Synopsis
Plan adnexal surgery around oncological safety, symptom control and future reproduction, preserving uterus and functioning ovarian tissue when appropriate while preventing incomplete treatment of suspicious disease.
- Fertility-sparing surgery is a strategy, not a single operation: define pregnancy intentions, age, ovarian reserve context, tubal and uterine factors, lesion biology and cancer risk before selecting the extent.
- For a presumed benign mass, laparoscopic cystectomy can preserve ovarian cortex; plan the dissection plane, careful haemostasis, specimen containment and the possibility that oophorectomy becomes unavoidable.
- In torsion, prompt laparoscopic detorsion and preservation is preferred before menopause when malignancy is unlikely, even if the ovary remains dark after untwisting.
- For an endometrioma when fertility is a priority, NICE supports laparoscopic cystectomy or drainage and ablation; both can improve spontaneous pregnancy, while ablation may preserve more reserve and excision may reduce recurrence.
- Repeated or bilateral ovarian surgery can remove normal follicles and thermal energy can injure adjacent cortex; discuss whether observation, medical symptom control or fertility treatment should precede another operation.
- AMH and antral follicle count estimate ovarian quantity and response, not whether spontaneous conception will occur; use them as part of counselling rather than gatekeeping access to conservation.
- A suspicious or confirmed borderline, germ-cell or epithelial tumour needs a gynaecological-oncology MDT: eligibility for fertility-sparing treatment depends on histology, grade, stage and adequate surgical staging.
- Preserving fertility does not mean compromising cancer care. Retain uterus and contralateral ovarian tissue only when oncologically appropriate, avoid tumour spill, retrieve intact specimens and review final histology promptly.
Key red flags
An irregular solid mass, papillary projections, ascites, metastases or strong vascularity requires oncology planning; ad hoc cystectomy can rupture tumour and leave incomplete staging.
Bilateral ovarian surgery, repeat endometrioma excision, a solitary ovary or already reduced reserve creates a high risk of iatrogenic ovarian insufficiency.
Acute torsion should be detorsed without waiting for AMH or fertility-clinic review; blue-black appearance alone does not justify oophorectomy in a premenopausal patient.
Uncontrolled haemorrhage or pelvic sepsis makes preservation secondary to resuscitation and source control, although unnecessary removal of uninvolved tissue should still be avoided.
The possibility of oophorectomy, conversion to open surgery, unexpected malignancy and later completion staging must be discussed before elective surgery whenever foreseeable.
Investigation priorities
Define lesion morphology, laterality, residual normal cortex, contralateral ovary and malignant risk before selecting surgery.
Management branches
Symptoms, growth or size justify surgery for a mass assessed as probably benign.
- Confirm fertility priorities, laterality, reserve context, morphology and the contingency for oophorectomy before obtaining procedure-specific consent.
- Use experienced laparoscopy where suitable, develop the cyst wall plane, minimise unnecessary thermal injury and contain the specimen during extraction.
- Document residual ovary and tube, send tissue for histology and assign postoperative result review and recurrence advice.