What You Need to Know Before You Decide

If you have endometriosis and your doctor has found ovarian cysts — called endometriomas — you may have heard that surgery to remove them is your best option, especially if you’re trying to get pregnant. That may be true. But a new study published in Fertility and Sterility, the journal of the American Society for Reproductive Medicine (ASRM), confirms something important that doesn’t always make it into the conversation: the surgery itself can reduce your ovarian reserve, sometimes significantly.

This doesn’t mean you shouldn’t have the surgery. It means you deserve to understand the tradeoffs before you decide.

What Is Ovarian Reserve — and Why Does It Matter?

Ovarian reserve describes the number and quality of eggs your ovaries hold at any given point in time. You can’t feel it changing, but it directly affects your ability to get pregnant — naturally or through IVF. (See Reproductive Medical Terms)

A blood test called AMH — anti-Müllerian hormone — measures ovarian reserve most reliably. Higher AMH signals more eggs in reserve. Lower AMH signals fewer. AMH doesn’t tell you everything, but right now it gives us the clearest single picture we have.

What the Study Found

Researchers in Iran followed 193 women with endometriomas who underwent laparoscopic cystectomy — the standard surgical procedure to remove the cysts. They measured AMH before surgery and again at 1 week, 3 months, and 9 months afterward.

The results were clear and consistent:

AMH dropped significantly after surgery — and stayed lower.

• Before surgery, the average AMH measured 3.86 ng/mL
• One week after surgery, it fell to 1.66 ng/mL
• At 3 months, it partially climbed back to 2.07 ng/mL
• At 9 months, it remained low at 1.77 ng/mL

That represents roughly a 54% drop from baseline that did not fully recover even nine months later.

Who Faces the Greatest Risk

Surgery doesn’t affect everyone equally. The study identified several factors that drive the impact higher:

Age over 38

Women over 38 enter surgery with lower AMH to begin with. After surgery, their levels fall further and recover less. Nine months out, women over 38 averaged just 0.34 ng/mL — a level that significantly limits IVF outcomes and natural conception.

Cysts on both ovaries (bilateral endometriomas)

Women with cysts on both ovaries lose more AMH and sustain the loss longer than women with a cyst on only one side. Operating on both ovaries puts more ovarian tissue at risk.

Multiple cysts

Women with multiple bilateral cysts showed the steepest AMH decline at three months compared to women with a single cyst on one side.

Cyst size matters less than you’d expect

The size of the cyst did not significantly predict how much AMH declined. Smaller cysts are actually harder to strip cleanly — surgeons risk taking more healthy tissue along with them — which may explain why size alone doesn’t protect ovarian reserve.

Why Does Surgery Reduce Ovarian Reserve?

Endometriomas sit inside a thin layer called a pseudo-capsule that presses directly against healthy ovarian tissue. When the surgeon removes the cyst, healthy follicle-containing tissue sometimes comes with it — even in the most skilled hands.

Immediately after surgery, inflammation and reduced blood flow to the ovary also drive AMH down. The ovary heals and AMH partially recovers by the three-month mark. But the nine-month data shows the recovery plateaus — what hasn’t come back by then may not come back.

What About FSH and Antral Follicle Count (AFC) ?

The study also tracked FSH (follicle-stimulating hormone) and antral follicle count (AFC) by ultrasound.

FSH rose significantly three months after surgery — a signal that the ovaries are working harder to keep up, which generally reflects lower reserve.

AFC — the count of small follicles visible on ultrasound — appeared to increase after surgery. The researchers think this happens because endometriomas physically block the view of follicles before surgery. Once the cyst comes out, follicles that were always there become visible. The AFC increase most likely reflects better visualization, not actual improvement in reserve.

This Is Not a Reason to Avoid Surgery

Laparoscopic cystectomy remains the standard treatment for endometriomas, particularly for women dealing with significant pain or infertility. The research consistently shows it reduces recurrence, improves response to ovarian stimulation, and raises pregnancy rates in certain patients.

This research doesn’t argue against surgery. It argues for informed consent — making sure women, especially those who are older, carry bilateral cysts, or start with limited ovarian reserve, walk into the operating room with a complete picture.

