Endometrioma is commonly seen in women of reproductive age who may wish to 
preserve their ovarian function. Surgical treatment is associated with a high 
recurrence rate and its employment for women undergoing assisted conception has 
recently been challenged. Medical treatment has not been shown to be effective 
in controlling symptoms or improving fertility potential. The results of 
retrospective and non-randomized studies have been inconsistent and created an 
ongoing debate between gynaecologists and fertility specialists. This manuscript 
reviews and critically appraises the evidence for management of endometrioma in 
women of reproductive age. In asymptomatic women, surgical treatment is usually 
recommended for women above the age of 40 and for large endometriomas. Except 
for pelvic clearance, there is insufficient evidence to suggest that surgical 
treatment of endometrioma is better than medical treatment with respect to the 
long-term relief of symptoms and quality of life. Laparoscopic excision of 
ovarian endometrioma prior to IVF does not offer any additional benefit over 
expectant management. A large, well-designed, adequately powered randomized 
controlled study that compares the effects of surgical removal versus expectant 
management of endometrioma on ovarian performance and pregnancy outcomes in 
women undergoing IVF is warranted.