{"paper_id":"ba87b116-409f-4075-8310-7f0d055912cd","body_text":"Amsterdam UMC\nPatient preference for treatment of an endometrioma, a qualitative study\nVeth, V. B.; Keukens, A.; Schreurs, A. M. F.; Bongers, M. Y.; Mijatovic, V.; Maas, J. W. M.\nPublished in:\nEuropean Journal of Obstetrics and Gynecology and Reproductive Biology\nDOI:\n10.1016/j.ejogrb.2025.113999\nPublished: 01/06/2025\nDocument Version\nPublisher's PDF, also known as Version of record\nDocument license\nTaverne\nLink to publication\nCitation for pulished version (APA):\nVeth, V. B., Keukens, A., Schreurs, A. M. F., Bongers, M. Y., Mijatovic, V., & Maas, J. W. M. (2025). Patient\npreference for treatment of an endometrioma, a qualitative study. European Journal of Obstetrics and\nGynecology and Reproductive Biology, 310, Article 113999. https://doi.org/10.1016/j.ejogrb.2025.113999\nGeneral rights\nIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s),\nother than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons).\nDisclaimer/Complaints regulations\nIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Amsterdam UMC\nMedical Library know, stating your reasons. In case of a legitimate complaint, the Medical Library will make the material inaccessible and/or\nremove it from the website. Contact address: outputregistratie@amsterdamumc.nl\nDownload date: 10. Nov. 2026\n\nFull length article\nPatient preference for treatment of an endometrioma, a qualitative study\nV.B. Veth\na , b , *\n, A. Keukens\nb\n, A.M.F. Schreurs\nc\n, M.Y. Bongers\na , b , d\n, V. Mijatovic\nc\n, J.W.M. Maas\nb , d\na\nDepartment of Obstetrics & Gynaecology, M ´axima Medical Center, Veldhoven, The Netherlands\nb\nGrow – Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands\nc\nAmsterdam UMC, Vrije Universiteit Amsterdam, Department of Gynaecology and Reproductive Medicine, Endometriosis Center, Amsterdam, The Netherlands\nd\nDepartment of Obstetrics & Gynaecology, Maastricht University Medical Center (MUMC + ), Maastricht, The Netherlands\nARTICLE INFO\nKeywords:\nDecision-making\nFocus groups\nQualitative research\nEndometriosis\nEndometrioma\nABSTRACT\nObjective: The aim of this qualitative study was to identify considerations, objections, and preferences of women \nwith symptomatic ovarian endometrioma in the shared decision-making process.\nDesign: This study was conducted as a qualitative study, including twenty patients facing or faced therapeutic \ntreatment options for an ovarian endometrioma.\nSetting: Four focus groups were held between February 2020 and June 2021 in the Netherlands. Two of them \nwere held online due to COVID-19 pandemic.\nPopulation: A qualitative study was performed using semi-structured in-depth focus group methodology. All \nwomen, aged 27 – 44 years, suffered from pain.\nMethods: The focus groups were audio recorded and fully transcribed using ATLAS-ti. Grounded theory meth -\nodology was applied for data analysis.\nMain outcome measures: Outcome measure includes the most important aspects during decision-making process \nfor patients facing or faced therapeutic treatment options for an ovarian endometrioma.\nResults: A total of twenty Dutch women with an ovarian endometrioma were included. Participants named “ relief \nof pain ” , “ fertility ” , “ adverse effects or surgical complications ” , “ recurrence of pain and lesions ” , and “ time untill \ntreatment effect occurs ” as most important aspects during their decision-making process. In addition, women \noften felt “ unheard ” , so more attention should be paid to symptoms of endometriosis.\nConclusion: Participants named “ relief of pain ” , “ fertility ” , “ adverse effects or complications ” , “ recurrence of pain \nand lesions ” , and “ time untill treatment effect occurs ” as most important aspects during their decision-making \nprocess.\nIntroduction\nEndometriosis is a chronic inflammatory disease defined as the \npresence of endometrium-like tissue outside the uterus [ 1 ]. The preva -\nlence of endometriosis varies between 2 – 10 % among the general female \npopulation of reproductive age, but rises up to 50 % in women suffering \nfrom infertility and/or chronic pelvic pain (CPP) [ 2 – 5 ]. Endometriosis \ncan be asymptomatic, but is associated with infertility and/or symptoms \nof, for example, dysmenorrhea, dyspareunia, chronic pelvic pain (CPP), \ndyschezia, or dysuria [ 6 , 7 ]. This pain can be explained by nociceptive \npain, due to actual tissue injury or inflammation or nociplastic pain \nwhich results from abnormal processing of pain in the nervous system, \neven without clear tissue damage or nerve injury. These symptoms of \nendometriosis result in significant reductions in women ’ s quality of life, \ntheir social participation, and their sexual health, despite its predomi -\nnately benign nature [ 8 , 9 ]. One of the most common manifestations of \nendometriosis is the formation of an ovarian endometrioma (ovarian \ncyst with endometrium-like