Dr. Steve Vasilev, MD, Gynecologist, Endometriosis Surgeon*:

In most cases leaving an endometrioma behind is suboptimal.  The reason is that they do not go away on their own, cannot be eliminated using medications or natural solutions (e.g. hormonal balancing), and likely will continue to grow, eventually causing problems.  If the endometrioma is already large enough to potentially cause problems, then there is no good excuse for leaving it behind, barring exceptional individual circumstances of some kind.  For example, at least in the short-run, small sub-centimeter endometriomas buried deep in the ovarian tissue would not likely cause the problems noted below.

What problems can it cause other than the impact on fertility?  Endometriomas tend to be or become thin-walled which means they are prone to rupture or leak.  This old blood can be very inflammatory in the peritoneal cavity and cause a lot of pain with a leak or rupture. Endometriomas are also not just old blood (chocolate cyst).  Contained in the bloody fluid are endo cells that can implant and grow on other pelvic structures.  So, at any one point, you can release the floodgates for many implantable cells, potentially making your overall endo burden larger very quickly.  This is not often talked about, and no one can prove this one way or the other.  The degree to which these wayward cells may implant may also be different from person to person, due to uncertain factors.  However, given the many theories about endo and knowing that these cells are definitely in the bloody fluid from published research, this is very concerning and plausible and not worth risking.  This is also a reason for trying to contain the fluid if an endometrioma ruptures during surgery, using containment bags to minimize spill.

Removing an endometrioma does not produce menopause.  Removing both ovaries, at the other extreme, will.  So, even if one ovary were to be removed, this would not induce early menopause in the vast majority of cases.  Lastly, most of the time, the endometrioma(s) can be removed without removing the ovary.  In this surgeon’s opinion, robotic surgery lends itself best to meticulous removal of endometrioma tissue, minimizing spill, because of the very fine instruments that rotate/articulate like tiny human hands, the 3D view which results in keen depth perception, and due to the magnification possible to find the edges of the endometrioma on/in the ovarian tissue.  So, while laparoscopy is perfectly adequate for many endo excision cases, if you want the most meticulous surgery with the least risk of injuring the underlying ovary, the tube, and the blood supply in a scarred operative field (i.e. hard to see what is what due to endo and fibrosis it causes), robotic surgery may be best for you.

*This is not medical advice and is aimed for informational use only. Please contact the doctor’s office or consult with your doctor for any medical questions.