Ovarian endometrioma is a common manifestation of endometriosis and an important clinical concern among women of reproductive age. Commonly referred to as a chocolate cyst, an endometrioma contains altered blood products and is associated with chronic pelvic pain, dysmenorrhea, infertility, and potentially reduced ovarian reserve.

The surgical management of ovarian endometrioma presents a significant challenge, particularly in women planning pregnancy. Although laparoscopic cystectomy using the stripping technique has traditionally been widely employed, concerns remain regarding inadvertent removal of healthy ovarian cortex, damage to ovarian follicles, and postoperative reduction in anti-Müllerian hormone (AMH) levels.

Alternative techniques, including ethanol sclerotherapy, have therefore attracted increasing interest as potentially ovarian-preserving treatments.

A recent article published in Cureus, entitled “Spontaneous Pregnancy After Laparoscopic Treatment of Ovarian Endometrioma: A Retrospective Cohort Study Comparing Stripping and Ethanol Sclerotherapy,” examines an important question in reproductive surgery: how does the choice of treatment for ovarian endometrioma relate to subsequent natural conception? 

Understanding the Two Surgical Techniques

1. Laparoscopic Cystectomy Using the Stripping Technique

Laparoscopic stripping involves identifying the cleavage plane between the endometrioma capsule and the surrounding ovarian tissue, followed by careful separation and removal of the cyst wall.

This technique permits histopathological examination and is effective in removing the cyst lining. It can also reduce the risk of recurrence compared with less definitive treatments.

However, the stripping procedure may inadvertently remove healthy ovarian tissue, particularly when the cyst capsule is densely adherent to the ovarian cortex.

Excessive bipolar coagulation during hemostasis may further compromise ovarian vascularity and follicular reserve.

Consequently, meticulous dissection and ovarian-sparing hemostatic techniques are essential, especially in patients with bilateral endometriomas, recurrent disease, or pre-existing diminished ovarian reserve.

2. Laparoscopic Ethanol Sclerotherapy

Ethanol sclerotherapy represents a conservative approach intended to treat the endometrioma while avoiding complete surgical excision of the cyst wall.

Following aspiration of the cyst contents, ethanol is introduced into the cyst cavity under controlled conditions to induce sclerosis of the cyst lining.

The theoretical advantage is preservation of ovarian cortex and reduction of surgical trauma.

Nevertheless, concerns include cyst recurrence, incomplete treatment, ethanol leakage, chemical irritation, and the possibility of missing unexpected histopathology.

Ethanol sclerotherapy should therefore be considered selectively rather than as a universal replacement for conventional cystectomy.

Spontaneous Pregnancy: The Most Important Outcome

For women seeking fertility, the success of endometrioma treatment should not be assessed solely by cyst removal, reduction in cyst size, or prevention of recurrence.

Spontaneous pregnancy and subsequent live birth are particularly important reproductive outcomes.

The Cureus study is described as a retrospective cohort comparison of laparoscopic stripping and ethanol sclerotherapy. However, although its publication was confirmed, the accessible publisher page did not expose the study's abstract, numerical results, or detailed methodology.

Therefore, the exact pregnancy rates, sample sizes, statistical significance, and comparative conclusions of this particular study could not be independently verified.

The following evidence helps place the comparison in clinical context.

Evidence From Related Research

A prospective cross-sectional study published in Reproductive Medicine and Biology in 2021 compared laparoscopic cystectomy with ethanol sclerotherapy among 101 infertile women undergoing assisted reproductive treatment.

The investigators reported:

The differences in clinical pregnancy and live birth rates were not statistically significant. However, recurrence was significantly more frequent following ethanol sclerotherapy (P = 0.017).

Importantly, these were assisted reproductive treatment outcomes, not spontaneous pregnancy outcomes, and should not be attributed to the October 2026 Cureus study.

Importance of Preserving Ovarian Reserve

One of the greatest concerns in endometrioma surgery is the preservation of functional ovarian tissue.

During laparoscopic cystectomy, the surgical plane between the cyst capsule and ovarian cortex may become difficult to identify, particularly near the ovarian hilum.

Excessive traction, removal of healthy cortical tissue, and extensive thermal coagulation may compromise ovarian reserve.

For patients planning future pregnancy, preoperative assessment should include serum AMH, antral follicle count, ovarian imaging, age, previous ovarian surgery, and overall infertility evaluation.

The 2022 European Society of Human Reproduction and Embryology (ESHRE) guideline recommends cystectomy rather than drainage and coagulation when surgery for ovarian endometrioma is indicated, while emphasizing the need to minimize ovarian damage.

The guideline also advises against routine endometrioma surgery solely to improve live birth rates before assisted reproductive technology because a reproductive benefit has not been demonstrated and surgery may adversely affect ovarian reserve. OUP Academic

Clinical Implications for Laparoscopic Surgeons

The comparison between stripping and ethanol sclerotherapy highlights the importance of individualized surgical decision-making.

Laparoscopic cystectomy remains an important treatment for symptomatic endometriomas, especially when definitive tissue diagnosis or reduced recurrence risk is a priority.

Ethanol sclerotherapy may be considered in selected patients in whom preservation of ovarian tissue is particularly important. Nevertheless, uncertainties regarding recurrence, long-term fertility outcomes, and appropriate patient selection must be considered.

For infertile women, surgical decisions should account for the complete reproductive picture rather than the presence of an endometrioma alone.

In particular, bilateral disease, recurrent endometriomas, diminished ovarian reserve, advanced maternal age, and previous ovarian surgery require careful multidisciplinary assessment.

Limitations of Retrospective Studies

Retrospective cohort studies can provide clinically useful information but cannot reliably establish that one treatment causes better pregnancy outcomes.

Potential confounding factors include differences in patient age, ovarian reserve, infertility duration, endometriosis severity, tubal function, male-factor infertility, previous treatment, and postoperative fertility management.

Differences in follow-up duration may also influence reported cumulative pregnancy rates.

These limitations are especially important when evaluating spontaneous pregnancy after endometrioma treatment.

Prospective randomized studies with standardized fertility assessments, clearly defined pregnancy outcomes, and long-term follow-up would provide stronger evidence.

Conclusion

The management of ovarian endometrioma in women desiring pregnancy requires a careful balance between effective disease treatment and preservation of reproductive potential.

Laparoscopic cystectomy offers established benefits in controlling endometrioma-related symptoms and reducing recurrence, but may damage healthy ovarian tissue.

Ethanol sclerotherapy offers a potentially tissue-preserving alternative, although recurrence and uncertainty regarding long-term reproductive outcomes remain important considerations.

Current evidence does not justify treating ethanol sclerotherapy as universally superior to laparoscopic stripping for spontaneous conception.

The most appropriate treatment depends on patient age, ovarian reserve, disease characteristics, fertility goals, surgical expertise, and the availability of assisted reproductive services.

Above all, fertility-preserving endometrioma surgery should prioritize meticulous technique, minimal thermal injury, and individualized patient care.

Original Research Article

Title: Spontaneous Pregnancy After Laparoscopic Treatment of Ovarian Endometrioma: A Retrospective Cohort Study Comparing Stripping and Ethanol Sclerotherapy

Journal: Cureus Journal of Medical Science
Publication: October 2026

Keywords: Ovarian Endometrioma, Laparoscopic Cystectomy, Ethanol Sclerotherapy, Spontaneous Pregnancy, Ovarian Reserve

Editorial disclosure: This is a clinically contextualized review of the subject of the Cureus article, supported by independently accessible research and guidelines. It is not a verified numerical summary of the Cureus cohort's results.