lining), affecting 17 – 44 % of women with \nendometriosis [ 10 , 11 ]. Treatment options include surgery or medical \ntreatment (analgesics and/or hormonal therapy). Evidence from previ -\nous studies showed that both treatment options for ovarian endome -\ntrioma are effective in reducing pain symptoms [ 12 – 16 ]. The ESHRE \nguideline recommends surgical or hormonal treatment as well as anal -\ngesics, using a shared decision-making approach and taking individual \npreferences into consideration [ 1 ]. As all different treatment options \nhave both advantages and disadvantages, optimal counselling is essen -\ntial to achieve a balanced shared decision-making. A first step towards \nbetter counselling of patients with an ovarian endometrioma is to obtain \n* Corresponding author at: Department of Obstetrics & Gynaecology, M ´axima Medical Center, Veldhoven, The Netherlands.\nE-mail address: V.Veth@mmc.nl (V.B. Veth). \nContents lists available at ScienceDirect\nEuropean Journal of Obstetrics & Gynecology and  \nReproductive Biology\njournal homepag e: www.jou rnals.elsev ier.com/europ ean-journa l-of-obste trics-and-gy necology-a nd- \nreproductive -biology\nhttps://doi.org/10.1016/j.ejogrb.2025.113999\nReceived 11 December 2024; Received in revised form 20 February 2025; Accepted 21 April 2025  \nEuropean Journal of Obstetrics and Gynecology 310 (2025) 113999 \nAvailable online 22 April 2025 \n0301-2115/© 2025 Published by Elsevier B.V. \n\ninsight into the decision-making process for women ’ s treatment of \nchoice. It is important for gynaecologists to gain a thorough under -\nstanding of which risks and benefits are important for patients, as well as \nwhich insights matter most.\nThe aim of this study is to identify considerations, objections, and \npreferences among women with an ovarian endometrioma facing \ntreatment. This will provide deeper understanding of the decision- \nmaking process for women with symptomatic ovarian endometriomas.\nMethods\nStudy design\nA qualitative study design was used, with a semi-structured focus \ngroup methodology. We chose a qualitative focus group study, because \nthis research method answers the questions best regarding experience \nand perspective of patients with an ovarian endometrioma [ 25 ].\nRecruitment and participants\nWomen included in this study were Dutch-speaking, premenopausal, \nwith a minimum age of 18 years old, diagnosed with a symptomatic \novarian endometrioma. Symptomatic was defined as pain, such as \ndysmenorrhea, dyspareunia or chronic abdominal pain complaints. We \nexcluded women who were facing fertility problems but did not have \nany pain complaints. These women were facing or faced a decision- \nmaking process for their treatment. After receiving oral and written \nstudy information, participants provided informed consent before \njoining the focus groups. No predetermined number of focus groups was \nestablished. The groups continued until data saturation was reached, \nwith 5 – 8 women per group as recommended [ 26 ]. Data saturation was \nreached if the last focus group no longer showed any new insights.\nFocus group one (FG1) took place in February 2020. The following \nfocus groups were postponed for several months due to COVID-19. The \nsecond focus group (FG2) took place in August 2020. With the intention \nto allow the other focus groups to take place on location, it was once \nagain decided to suspend the focus groups after the second focus group. \nHowever, given the increased restrictions by the COVID-19 pandemic, \nthe decision was made to conduct the remaining focus groups digitally. \nThese took place May 2021 (Focus group 3, (FG3)) and June 2021 \n(Focus group 4, (FG4)). FG1-FG3 included participants treated at \nEndometriosis Expertise Center of M ´axima Medical Center \n(M ´aximaMC), Veldhoven, while FG4 also included patients from \nEndometriosis Expertise Centers of Maastricht University Medical Cen -\nter (MUMC + ) and Amsterdam UMC, the Netherlands. Travel costs were \nreimbursed for FG1 and FG2 participants.\nResearch methodology and data collection method\nAll focus groups were facilitated by the same researcher (AS). This \nresearcher was not involved in other studies these women were involved \nin, nor is the researcher involved in the follow-up study, to completely \navoid personal bias as advised by the COREQ checklist [ 27 ]. Prior to the \nfocus group, we asked these women to complete a short questionnaire \nwith baseline questions about time to diagnosis, previous pregnancies or \nwhat treatments they already had received for their endometrioma. \nPermission for audio recording, and, for FG 3 and FG4 video recording, \nwas obtained before the start of the focus group, whereby confidentiality \nand anonymity in data processing and reporting were assured.