Monday, January 10, 2011

Chocolate cysts - how we manage them at Malpani Infertility Clinic

A chocolate cyst of the ovary ( also known as an endometrioma, endometrioid cyst, or endometrial cyst) is found in some infertile women who have endometriosis. In this disease, the inner lining of the uterus ( called the endometrium ) grows in various abnormal locations within the pelvis . One of the commonest sites this aberrant endometrial tissue can be found in is the ovary. With every menstrual period, this tissue grows, enlarges , bleeds, and sloughs off . Here it forms a cyst; and because the contents of this cyst are black, tarry and thick, they resemble dark chocolate , hence the name ! ( I feel that sometimes doctors can have a perverse sense of humor . For most women, the word chocolate produces happy feelings, because chocolates are a woman’s favourite treat. To label a disease condition after a dessert is something which only an unfeeling man would do ! )

How is the diagnosis made ? While an alert doctor will often suspect the diagnosis in infertile women with progressively painful periods, often women with chocolate cysts may have no symptoms at all. This means this diagnosis is made during a regular infertility workup ; or even during a routine pelvic examination. While some cysts are large enough to be felt on pelvic examination, many are small and cannot be detected on clinical examination.

Ultrasound scanning is an excellent way of diagnosing chocolate cysts and can pick up cysts which are very small. On scanning, chocolate cysts are complex masses ( which have both solid and cystic components); and are often tender. They have a typical ground glass appearance because they contain old blood. They can vary in size from a few mm to over 10 cm; and can be bilateral. However, it’s not possible to make a definitive diagnosis of endometriosis on ultrasound scanning, as many other conditions can also produce cysts in the ovary. The diagnosis can be confirmed either by aspirating the cyst under ultrasound guidance ( and finding the typical dark old blood which is diagnostic of endometriosis); or by doing a laparoscopy.

In the past, a laparoscopy was the gold standard for making the diagnosis of endometriosis, as this allowed the doctor to actually inspect the pelvic contents. However, because it involves surgery, many infertility specialists no longer do a laparoscopy for their patients.

There are 3 key factors which doctors need to evaluate when making a decision as to how to treat chocolate cysts in infertile women.

1. Whether the patient has any symptoms
2. The size of the cyst
3. The AMH level

Thus, when a small chocolate cyst is picked up when doing a routine vaginal ultrasound scan in a young asymptomatic infertile woman , the best course of action maybe masterly inactivity. This is because this is an incidental finding which is best documented and left alone. Remember that doctors do not treat ultrasound images - we treat patients ! Many fertile young women also have endometriotic cysts which they live with happily for all their lives ( and because they have enough sense not to go to a doctor, they often do not even know that they have a chocolate cyst !) Unfortunately, many doctors tend to be trigger-happy, and when they find a cyst on a pelvic ultrasound scan, they reflexly perform laparoscopic surgery – both to confirm the diagnosis; and to treat the cyst ! The danger is that this unnecessary surgery can actually reduce your fertility , as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.

Small cysts ( less than 3 cm in size) can be happily left alone . If they are larger, they can be monitored by serial scans, before making a decision as to what the definitive treatment should be.

As regards treatment choices, the options include medical therapy or surgery. Medical therapy consists of medicines such as danazol or GnRH analogs to suppress the endometriosis; and while this is very effective in providing temporary symptom relief , it is not very effective in treating the cyst, which tends to remain inspite of the treatment.

The definitive solution is surgical; and this usually consists of operative laparoscopy . Very few doctors will now do open surgery ( laparotomy) to treat a cyst, no matter how large it is.
There are many controversies regarding the optimal surgical management of chocolate cyst s in an infertile woman, which is why it is important that you go to an expert. In the past , doctors would try to excise ( completely remove) the entire cyst , to reduce the risk of its recurring . However, because this meant that they needed to also sacrifice normal ovarian tissue during this process, they often ended up pushing infertile patients from the frying pan into the fire by reducing their ovarian reserve and worsening their infertility ! This is why most doctors today prefer to be far more conservative in infertile women with chocolate cysts ; and will usually just create an opening in the cyst wall ( marsupialisation) to drain the contents. This often provides dramatic temporary relief. During the operative laparoscopy, the doctor also has an opportunity to remove the adhesions (scar tissue) and the other endometrial implants which are often found in women with chocolate cysts and treating these can also help to enhance their fertility for a few months. The chances of achieving a pregnancy are maximal within a few months after the surgery. However, if a patient has failed to conceive within one year of the surgery, then the chances of success with repeat surgery are quite poor; and it’s better to consider assisted reproduction.

