Surgeon Subspecialty Affects Ovarian Preservation in Endometriosis Care

Surgeon Subspecialty Shapes Ovarian Preservation and Disease Excision in Endometrioma Surgery

Key Points

 Highlights:

• Surgical management of ovarian endometriomas varies significantly by gynecologic subspecialty. 
• Minimally invasive gynecologic(MIG) surgeons and Reproductive Endocrinology & Infertility (REI) surgeons demonstrated higher rates of ovarian preservation and more frequent excision of extra-ovarian disease compared with general OB/GYN and gynecologic oncology surgeons.

Importance:

• Surgical decisions in endometrioma management may influence reproductive potential, hormonal function, and long-term symptom outcomes, making it important to understand practice variation across surgical specialties.

 What’s done here?

• This retrospective cohort study analyzed 351 patients (aged 18–45) who underwent surgery for pathology-confirmed ovarian endometriomas between 2012 and 2024.
• Surgical approach and outcomes were compared across four subspecialties: general OB/GYN, MIGS, REI, and gynecologic oncology. 
• Primary outcomes were rates of ovary-sparing surgery and excision of extra-ovarian endometriosis in advanced disease. 

Key results:

• Ovary-sparing surgery was significantly more common among REI (84%) and MIGS (76%) surgeons than general OB/GYN (45%) and gynecologic oncology (20%) surgeons. 
• After adjusting for surgical complexity, MIGS and REI subspecialists had markedly higher odds of ovarian preservation compared with general OB/GYN surgeons. 
• In rASRM stage III–IV disease, excision of extra-ovarian endometriosis was performed more frequently by MIGS (91%) and REI (83%) surgeons than by general OB/GYN (22%) or gynecologic oncology (12%) surgeons. 
•  Increasing age and prior surgeries were associated with lower likelihood of ovarian preservation, while desire for future fertility increased the likelihood of ovary-sparing surgery.

Strengths and Limitations:

• Strengths are: the inclusion of a large cohort across multiple surgical subspecialties enables evaluation of real-world practice variation; and the adjustment for surgical complexity strengthens interpretation of differences in operative approaches.
• Limitations are the retrospective design may not capture all factors influencing surgical decision-making, including patient preferences and intraoperative judgment; also long-term reproductive, pain, and recurrence outcomes were not assessed.

From the Editor-in-Chief – EndoNews

"Surgical management of ovarian endometriomas requires careful balance between complete disease excision and preservation of ovarian reserve. This balance becomes particularly relevant in reproductive-age patients, where operative decisions may influence future fertility, hormonal function, and long-term symptom control. The present study examines an often underexplored dimension of surgical care: how subspecialty training may shape operative strategy in endometrioma management.

The findings demonstrate substantial variation in surgical approach across gynecologic subspecialties. Surgeons with fellowship training in minimally invasive gynecologic surgery (MIGS) or reproductive endocrinology and infertility (REI) were more likely to perform ovary-sparing procedures and, in advanced-stage disease, more frequently excised extra-ovarian endometriosis. Importantly, these differences persisted after adjustment for patient age and operative complexity, suggesting that training background may independently influence intraoperative decision-making.

These observations do not imply superiority of one specialty over another; rather, they highlight how structured training pathways may prioritize distinct operative objectives. In the context of endometriosis, where surgical goals include symptom relief, recurrence reduction, and preservation of reproductive potential, variability in approach may have meaningful clinical implications. The comparable perioperative complication rates across groups further suggest that differences in operative strategy were not accompanied by increased short-term surgical risk.

Several considerations temper interpretation. As a retrospective analysis, the study cannot fully account for referral patterns, case selection biases, or unmeasured patient preferences that may influence surgical planning. Additionally, long-term outcomes—including fertility rates, recurrence, and ovarian reserve markers—were not assessed, limiting conclusions about the downstream impact of these operative differences.

Nevertheless, this work underscores an important point: endometrioma surgery is not a uniform procedure, and surgeon training background may influence how competing priorities are balanced in the operating room. Future prospective studies incorporating long-term reproductive and symptom outcomes will be essential to determine whether these practice variations translate into meaningful differences in patient-centered results."

Lay Summary

Balancing effective disease removal with preservation of ovarian function remains one of the central challenges in the surgical management of ovarian endometriomas.

Because the fibrotic capsule of these lesions is often tightly adherent to the ovarian cortex, excision requires meticulous technique to avoid inadvertent loss of healthy ovarian tissue. In advanced disease, surgeons must also address extra-ovarian endometriosis and complex pelvic adhesions, further increasing operative complexity and highlighting the importance of surgical expertise.

In a study published in the Journal of Minimally Invasive Gynecology, Dr.Billow and colleagues investigated whether surgeon subspecialty training influences operative decision-making and surgical outcomes in patients undergoing surgery for ovarian endometriomas.

The retrospective cohort included 351 reproductive-age patients and compared outcomes across four gynecologic subspecialties: general obstetrics and gynecology, minimally invasive gynecologic surgery (MIGS), reproductive endocrinology and infertility (REI), and gynecologic oncology.

MIGS and REI surgeons were significantly more likely to perform ovary-sparing surgery than general OB/GYN surgeons, even after accounting for patient age and surgical complexity.

In advanced-stage disease, these subspecialists also more frequently excised extra-ovarian endometriosis, indicating a more comprehensive surgical approach. Importantly, perioperative complication rates and conversion to open surgery were low and comparable across all groups.

Together, these findings suggest that subspecialty training may influence how surgeons balance disease excision with preservation of ovarian tissue, underscoring the potential role of specialized expertise in optimizing surgical strategies for patients with endometriosis.

Research Source: https://pubmed.ncbi.nlm.nih.gov/41571147/