What You Need to Ask Before You Consent to Any Treatment

Before you sign a consent form or schedule surgery, you have the right — and the responsibility to yourself — to get clear answers to these questions. If your doctor dismisses them or rushes past them, that is important information too.

1. What is my current AMH level?

If your doctor hasn’t measured it, ask for the test before any treatment discussion moves forward. You cannot make an informed decision about surgery without knowing your baseline ovarian reserve.

2. What do my ultrasound findings show specifically?

Ask how many cysts you have, which ovaries they sit on, and how large they are. Unilateral versus bilateral, single versus multiple — these details directly affect your surgical risk and your options.

3. Is surgery medically necessary right now, or is it elective?

Some endometriomas grow slowly and cause minimal damage. Others are large, symptomatic, or actively threatening fertility. Know which situation applies to you before you agree to anything.

4. What happens to my ovarian reserve if I have this surgery?

Ask your doctor directly. If they don’t raise AMH decline as a risk, you raise it. The peer-reviewed literature is clear that surgery significantly lowers AMH — especially in women over 38 and those with bilateral cysts. You deserve a direct answer about what that means for your specific situation.

5. Should I freeze eggs or embryos before surgery?

If your AMH is already low, if you have bilateral cysts, or if you are over 35, this question is critical. Freezing before surgery preserves the reserve you have now. Once surgery reduces your AMH, you cannot undo that.

6. What surgical technique do you use, and why?

The stripping technique is standard but carries real risk to healthy ovarian tissue. Ask whether ablation — laser or plasma energy — makes sense for your cyst type and size. Ask what your surgeon’s recurrence rates look like with each approach.

7. How many endometrioma surgeries have you performed, and what are your outcomes?

Surgical skill directly affects how much healthy ovarian tissue a surgeon preserves. You have every right to ask about experience and outcomes. A surgeon confident in their work will answer without hesitation.

8. What are my non-surgical options?

Hormonal suppression, GnRH analogues, and careful monitoring are legitimate options in some cases — particularly for women who want to pursue IVF soon or who are not yet ready for surgery. Ask whether any of these apply to your situation.

9. If I have cysts on both ovaries, can you operate on only one side?

For bilateral disease, some clinicians advocate sparing the less affected ovary to preserve whatever reserve remains. Ask whether a staged or conservative approach makes sense for you.

10. What does success look like, and how will we measure it?

Define the goal of surgery together — pain relief, improved IVF response, reduced recurrence — and ask how your doctor plans to track whether the surgery achieved it.

The bottom line on consent: Informed consent means more than signing a form. It means your doctor has explained the risks specific to your age, your cyst burden, and your fertility goals — and you have had the chance to ask every question you carry into that room. If you feel rushed, seek a second opinion. The surgery will still be available next week. Your ovarian reserve may not recover.

What the Science Is Still Debating

This study adds to a body of research that hasn’t reached full consensus. Several important questions remain actively contested in peer-reviewed literature, and you deserve to know they exist.

Should you even operate before IVF?

Some reproductive endocrinologists now argue that for women pursuing fertility treatment, surgeons should leave endometriomas alone before IVF. Several studies suggest the surgery causes more damage to ovarian reserve than the cyst itself does. A 2012 systematic review and meta-analysis by Raffi, Metwally, and Amer in the Journal of Clinical Endocrinology and Metabolism found that surgical excision drives up to a 40% decrease in serum AMH levels. A second 2012 systematic review by Somigliana and colleagues in Fertility and Sterility called for larger studies to clarify the risk factors and better understand the mechanisms of damage. Neither review endorsed a single clear answer — but both raised serious flags about operating before IVF without strong clinical justification.

Does the cyst itself damage ovarian reserve before surgery even happens?

Yes — and this matters. Kim and colleagues showed in Yonsei Medical Journal (2013) that women with advanced ovarian endometrioma already carry lower AMH values before any surgical intervention. Stage IV endometriosis appears to deplete ovarian reserve independently, even without surgery. This means the damage may start earlier than the operating room — which complicates the decision to wait.

Does stripping cause more damage than ablation?

