Should ovarian endometriomas be surgically removed before IVF?

[Verified against ESHRE Guideline: Endometriosis 2022] Not routinely. ESHRE makes a strong recommendation that clinicians are not recommended to routinely perform surgery for ovarian endometrioma prior to ART to improve live birth rates, because the current evidence shows no benefit. That sits alongside a broader strong recommendation that routine surgery prior to ART to improve live birth rate is not recommended in endometriosis generally. The distinction that matters clinically: ESHRE does state that surgery for endometrioma prior to ART can be considered to improve endometriosis-associated pain, or to improve accessibility of follicles at retrieval. Those are legitimate indications. Improving live birth rate is not. So the question to ask before operating is which of those you are actually treating. If the answer is "to improve IVF success", the evidence does not support it. The counter-consideration is ovarian reserve. Cystectomy removes functional ovarian tissue adjacent to the cyst wall, and this is the principal harm of operating without a clear indication — particularly in bilateral endometriomas or where reserve is already reduced. Where surgery is indicated, ESHRE recommends cystectomy over drainage and coagulation, as cystectomy reduces recurrence. Cystectomy and CO2 laser vaporisation can both be considered, with similar recurrence beyond the first year, though early post-surgical recurrence may be lower after cystectomy.