Chocolate cysts – how we manage them at Malpani Infertility Clinic

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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 favorite 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 work up; 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 in spite 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 battlefield, 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!

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19 Responses to Chocolate cysts – how we manage them at Malpani Infertility Clinic

  1. Commenter says:

    My wife is 32yrs old has endometrial cyst of size 2x2cm on her overy and the AMH is 0.53(first report) 0.22(second review) with in the gap of 1month. What are her chances of getting pregnant in normal way. Or shld we go for IVF directly. Is there any medicine to improve her AMH. Pls guide us

    • Your wife has Stage IV endometriosis and diminished ovarian reserve. It is reasonable to pursue pregnancy aggressively with IVF. Her AMH level is low and she will probably produce few eggs. At age 32, she is still relatively young — this increases her chance of conceiving even with few eggs.
      AMH levels reflect the egg pool that is still available. Since we cannot increase the number of available eggs, it is not possible to increase the AMH level.

      Dr V Karande

  2. Commenter says:

    Very informative.

  3. Commenter says:

    Hi, I am 35 years old, have been TTC for 3 yrs, had two failed IVF cycles (both with blastocysts; one fresh, one medicated FET). During last cycle, scan found small endometrioma on ovary (2cm) after a ruptured cyst on same ovary 2 yrs ago. Have asked for laparoscopy several times over the years to confirm endometriosis diagnosis but my IVF clinic is pushing me to do another FET despite pain/ repeated implantation failure. My FSH levels were 5.6. Should I consider surgery to remove endometriosis before wasting another embryo? Many thanks, Rh.W

  4. Anonymous says:

    Hi,i have cholete cyct

  5. Commenter says:

    hello. I had endometrial cyst on both ovaries, On the right ovary it measures for about 5.37×4.37×4.25 cm while on the left measure for about 1.59×1.55×1.57 cm. what kind of medication is advice in my case?

  6. Commenter says:

    Dear Dr V, I recently had a pelvic scan and the doctor found an endometriotic cyst (26mmx16mmx18mm) in my left ovary. He said it was small and recommended to wait and monitor the evolution. I had no symptoms, it was a routine check. I am scared that my fertility could be compromised. I am 33 years old and planning to become pregnant next year. Is there anything that I could change in my lifestyle/diet to stop it from growing?

    • At present it is an incidental finding.
      This is especially so since you are not having any symptoms.
      I would not recommend any active intervention other than a repeat ultrasound in 6 – 12 months.
      If you do not conceive within 12 months of trying, please consult with a Board Certified REI.
      We would welcome you as a patient at InVia.
      Dr V Karande

  7. lucy says:

    I am 29yrs old,i have been trying to get pregnant for 4yrs. Last year,I was diagnosed with endometriosis. I was placed on zoladex for 4 months and did Ivf after but it was not successful. Dr said I shd do operation but am afraid. Help I really want to get pregnant

  8. Anonymous says:

    hi. I am 34yrs old. I have suffered symptoms of heavy painful periods, flooding, pelvic pain radiating down legs, fatigue, etc for over five years. last year a tv ultrasound picked up a 5cm endometrioma on my right ovary and I was told this meant I have stage 4 endo and my only option was removal by laparoscopy. I had to agree to removal of cyst along with high possibility of needing ovary and tube taken too. I had my op in November which ended up as a laparotomy due to a umbilical hernia repair when I was a child. I saw gynae a couple of weeks after and they said there was nothing there and they didnt need to do anything. I was left feeling very confused especially when the op/recovery was 5 hours. I have since had irregular bleeding and rectal bleeding on top of my usual symptoms so I went back to my gp. I had another tv ultrasound and this showed two 2cm endometriomas again on the right ovary. this time I saw a different gynae. she was very reluctant to give her opinion about my op and she has put me on cerazette. will cerazette get rid of them if they are endo (my periods are the same so far)? is this just delaying the need for an operation? can endometriomas dissappear on their own? I really dont know what to do now. I just want life to be better for my family. this horrible disease affects all of us.

    • Please see a GI specialist to further evaluate the rectal bleeding.
      It is probably secondary to the endometriosis but you need to make sure something else is not going on.
      Cerazette is a progestin-only oral contraceptive (Desogestrel is the active ingredient). It does help suppress endometriosis.
      Endometrioma can rupture (and reform). They usually do not disappear on their own.
      The need for repeat surgery will depend on the severity of your symptoms.
      Dr V Karande

  9. Anonymous says:

    I have two cysts on my one ovary. I have endometriosis with pain. My tubes are open after an hsg was preformed. Just found out my husband has low sperm count and mobility is bad. We are in our late 20’s. Should we just go straight to IVF? Or attempt IUI???

    • Excellent question.
      IVF + ICSI will have the highest pregnancy rate per cycle.
      I generally like to start with 3 IUI cycles. However, with male factor, IVF + ICSI is a better choice when you already have stage IV endometriosis.
      Your young age is a huge factor in your favor.
      Dr V Karande

  10. Commenter says:

    Hi Dr. I’m 32 years. Had done one Ivf which failed. I had a cyst on my right ovary 3.8, which was aspirated, before egg retrieval. During my ivf scans the cyst started growing and is now 3.6. We had 8 follicles and all matured .3 grade a embryos were transfered but didn’t implant. Et was 8.6. Now I am planning for fet in my next cycle. Can you tell me will the endometriosis affect it.

    • I am not sure you have endometrioma.
      These could be functional cysts especially if the aspirated fluid was clear.
      To consider a diagnosis of endometrioma, the fluid should be dark brown (Chocolate cyst, old blood).
      You have not given me all the information regarding your IVF cycle.
      If the egg quality was not compromised, you have a good chance of success.
      Good luck!
      Dr. V Karande

About Dr. Aniruddha Malpani

Dr. Aniruddha Malpani is an IVF specialist with a brilliant career with numerous awards, educational distinctions and prizes. Dr. Malpani completed his postgraduate degree in Gynecology from the University of Bombay in 1986. He received further training in IVF from UCSF, San Francisco, and U.S.A. As a medical student, he studied at Harvard, Johns Hopkins and Yale. He practices in Mumbai, India along with his wife Anjali. He can be contacted at

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