Prepared for patient education. Written specifically for patients in the care of Dr. Antonio Gargiulo, reproductive medicine and advanced reproductive surgery.
Why Your Doctor Is Recommending Egg Retrieval First
You have been told you have an endometrioma — a cyst on your ovary filled with old blood, caused by endometriosis — and that surgery to remove it is being considered. You have also been told that your doctor wants you to go through egg retrieval (also called egg freezing or egg banking) before that surgery. This may feel backwards. You might be wondering: shouldn’t the cyst be removed first, so the eggs can be collected more easily?
The answer — backed by a growing body of scientific evidence — is no.
In most cases, doing the egg retrieval first and the surgery second is safer for your future fertility. Here is why.
Surgery Damages the Ovary. Going Through It Before Egg Retrieval Is a Mistake You Cannot Undo.
Your ovaries contain a fixed, lifetime supply of eggs. You are born with all the eggs you will ever have. You cannot make new ones. Every time something reduces that supply — whether it is age, a disease, or a surgical procedure — that reduction is permanent.
Endometriomas already harm the ovary. The endometrioma itself damages the normal ovarian tissue around it, compresses healthy follicles (the tiny sacs that contain immature eggs), and causes low-grade inflammation that reduces the overall egg supply over time. A blood test called AMH (anti-Müllerian hormone) measures your ovarian reserve. Women with endometriomas consistently show lower AMH levels than women without them, even before any treatment has started.
Surgery makes this worse — significantly. When a surgeon removes an endometrioma by peeling it away from the ovary (a technique called cystectomy, which is currently the standard approach), healthy ovarian tissue inevitably comes with it. The follicles embedded in the wall of the cyst are pulled away and lost. Studies consistently show that AMH levels drop by 40 to 60% in the months after endometrioma surgery. A large systematic review and meta-analysis covering 36 studies found that this drop in ovarian reserve persists in the short term, medium term, and long term — and does not fully recover even a year after surgery. The damage is greatest for women who have large cysts (over 5–7 cm) or cysts on both ovaries.
The critical message: If you have surgery first and then try to collect eggs afterward, you will be collecting eggs from an ovary that has already been surgically reduced. You will get fewer eggs — and some of those eggs may never have existed had the surgery not happened first.
Multiple research teams have confirmed this directly. A 2022 study published in Reproductive Biomedicine Online followed 71 women with endometriomas undergoing egg banking. Women who had surgery before their egg retrieval had a 51.7% reduction in the number of mature eggs collected, compared to women who had not yet had surgery — even when accounting for age and cyst size. Women with endometriomas larger than 4 cm who had **not** yet had surgery collected just as many eggs as women with smaller cysts. A 2021 study from a Paris university hospital (Santulli et al., Reproductive Biomedicine Online) reached the same conclusion after analyzing 146 women across 258 stimulation cycles: prior endometrioma surgery was the strongest single predictor of lower egg yield — stronger than age, stronger than cyst size. The title of that paper says it plainly: “Fertility preservation for patients affected by endometriosis should ideally be carried out before surgery.”
What does the evidence tell us about outcomes after banking?
In 2020, Dr. Ana Cobo and colleagues at the Instituto Valenciano de Infertilidad published a landmark study in Fertility and Sterility — one of the most important journals in reproductive medicine — reporting on 1,044 women with endometriosis who chose to bank their eggs. This is the largest series of its kind in the world. The results were striking:
– 43% of women returned to use their frozen eggs — a remarkably high rate compared to other fertility preservation programs. This tells us that these women correctly anticipated they would need those eggs in the future, and that they were glad to have banked them.
– Women who banked before surgery, while their ovarian reserve was still intact, had the most favorable outcomes.
– High cumulative live birth rates were reported, particularly in women younger than 35 at the time of banking, leading the authors to explicitly recommend that women with endometriomas be encouraged to freeze eggs at a younger age and before any surgical intervention.
– A subsequent Cobo series of 485 patients with endometriomas of at least 1 cm documented an oocyte survival rate of 83.2% after the eggs were warmed and a cumulative live birth rate of 46.4% — results comparable to fertility preservation in healthy young women.
An editorial published alongside the Cobo data in Fertility and Sterility by leading Italian endometriosis experts Somigliana and Vercellini noted that the return-to-thaw rate of 43% means “the ultimate number needed to be treated” to achieve one live birth through this strategy “will be below 2” — meaning for every two women who bank eggs before endometrioma surgery, at least one will have a baby because of it.
The biological reason egg quality remains good even with an endometrioma in place is also supported by donor-egg research. Studies using the oocyte donation model — where eggs from donors with endometriosis are transferred to healthy recipients — show that the eggs themselves do not appear to be fundamentally compromised in quality. A 2022 analysis of over 13,000 donor and autologous IVF cycles (Kamath et al., Human Reproduction Open) found no significant difference in live birth rates between recipients receiving eggs from donors with endometriosis versus women using their own eggs. This is reassuring: the eggs of a woman with endometriosis can lead to healthy pregnancies — the disease does not poison the eggs themselves. What matters is having enough of them, and banking before surgery is the strategy that protects that supply.
