Obgyn · Year 3 · from Obgyn

Case 3: Endometrioma in a Woman Desiring Fertility

Patient Demographics

• Age: 32 years
• Sex: Female
• Occupation: Marketing director

Chief Complaint

"I'm having trouble getting pregnant and my periods are very painful."

History of Present Illness

The patient and her husband have been trying to conceive for 18 months without success. She has progressively worsening dysmenorrhea that now requires her to take time off work. The pain starts before her period and continues throughout menstruation. She also experiences pain with deep penetration during intercourse. She has been using ovulation predictor kits and timing intercourse appropriately.

Gynecologic History

• Menarche: Age 12
• Cycles: Regular, 28 days, heavy flow x 7 days
• Severe dysmenorrhea since mid-20s, progressively worsening
• Dyspareunia with deep penetration
• LMP: 3 weeks ago
• Sexually active: Yes, married
• Prior pregnancies: G0
• Contraception: None x 18 months (trying to conceive)

Past Medical History

• No chronic conditions
• No prior surgeries

Physical Examination

• Abdomen: Soft, non-tender
• Pelvic:
• Cervix: Normal
• Uterus: Normal size, fixed, tender with manipulation
• Right adnexa: 5 cm tender mass, minimally mobile
• Left adnexa: Normal
• Cul-de-sac: Nodularity palpated (concerning for deep endometriosis)

Diagnostic Workup

Transvaginal Ultrasound:

• Right ovary: 5.2 cm cyst with homogeneous low-level internal echoes
• "Ground glass" appearance - classic for endometrioma
• No solid components
• No internal vascularity
• Left ovary: Normal, multiple antral follicles
• Uterus: Normal appearance

Laboratory Studies:

Diagnosis

Right Ovarian Endometrioma (Chocolate Cyst)

• Characteristic ultrasound appearance
• Associated symptoms (dysmenorrhea, dyspareunia)
• Cul-de-sac nodularity suggesting endometriosis
• Infertility

Management Discussion

The Dilemma:

• Endometrioma may contribute to infertility
• Surgery (cystectomy) can reduce ovarian reserve
• Need to balance treatment benefits vs. ovarian damage

Options:

1. Proceed Directly to IVF (Without Surgery):

• Can retrieve oocytes from ovaries with endometriomas
• Avoids surgical risk to ovarian reserve
• Endometrioma <4-5 cm generally does not preclude IVF

2. Surgical Excision (Laparoscopy):

• Cystectomy removes endometrioma
• Also allows diagnosis and treatment of concurrent deep endometriosis
• Risk: AMH decline post-surgery (ovarian tissue removed with cyst wall)
• May improve natural conception and IVF outcomes for some patients

3. Medical Suppression:

• GnRH agonist or progestin
• Only suppresses symptoms; does not treat cyst or improve fertility
• Not appropriate for patient trying to conceive

Multidisciplinary Discussion (With Reproductive Endocrinologist)

Recommendations:

• Given 5 cm endometrioma and cul-de-sac nodularity suggesting deep endometriosis
• Laparoscopy offers both diagnostic and therapeutic value
• Complete staging of endometriosis
• Excision of endometrioma
• Treatment of any deep infiltrating endometriosis
• May improve fertility outcomes

Patient Counseled About:

• Risk of reduced ovarian reserve post-surgery
• Pre-operative AMH is normal; will check post-operatively
• Surgical technique (stripping vs. ablation) - stripping provides tissue for pathology
• Recurrence rate: 20-30% within 2 years

Surgical Management: Diagnostic Laparoscopy and Cystectomy

Operative Findings:

• Right ovarian endometrioma (5 cm) - chocolate-colored fluid aspirated
• Stage III endometriosis (revised ASRM classification)
• Deep infiltrating endometriosis in cul-de-sac
• Left ovary: Superficial endometriotic implants
• Bilateral fallopian tubes: Patent (chromopertubation positive)

Procedure Performed:

• Right ovarian cystectomy (stripping technique)
• Excision of deep infiltrating endometriosis
• Ablation of superficial implants
• Lysis of pelvic adhesions

Pathology:

• Endometriotic cyst confirmed
• No malignancy

Postoperative Course

• Discharged home same day
• AMH checked at 3 months post-op: 2.4 ng/mL (slight decline, still adequate)
• Advised to attempt conception for 6-12 months
• If not pregnant: Proceed to IVF

Follow-up (6 months post-surgery)

• Dysmenorrhea significantly improved
• Dyspareunia resolved
• Currently 8 weeks pregnant (spontaneous conception)
• Early prenatal care initiated

Teaching Points

• Endometriomas have a characteristic "ground glass" ultrasound appearance
• Endometriosis is a common cause of infertility (30-50% of infertile women)
• Surgery for endometrioma must weigh benefits against ovarian reserve loss
• Surgical planning should involve reproductive endocrinology input
• Recurrence is common; long-term suppression or monitoring needed after treatment
• Malignancy risk is low (<1%) but endometriomas are associated with clear cell and endometrioid ovarian cancers

Clinical Image

Image Description: Transvaginal ultrasound image demonstrating an endometrioma (chocolate cyst) with the characteristic homogeneous low-level internal echoes described as a "ground glass" pattern. The cyst wall is smooth and there are no solid components or internal vascularity.

Attribution: Image from Radiopaedia. Case courtesy of Dr. Andrew Dixon. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/endometrioma

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