The stripping technique this study used — and that many surgeons use — physically peels the cyst wall away from the ovary. Ablation techniques, including laser vaporization and plasma energy, destroy the cyst lining without stripping it. Tsolakidis and colleagues reported in Fertility and Sterility (2010) that a three-stage approach using GnRH analogues followed by laser vaporization produced no decrease in AMH levels. Roman and colleagues found that plasma energy ablation better preserved ovarian volume and antral follicle count compared to cystectomy. However, ablation carries higher recurrence rates — and no randomized trial has yet declared a definitive winner.

Does AMH recover beyond nine months?

This study followed women for nine months, and the authors acknowledge that as a limitation. Sugita and colleagues (Fertility and Sterility, 2013) tracked women for a full year and found that some patients showed higher AMH at twelve months than at one month post-surgery — suggesting continued recovery is possible for some women. But the pattern isn’t consistent across patients or studies, and no long-term data establishes how far or how reliably AMH rebounds.

For bilateral disease, does operating on only one side make sense?

Some clinicians advocate a conservative approach for bilateral endometriomas — operating on only the larger or more symptomatic cyst to spare the other ovary. No large randomized trial has validated this approach, but the principle of preserving whatever reserve remains drives the clinical logic.

The honest answer is that the field doesn’t have all the answers yet. What it does have is enough evidence to demand that you and your doctor weigh these questions together — before you schedule surgery.

The Bottom Line

Endometrioma surgery can permanently reduce ovarian reserve. The risk runs highest for women over 38 and women with cysts on both ovaries. Before you agree to surgery, make sure your doctor has measured your AMH, walked through the risks specific to your situation, and considered whether freezing eggs or embryos first makes sense for you.

You deserve that conversation — and you deserve to have it before you’re on the operating table.

This article content is based on a study by: Alborzi S, Keramati P, Younesi M, Samsami A, Dadras N. “The impact of laparoscopic cystectomy on ovarian reserve in patients with unilateral and bilateral endometriomas.” Fertility and Sterility, 2026. DOI: 10.1016/j.fertnstert.2026.03.009

References

1. Alborzi S, Keramati P, Younesi M, Samsami A, Dadras N. The impact of laparoscopic cystectomy on ovarian reserve in patients with unilateral and bilateral endometriomas. Fertility and Sterility. 2026. DOI: 10.1016/j.fertnstert.2026.03.009. Published by Elsevier Inc. on behalf of the American Society for Reproductive Medicine.
2. Raffi F, Metwally M, Amer S. The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis. Journal of Clinical Endocrinology and Metabolism. 2012;97:3146–54.
3. Somigliana E, Berlanda N, Benaglia L, Viganò P, Vercellini P, Fedele L. Surgical excision of endometriomas and ovarian reserve: a systematic review on serum antimullerian hormone level modifications. Fertility and Sterility. 2012;98:1531–8.
4. Kim JY, Jee BC, Suh CS, Kim SH. Preoperative serum anti-mullerian hormone level in women with ovarian endometrioma and mature cystic teratoma. Yonsei Medical Journal. 2013;54:921–6.
5. Tsolakidis D, Pados G, Vavilis D, Athanatos D, Tsalikis T, Giannakow A, et al. The impact on ovarian reserve after laparoscopic ovarian cystectomy versus three-stage management in patients with endometriomas: a prospective randomized study. Fertility and Sterility. 2010;94:71–7.
6. Roman H, Auber M, Mokdad C, Martin C, Diguet A, Marpeau L, et al. Ovarian endometrioma ablation using plasma energy versus cystectomy: a step toward better preservation of the ovarian parenchyma in women wishing to conceive. Fertility and Sterility. 2011;96:1396–400.
7. Sugita A, Iwase A, Goto M, Nakahara T, Nakamura T, Kondo M, et al. One-year follow-up of serum antimullerian hormone levels in patients with cystectomy: are different sequential changes due to different mechanisms causing damage to the ovarian reserve? Fertility and Sterility. 2013;100:516–22.

INCIID provides health information for educational purposes. This article does not substitute for medical advice. Please consult your reproductive endocrinologist or gynecologist about your individual situation.