Is It Safe to Collect Eggs When a 5 cm Endometrioma Is Still in Place?
This is a completely reasonable concern, and it has been studied directly.
The short answer: YES, it is safe — with some nuance.
Access to your follicles. A 5 cm cyst takes up space in the ovary, and some patients worry it will prevent the doctor from reaching the eggs behind it. Research shows this concern, while understandable, is generally manageable. A 2024 Italian study (European Review for Medical and Pharmacological Sciences, Baldini et al.) followed 251 women with endometriomas undergoing egg retrieval and compared them to 251 women without endometriomas. Fertilization rates, embryo numbers, pregnancy rates, and live birth rates were not significantly different between the two groups. The authors concluded that “patients with endometrioma can undergo high-performance oocyte recovery procedures thanks to safe accessory maneuvers during the ovum pick-up.”
A 2018 prospective study by Benaglia et al. (Reproductive Biomedicine Online) found that in some cases the cyst needs to be gently moved aside or punctured to reach follicles behind it, and that follicle aspiration was occasionally incomplete — but critically, no pelvic infections and no cyst ruptures were recorded among 56 women with endometriomas.
The risk of infection. The most commonly discussed concern is whether the egg retrieval needle could puncture the endometrioma, introducing its contents into the pelvic cavity and causing an infection (called a tubo-ovarian abscess). This is a real risk, but the evidence consistently shows it is low. The most definitive data comes from a large 2025 study by Parpex et al. (Reproductive Biomedicine Online) at a French university hospital analyzing 1,668 egg retrieval cycles in women with endometriomas. Endometrioma infection requiring surgical drainage occurred in only 6 out of 1,668 cycles — a rate of 0.36%. Even among the 76 cases where the cyst was intentionally punctured, infection occurred in only 1 case (1.3%). No cases of sepsis occurred. The authors concluded that the risk of serious infection is low when procedures are performed under proper conditions with antibiotic prophylaxis.
A 2016 study by Villette et al. in Fertility and Sterility added an important clarification: some infections in women with endometriosis occur spontaneously, without any egg retrieval, suggesting that even the small observed infection rate may not all be attributable to the retrieval procedure itself.
What your medical team does to minimize the risk. Egg retrieval is performed under ultrasound guidance with careful planning to avoid the cyst where possible. Antibiotics are given before and after the procedure. The low residual risk does not outweigh the very real and permanent benefit of collecting eggs before surgery reduces your ovarian reserve.
When Should Surgery Come First?
The “egg retrieval before surgery” approach is right for most patients — but not every situation. Your doctor will prioritize surgery first if any of the following apply:
Severe pain that cannot be controlled. If the endometrioma is causing pain severe enough to seriously affect your daily life, surgery may need to come first, even if this means some impact on future egg numbers.
Concern about the nature of the cyst. Not all ovarian cysts are endometriomas. In rare cases, a cyst that resembles an endometrioma on ultrasound may turn out to be something more concerning. If imaging has any features that raise concern about malignancy, surgery for a definitive tissue diagnosis takes priority.
Technical impossibility of reaching the follicles. In some women, the size, location, or surrounding scar tissue (adhesions) makes it technically unsafe or impossible to retrieve eggs around the cyst. Surgery to improve access may be considered first, though this is uncommon and requires careful individualized judgment.
Both ovaries are involved and the reserve is already very low. In this situation — bilateral endometriomas with severely diminished reserve — the risk-benefit calculation shifts significantly. The strategy must be rethought entirely with a specialist.
Current guidelines from international fertility societies recommend that for women with bilateral endometriomas, recurrent endometriomas, or a planned operation on an ovary that has been previously operated on, oocyte banking before any further surgery should be strongly considered and explicitly discussed.
In Summary
Here is what the scientific evidence tells us:
– Endometrioma surgery reduces egg supply by 40–60%, and this reduction does not fully recover.
– Women who bank eggs before surgery consistently retrieve more eggs than those who operate first.
– A landmark study by Dr. Ana Cobo and colleagues (Fertility and Sterility, 2020) followed 1,044 women with endometriosis who froze their eggs: 43% returned to use them, live birth rates were high — especially in those who banked before age 35 and before surgery.
– Egg retrieval with a 5 cm endometrioma in place is feasible and safe — the risk of serious infection is under 0.4% in experienced hands.
– The eggs of women with endometriomas are of good quality; banking protects the quantity that surgery would otherwise reduce.
– Surgery should be prioritized when pain is severe, when diagnostic uncertainty exists, or when follicle access is technically impossible.
For most women who still want to have children and are facing endometrioma surgery, retrieving and freezing eggs first is the strategy most likely to protect their future. This is not an experimental recommendation — it is supported by the largest outcomes series in the world and endorsed by multiple international guidelines.
Sources We Used
So You Can Read Them, Question Them, and Decide for Yourself
We believe that informed patients are empowered patients. In an age where artificial intelligence and open-access science place original research within reach of anyone, you have every right to go to the source, read it yourself, and form your own conclusions. Patient education on this website is taken seriously: we do not simplify at the cost of truth, and we do not ask you to take our word for it.