The major bugbear with chocolate cysts is that they tend to recur. This is why doctors will often combine medical suppression with surgical treatment. However, all these are temporizing measures, which help to buy the patient time – we really do not have any way of curing this enigmatic disease !

If the chocolate cyst recurs, patients are understandably upset, and feel that the doctor was incompetent and did not do a good job with the surgery. This is not always true, because endometriosis can be quite an aggressive disease in some women, and can recur even if the surgeon was very skilled. It’s important to ask for DVD documentation of all surgical intervention, so that the video can be reviewed later on, if needed.

If the cyst recurs, patients will often go to another surgeon ( who they feel is more expert) to try to correct the problem. The pelvis in some of these patients starts resembling a battle field, because they often end up having many laparoscopies done by many different surgeons, each of whom claims to be the best ! The surgery can be extremely challenging in these patients . The scarring , adhesions and previous surgery tend to distort the anatomy and the pelvis sometimes is completely frozen. Operative complications in these cases ( for example, inadvertently opening the bladder or rectum) are not uncommon.

The AMH level is a very important factor which many doctors tend to overlook in treating infertile women with endometriosis. The major danger with endometriosis is that the chocolate cyst replaces normal ovarian tissue, as a result of which many of these patients have little normal ovarian tissue and poor ovarian reserve as a result of their disease. This is why it’s important to assess your ovarian reserve by checking your AMH level and your antral follicle count before doing anything further ! If your AMH level is low, then it’s best to avoid surgery and to move on to IVF to maximize your chances of having a baby quickly ( before the disease becomes worse and eats away more of your precious reserve).

For young women with normal ovarian reserve, open fallopian tubes ( as proven on HSG) and small chocolate cysts who have no symptoms, it’s worth trying IUI before doing anything more aggressive. However , if the patient is symptomatic and the endometriosis is causing pain, then this become a trickier issue ! You need to set your priorities – is pain control more important ? Or is having a baby more important ? This is often a difficult decision to make, but you need to decide. It’s best to make a list of all your options so you can think through these logically.
If having a baby is key, then it’s best to manage your pain symptomatically and concentrate your energies on getting pregnant quickly. IVF is very effective , as it maximizes your chances of getting pregnant quickly . The beauty with IVF is that it allows you to kill 2 birds with one stone – not only do you get your deeply desired baby, you also have dramatic pain relief for at least 1 year ( because your periods will stop during your pregnancy and your postpartum period ). As an added bonus, the endometriosis will also get better as a result of the pregnancy in some women ! This is why many doctors advise that the best treatment for a young woman with endometriosis is a pregnancy. Of course, this is easier said than done, because endometriosis does affect your fertility !

Do you have a chocolate cyst and are unsure what to do ? Send me your medical details by filling in the free second opinion form and I'll be happy to help !

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  1. Anonymous4:38 AM

    Hi! I was hospitalized a couple of months ago with a ruptured ovarian cyst. I improved some over the next couple of months, but was still having pain, so I had it removed laparoscopically. My doctor said it was an endometrioma but there was no other evidence of endometrial tissue in my abdomen or on the other ovary. She then said that I did not have endometriosis and I should be fine coming in for just an annual exam. I am under the impression that scar tissue from the surgery could still effect my fertility. I'm also afriad that I could still have endometriosis, it might just develop later. Shouldn't she be following up on this regularly? Isn't there a chance I could still have endometriosis, since this happened once? I would appreciate any information! Loved the article.

  2. Therefore the moral of the story could be that there is a need for regular and routine checks so that the cyst when found could be tackled and treated.

  3. Anonymous8:47 PM

    I am diagnosed with a chocolate cyst about 4 cm. Sometimes I have just a little pain as you are tired and sometimes rarely during my period strong pains.
    The doctor said to tried to get pregnant and if after 9month I will not be pregnant then we can do a surgery. I have no children yet. What do you sugest?

  4. Anonymous4:41 PM

    Sir 21years girl... operated twicw for cyst.. now she have another cyst in ovary. what to be management line? cyst drainage? or laparoscopic? if cyst drain done, it should be followed by what? not married yet. How to go for fertility presevation for nxt3-4years? she had luperiod shots for3-4times. Pls sir What can be the solution for cyst at present? Everything thing looking helpless

  5. I would NOT advise you to have any surgery. Unnecessary surgery reduces her fertility as normal ovarian tissue is also removed along with the cyst wall, thus reducing her ovarian reserve.