\nWe ensured an open and safe discussion in which women could name \nall the aspects that were essential to them in their treatment decision. At \nthe end of the session, women were asked to rank their aspects, with \nnumber one indicating which aspect is most contributing to their choice \nof treatment option, and number five being the least contributing aspect.\nData analysis\nAudio tapes were transcribed verbatim and analyzed thematically \nusing ATLAS-ti. Thematic analysis means that the transcribed focus \ngroups were examined to extract core themes within transcripts [ 28 ]. \nThis analysis started with reading the transcripts and classifying the data \nby codes. These codes were divided into attributes. This was performed \nby two researchers (AK and VV), who started with inductive coding. \nAfter the first focus group, also deductive coding was used, as the at -\ntributes obtained from the first focus group were also known. The results \nof this thematic analysis were discussed within the research team (AK \nand VV), to reach consensus.\nResults\nSample characteristics\nA total of four focus groups were held. Of these four, two of them \nwere held face to face and the other two online due to the COVID-19 \npandemic. A total of twenty women participated. FG1 consisted of five \nwomen, FG2 of four women, FG 3 of six women and FG 4 of five women. \nThe average time per session was 106 min, with a range of 74 to 127 \nmin.\nAll focus groups started with a short general introduction by all \nparticipants and the involved researcher. In the first focus group, the \ngeneral question, namely “ what is important in the choice of treatment \nfor your endometrioma ” , was not fully understood by the participants, \nso afterwards, this general question was evaluated and adapted to “ we \nwould like to know what important aspects are for you to choose one or \nthe other treatment ” . During the focus groups, we clarified this question \nby adding “ it is not about which treatment you would choose, but which \naspects of the treatment are important to you ” . After this, we moved on \nto the research question that we would like to have answered at the end \nof the focus groups, which was: “ which aspects are important when \nchoosing surgical treatment, or medical treatment? ” . This study is a \npreparation for the SOMA study, an ongoing study in the Netherlands. \nThis study is a RCT and prospective cohort study that compares opera -\ntive treatment to medication in women with an endometrioma (SOMA \ntrial) [ 29 ].\nBaseline characteristics are stated in Table 1 . Pain symptoms asso -\nciated with endometriosis were obtained through questionnaires which \nwere completed prior to the focus group. A numeric rating scale (0 – 10, \nwith0indicatingnopain) was requested for dysmenorrhea, dyspareunia, \nchronic pelvic pain, dysuria and dyschezia, based on the past month \n( Table 2 ).\nIdentified themes\nIn this qualitative study where we have explored motives in the \ntreatment decision-making process for women with symptomatic \nendometrioma, the following fixed themes were identified: “ relief of \npain ” , “ fertility ” , “ adverse effects or complications ” , “ recurrence of pain \nof lesions ” , and “ time untill treatment effect occurs ” . Fig. 1 shows the \nthemes that recurred in all focus groups. The data was merged for each \ntheme separately and are illustrated with quotes from the transcripts.\nTheme 1: Relief of pain\nSymptomatic women with endometrioma mainly want to get rid of \npainful symptoms related to their ovarian endometrioma or endome -\ntriosis in general. Pain is the primary complaint mentioned which is also \nillustrated by the high pain scores and associated moderate QoL \n( Table 2 ). Different types of pain were described, such as dysmenorrhea, \ndyspareunia and low back pain. In the questioning we did not distin -\nguish between complaints that fit with nociceptive or nociplastic pain. \nPatients did not make a distinction either.\nV.B. Veth et al.                                                                                                                                                                                                                                  European Journal of Obstetrics & Gynecology and Reproductive Biology 310 (2025) 113999 \n2 \n\nWomen said that initially it does not matter how the pain goes away, \nas long as it goes away. \n“ For me the pain was really so high actually. It was so painful that just the \nsimplest things in life were actually already very difficult. So, yes, [ … ] the \npain was for me at that moment also really unbearable, so to speak ” \n(FG4).\nAnother women stated: “ If I ’ m just in so much pain that you can ’ t even \nmove or can ’ t even put on a sweater because of the pain[ … ] no, that has \nto be resolved first and then move on. [ … ] it was just too extreme ” (FG4).