Every statement in this article carries two layers of accountability. It has been filtered through the critical eye of Dr. Antonio Gargiulo, drawing on four decades of clinical and surgical experience in reproductive medicine and advanced gynecologic surgery. And it is independently traceable to a peer-reviewed scientific publication, listed below with its full reference and digital identifier (DOI), so you can retrieve and read the original source at any time.
We see healthcare as a shared responsibility between doctors and patients. Shared responsibility requires shared access to information. These references are not a formality. They are here for you.
1. Cobo A, et al. **Oocyte vitrification for fertility preservation in women with endometriosis: An observational study.** *Fertility and Sterility.* 2020;113(4):836–844. DOI: 10.1016/j.fertnstert.2019.11.022
2. Somigliana E, Vercellini P. **Fertility preservation in women with endometriosis: speculations are finally over, the time for real data is initiated.** *Fertility and Sterility.* 2020;113(4):750–751. DOI: 10.1016/j.fertnstert.2019.12.020
3. Santulli P, Bourdon M, Koutchinsky S, et al. **Fertility preservation for patients affected by endometriosis should ideally be carried out before surgery.** *Reproductive Biomedicine Online.* 2021. DOI: 10.1016/j.rbmo.2021.08.023
4. Elizur SE, Aizer A, Yonish M, et al. **Fertility preservation for women with ovarian endometriosis: results from a retrospective cohort study.** *Reproductive Biomedicine Online.* 2022. DOI: 10.1016/j.rbmo.2022.11.014
5. Kim SJ, Kim S, Lee JR, et al. **Oocyte cryopreservation for fertility preservation in women with ovarian endometriosis.** *Reproductive Biomedicine Online.* 2020. DOI: 10.1016/j.rbmo.2020.01.028
6. Hong Y, Lee HK, Kim S, et al. **The Significance of Planned Fertility Preservation for Women With Endometrioma Before an Expected Ovarian Cystectomy.** *Frontiers in Endocrinology.* 2021. DOI: 10.3389/fendo.2021.794117
7. Parpex G, Bourdon M, Marcellin L, et al. **Low risk of endometrioma infection after oocyte retrieval.** *Reproductive Biomedicine Online.* 2025. DOI: 10.1016/j.rbmo.2025.105344
8. Baldini GM, Laganà AS, Mastrorocco A, et al. **Can the endometrioma be an obstacle to complete oocyte retrieval in IVF cycles? A retrospective study.** *European Review for Medical and Pharmacological Sciences.* 2024. DOI: 10.26355/eurrev_202404_35911
9. Benaglia L, Busnelli A, Biancardi R, et al. **Oocyte retrieval difficulties in women with ovarian endometriomas.** *Reproductive Biomedicine Online.* 2018. DOI: 10.1016/j.rbmo.2018.03.020
10. Moreno-Sepulveda J, Romeral C, Niño G, Pérez-Benavente A. **The Effect of Laparoscopic Endometrioma Surgery on Anti-Müllerian Hormone: A Systematic Review of the Literature and Meta-Analysis.** *JBRA Assisted Reproduction.* 2021. DOI: 10.5935/1518-0557.20210060
11. Goodman LR, Goldberg JM, Flyckt RL, et al. **Effect of surgery on ovarian reserve in women with endometriomas, endometriosis and controls.** *American Journal of Obstetrics and Gynecology.* 2016. DOI: 10.1016/j.ajog.2016.05.029
12. Villette C, Bourret A, Santulli P, et al. **Risks of tubo-ovarian abscess in cases of endometrioma and assisted reproductive technologies are both under- and overreported.** *Fertility and Sterility.* 2016. DOI: 10.1016/j.fertnstert.2016.04.014
13. Kamath MS, Subramanian V, Antonisamy B, Sunkara SK. **Endometriosis and oocyte quality: an analysis of 13,614 donor oocyte recipient and autologous IVF cycles.** *Human Reproduction Open.* 2022. DOI: 10.1093/hropen/hoac025
14. La Marca A, Semprini M, Mastellari E, et al. **Fertility preservation in women with endometriosis.** *Human Reproduction Open.* 2025. DOI: 10.1093/hropen/hoaf012
15. Chon S, Jee BC. **Oocyte cryopreservation for women with endometriosis: Justification, indications, and reproductive outcomes.** *Clinical and Experimental Reproductive Medicine.* 2024. DOI: 10.5653/cerm.2023.06492
16. Riemma G, García-Velasco J, Abrão M, et al. **IVF/ICSI or surgery as first approach for the treatment of infertility associated with ovarian and deep infiltrating endometriosis? A systematic review and meta-analysis.** *Reproductive Biomedicine Online.* 2025. DOI: 10.1016/j.rbmo.2025.105178
17. Nicolì P, Viganò P, Saccone G, et al. **Oocyte cryopreservation for patients with endometriosis: where are we now? A systematic review.** *Reproductive Biomedicine Online.* 2025. DOI: 10.1016/j.rbmo.2025.104839
This document is intended to help you understand the medical reasoning behind your doctor’s recommendation. It does not replace a personal consultation with your care team.