    Is the cyst bothering her ? If so, you can always get it aspirated ( punctured) under ultrasound guidance ! If not, then leave it alone

    Birth control pills may help to prevent an increase in the cyst size

    Please test her AMH and AFC to check her ovarian reserve

  6. Anonymous3:03 PM

    Dear Sir ,

    I have a cyst measuring 4.5 cm and 5 Cm in the both right and left Ovary. doctor suggested me few hormonal tablets ( birth Control Pill) for the cyst to go, but the cyst did not respond . I am taking Metformin tablets , Folic acid and APCOD Obis . I am 90 Kilo.I have reduced 8 kilos. I am Married since 1.6 Years no children. Doctor suggested me a laproscopy surgery to remove the cyst . I am on treatment form past 7 months.
    Now my blood glucose levele is normal
    T3 , T4 , TSH is normal .
    i also did CA 125 test the result was 8 .
    Do i Have a chocolate cyst . I am more worried

    we are planning for children.
    let me know if i am taking a right decision.


    1. I would NOT advise you to have this surgery. Unnecessary surgery reduces your fertility as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.

      Is the cyst bothering you ? You can always get it aspirated ( punctured) under ultrasound guidance !

      Do a complete workup before starting treatment haphazardly.

      You need to do ALL the following simple medical tests:

      semen analysis for your husband ( to check his sperm count and motility).

      blood tests for you for the following reproductive hormones - FSH ( follicle-stimulating hormone),LH ( luteinising hormone),PRL ( prolactin) , AMH ( antiMullerian hormone) and TSH ( thyroid stimulating hormone) on Day 3 of your cycle, ( to check the quality of your eggs). Do this from a reliable lab such as SRL ( Day 1 = Day the period starts.

      HSG ( hysterosalpingogram, X-ray of the uterus and tubes, on Day 8 of your cycle ( to confirm
      your fallopian tubes are open);

      The vaginal ultrasound scan on Day 10-11 should check for the following. a. ovarian volume b. antral follicle count c. uterus morphology d. endometrial thickness and texture

      Please send me ALL the detailed test results and medical reports . You can scan them in as a single doc or pdf file and email them to me.

      Please send me all the results together, rather than piecemeal, so I can interpret them intelligently

      With these test results, we can determine what medical problems are causing your

      If there is a problem, then we can treat it !

      Taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !

      You can talk to some of our patients by email at

      We look forward to helping you to have a baby !


      Dr Aniruddha Malpani, MD
      Malpani Infertility Clinic, Jamuna Sagar, SBS Road, Colaba
      Mumbai 400 005. India

      Clinic Mobile: 9867441589

      Tel: 91-22-22151065, 22151066, 2218 3270, 65527073

      Helping you to build your family !

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      relationship at

    2. Anonymous7:17 PM

      What if the Cyst Fills up even if it is aspirated, we have already done Semen Analysis for my Husband too which doctor said normal.

      will send all the reports to your mail as soon as possible


    3. Yes, it can re-fill - the cyst aspiration is a temporising measure, which helps buy time to start fertility treatment . It is not a definitive solution. Thus, if the cyst is aspirated and an IVF cycle started, and you get pregnant, the cyst will resolve during the pregnancy

  7. I have a 8.7cm cyst in the left ovary and am 6 weeks pregnant. The ultrasound detected it as a possible complex cyst. I have no pain or any other symptoms. Should I opt for surgery in the second trimester to remove the cyst or let it co exist with the pregnancy

    1. Dear Anusuya,

      Please leave the cyst alone - unnecessary surgery can induce a miscarriage

  8. Anonymous10:54 AM

    I m 21, got operated for chocolate cyst on right ovary , 7cm , I was asked to get pregnant soon ..but I don't want ..can I wait for another 10 years ?

    1. I need more information to be able to provide you with intelligent advise.

      We need to test your ovarian reserve

      One option maybe to freeze your eggs

      What’s your AMH level ?

      Can you please test your antral follicle count by doing a vaginal ultrasound scan ? Read more at

  9. Anonymous2:50 PM

    I am having a cyst on my left ovary of6 cm, my CA 125 was 19 six months back and now it is 22 am I at a risk of getting ovarian cancer , why has the level of CA 125 increased

    1. This is a normal variation - please don't worry about it. No, you are not at risk of developing ovarian cancer


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