\nThere was a conflicting opinion as to whether endometriosis lesions \nshould be completely removed. Some of the women indicated that if the \npain was gone, they were satisfied. If there were still endometriosis le -\nsions left, that is not a problem, provided this would not lead to disease \nrecurrence in the long-term and could not cause complications/prob -\nlems in the future. Others indicated that even if the pain would be \ncompletely gone, they also wanted the endometriosis lesions to be \nremoved. These two different basic principles determined the treatment \nchoice that these women preferred. The women who had expressed the \npreference of the endometriosis lesions to be gone were much more \nlikely to opt for surgery compared to the other group.\nTheme 2: Fertility\nThe desire to conceive and the adverse effects of both ovarian \nendometriomas and the various treatment options on fertility were an \nextensively discussed topic during these focus groups. In contrast to \nwomen who had no desire to conceive, women with a current or future \ndesire to conceive took the effects of the endometrioma itself and the \neffects of the chosen treatment on their fertility into account in their \ndecision-making process. \n“ I had written down as the first point, and the most important point, the \ninfluence of treatment on fertility. That this would actually be the, yes, \nimmediately the decisive factor in whether or not to operate or whether or \nnot to use medication ” (FG4).\nOn the other hand, there were also women in the focus groups who \ndo not wish to conceive, or women with a fulfilled wish to conceive. The \nfirst group clearly indicated that the desire to conceive did not play an \nobvious role in their decision to choose a treatment. This compared to \nwomen with a completed desire to conceive, who indicated that they \ncurrently do not take fertility into account, but that this is a subject that \nshould be discussed and included in the treatment decision options.\nTheme 3: Adverse effects of medication or complications of surgical \ntreatment\nAdverse effects of medication were mentioned several times as a \nmajor objection to use hormonal treatment, especially mentioned by \nwomen who have used hormonal medication in the past. Several adverse \neffects that have been mentioned were: increased pain, irregular blood \nloss, headache, nausea and vomiting, changes in mood, depressed feel -\nings and decreased libido.\nDuring the focus groups, women repeatedly indicated that care \nproviders should pay more attention to the adverse effects of hormonal \ntreatment. In particular, the changes in mood, libido and the develop -\nment of negative or even depressive feelings were, according to most \nwomen, too little exposed. “ I then opted for the operation and also because \nI prefer not to have a lot of hormones myself. Yes, because I have the idea that \nyou also change your personality? a bit, or mentally [ … ] ” (FG1). The \nTable 1 \nBaseline characteristics of the focus groups and participants. \na \nOne woman did \nnot respond to this question. \nb \nOne woman did not respond to this question. \nc \nTriptorelin and Gonadotropin preparations for IVF.\nCharacteristics Total (N ¼\n20)\nDuration of Interview (min) 105.5\nAge, y 34.60 ± 5.51\nAge at diagnosis\na\n24.63 ± 7.85\nTime untill diagnosis in months 30.40 ± 5.72\nEducation level  N (%) ​\nPre-vocational secondary education 1 (5)\nSecondary vocational education 9 (45)\nSenior general secondary education 2 (10)\nHigher vocational education 5 (25)\nGraduate degree 3 (15)\nRelationship\nb \n N (%) ​\nYes 15 (79)\nNo 4 (21)\nChildren  N (%) ​\nYes 6 (30)\nNo 13 (65)\nCurrently pregnant 1 (5)\nWish to conceive in the future  N (%) ​\nYes 12 (60)\nNo 8 (40)\nUnfulfilled desire for children  N (%) ​\nYes 7(35)\nNo 13 (65)\nCurrent hormonal medication  N (%) ​\nNo hormonal medication 9 (45)\nEthinylestradiol/levonorgestrel 4 (20)\nEtonogestrel (Implanon) 1 (5)\nProgesterone only 2 (10)\nTransdermal estradiol 1 (5)\nContraceptive vaginal ring 1 (5)\nIUD 1 (5)\nGnRH analogue 0 (0)\nOther 1 (5)\nPrevious surgery for endometriosis  N (%) ​\nYes 12 (60)\nNo 8 (40)\nEver experienced a complication during endometriosis surgery  N \n(%)\n​\nYes 3 (15)\nNo 17 (85)\nNote: Data presented as mean ± standard deviation of n (%) unless noted \notherwise. GnRH = gonadotrophin releasing hormone; IUD = intrauterine de -\nvice, N = number, y = year.\nTable 2 \nPain scores and overall quality of life scale. Note: Data presented as mean ±\nstandard deviation. N = number, NRS = numeric rating scale, VAS = visual \nanalogue scale.\nPain scores (NRS 0 – 10) Total (N)\nDysmenorrhea 7.06 ± 2.44 (16)\nChronic pelvic pain 5.38 ± 2.96 (16)\nDyspareunia 5.06 ± 3.11 (16)\nDysuria 3.13 ± 2.70 (15)\nDyschezia 4.63 ± 3.14 (16)\nOverall quality of life scale (NRS 0 – 10) Total (N)\nOverall quality of life 6.05 ± 2.97 (20)\nFig. 1. Theme ’ s resulted from focus groups.\nV.B. Veth et al.                                                                                                                                                                                                                                  