Abstract
To evaluate recurrence/persistence after the initial transvaginal ultrasound-guided ethanol sclerotherapy (EST) for ovarian endometriomas, identify recurrence-associated factors, and assess feasibility, safety, and ovarian reserve outcomes after the initial procedure. Retrospective cohort study. Tertiary referral center, Ankara, Türkiye. Women aged 18-45 years undergoing transvaginal ultrasound-guided EST for ovarian endometriomas between January 2021 and January 2026. A total of 115 EST attempts were screened; 112 were technically successful. The primary study cohort included 91 patients; time-to-event analysis was available for 88 patients. A standardized 10-step transvaginal EST technique was used: aspiration, saline irrigation, instillation of 96-96.5% ethanol at 60% of aspirated volume (maximum 100 mL), 10-minute retention, and complete aspiration. Recurrence/persistence was defined as ultrasonographic detection of an endometrioma-like cyst ≥20 mm after the initial EST; repeat intervention alone was not a recurrence criterion. Recurrence/persistence occurred in 22 of 88 evaluable patients (25.0%); Kaplan-Meier cumulative estimates were 22.3% at 12 months and 29.1% at 24 months. Higher BMI was associated with recurrence/persistence in univariable analysis (HR, 1.21 per 1 kg/m; 95% CI, 1.10-1.33; P<0.001) and in the primary multivariable model (HR, 1.20; 95% CI, 1.10-1.32; P<0.001). In an expanded sensitivity model, the adjusted HR for BMI was 1.22 (95% CI, 1.11-1.35; P<0.001). Technical success was 97.4% (112/115; 95% CI, 92.6%-99.5%). Periprocedural complications occurred in 8 of 91 patients (8.8%; 95% CI, 3.9%-16.6%); no Clavien-Dindo grade IIIb-V complications occurred (0/91; 95% CI, 0.0%-4.0%). Median AMH declined modestly at 1 month (-0.16 ng/mL; P<0.001) and 6 months (-0.12 ng/mL; P=0.019). EST achieved high technical success in this carefully selected cohort. Recurrence/persistence remained clinically relevant, and higher BMI was associated with recurrence/persistence across primary and sensitivity analyses. This observational association should not be interpreted as causal, and the absence of histological confirmation limits conclusions regarding oncologic safety.