healthy ovarian tissue can also be damaged while removing the cyst capsule (cyst wall). This can seriously reduce the chances of pregnancy, especially in patients with low reserve (UpToDate, 2024; ASRM, 2023).

Therefore, as Assoc. Prof. Dr. Cengiz Andan, we:

• Perform surgery only when necessary,

• Use reserve-preserving techniques,

• Consider the decision for surgery before IVF as a last resort.

When is the Decision for Surgery Made?

Surgery may be medically necessary in the following situations:

• If the cyst is growing rapidly.

• If pelvic pain severely affects quality of life.

• If there is a risk of a malignant tumor in the cyst.

• If IVF is planned and the cyst obstructs the procedure (e.g., blocks needle access, compresses the ovary).

However, in a woman who desires pregnancy, if the cyst causes no symptoms and the reserve is borderline, surgery is generally not recommended.

How is Laparoscopic Surgery Performed?

If surgery is required, the laparoscopic (minimally invasive) method is preferred.

With this method, a camera and special surgical instruments are inserted through small incisions in the abdomen. The cyst capsule is punctured, and the cyst contents are aspirated (suctioned) without spilling them into the abdomen as much as possible. Then, the cyst capsule (cyst wall) is carefully peeled (stripped) from the ovary and removed. During this process, cauterization (burning) should be avoided as much as possible. Thus, the ovarian tissue is maximally preserved while removing the cyst, which reduces the risk of recurrence and minimizes the impact on the ovarian reserve.

Instead of “excision” (stripping), alternatives such as “drainage + ablation” (vaporization) may sometimes be chosen to preserve the reserve (ESHRE, 2022).

What to Expect After Surgery?

• Short-term pain and abdominal tenderness are normal.

• A return to daily life usually occurs within 5-7 days.

• Hormonal levels are re-evaluated after 1-2 menstrual cycles.

• Reserve tests are repeated (especially for those planning pregnancy).

What Happens if the Cyst is Not Removed?

The belief that every chocolate cyst must be removed is incorrect. In some patients, the cyst may remain “silent” (asymptomatic) for years.

Therefore:

• Monitoring (expectant management) may be recommended.

• Medical suppression (birth control pills, GnRH analogs) may be offered.

• If fertility preservation is desired, embryo or egg freezing may be considered.

Personalized Planning, Aligned with Scientific Sources

There is no single right path in this matter. Every woman’s age, reserve, desire for children, cyst size, and symptoms are different.

Scientific guidelines now recommend a patient-specific approach:

“The benefit-risk balance of surgery must be analyzed very carefully; evaluation of reserve before surgery is essential, especially in patients of reproductive age.” (ACOG Committee Opinion No. 785, 2022)

“The removal of endometriomas can reduce ovarian reserve. Therefore, surgery should only be considered in carefully selected cases.” (ESHRE Endometriosis Guideline, 2022)

An Informed and Preservative Approach with Assoc. Prof. Dr. Cengiz Andan

Chocolate cyst surgery is an extremely beneficial method if there is a medical necessity. However, in women of reproductive age, unnecessary surgery should be avoided to prevent damage to the ovarian reserve, and treatment must be individualized.