European Journal of Obstetrics & Gynecology and Reproductive Biology 310 (2025) 113999 \n3 \n\npsychological changes due to hormonal treatment are not always un -\nderstood, either by the patient’s environment or by the care giver \ninvolved. Women therefore had the feeling that they were not heard \nand/or understood by those who should be supporting them. Women \nindicated that the dialogue should be started between women and health \ncare providers about the advantages, but even more about the disad -\nvantages of hormonal treatment.\nBesides, women indicated that the adverse effects were sometimes \neven worse than the symptoms associated with endometriomas. If this \nwas the case, women withdrew from hormonal treatment. \n“Well, I’d rather have the pain than the symptoms I had as a result of the \nhormones. And the pain that was really very intense. […] I could still \nwork with the pain, but not with those hormonal side effects.” (FG3).\nIn addition to the adverse effects of the hormonal medication, the \nrisks of complications from surgery were also mentioned. Women \nmentioned the fear that more damage will be done due to complications \nduring surgery and that more tissue would be removed, more than only \nthe ovarian endometrioma. It is also indicated that the fear of compli -\ncations is also related to the expertise of the doctor involved. \n“But in such a consideration also the quality of the doctor, because I \nwouldn’t want to let just anyone do this.” (FG3).\nDespite perceptions on side effects and complications, women were \nwilling to accept some of them and accept that there were risks involved \nwith an operation, as long as the pain symptoms disappeared.\nTheme 4: Recurrence of endometriosis lesions or endometriosis related pain\nDuring all focus groups, it was often said that recurrence of endo -\nmetriosis, especially if it is accompanied by recurrence of endometriosis- \nrelated pain, would certainly be a theme that determines treatment \nchoice.\nThe fear of recurrence was often associated with either needing \nsurgery again, or damage to healthy, non-endometriotic ovarian tissue. \nOne woman stated: “If you need to have an ovary removed or partially \nremoved then of course you hope that the other one continues to work. And if \nthere is a chance that it will come back in the other ovary, then what? Because \nthen you won’t have a working ovary anymore. Not a good one. Just saying. \nA clean one” (FG 4).\nThe disadvantage of having surgery was also mentioned, with both \naesthetic problems (for example scars on the skin), as well as recovery \ntime and, again, the risk of complications during this surgery. The \nsuppression of endometriosis by hormonal treatment was not equally \ndesirable for all women. Some women accepted the potential side effects \nof hormonal treatment to limit the risk of lesions recurrence after sur -\ngery, while others considered the risk of reoperation less decisive than \nthe side effects of the hormonal treatment. The realization that endo -\nmetriosis lesions can recur, especially without hormonal suppression, \nwas well known to the women involved. As one woman mentioned: “I \nalways call it weeds that keep coming back” (FG3).\nTheme 5: Time until treatment effect occurs\nThe time until the pain symptoms decrease, is the fifth theme that \nwomen included in their decision-making process. One woman stated: \n“So the only option was going into menopause. I said yes, I said I don’t care, I \nsaid: how long will it take until I’m no longer in pain?” (FG1). It was \nindicated during the focus groups that the amount of pain, and its \nlimiting character, helped to determine an acceptable time until effect \noccurs. If the quality of life was severely limited, a shorter time to effect \nwas being desired. \n“Then the operation, there I had a huge advantage that the pain was \nreally gone immediately from that, right off the operating table. Of course, \nyou had the wound pain, but that was nothing compared to the pain \nbefore” (FG4).\nIf there was a wish to conceive, it was also mentioned that the time \nuntil continuing fertility treatment, or the time until trying to conceive \nagain, was also a factor. “For me the duration until effect is important, \nbecause yes, we want to waste as little time as possible of course. (FG4).\nOther items mentioned\nIn addition to the themes mentioned above, some themes were \nmentioned that did not occur often. For example, women indicated that \nby choosing surgical treatment, they had a greater sense of being ’in \ncontrol’. It was also stated that the contact with the care provider, the so- \ncalled doctor-patient relationship, partly determines the choice of \ntreatment. The opinion/counselling of the healthcare provider was then \nconsidered more than if the doctor-patient relationship was less \npleasant. Contact with other patients with endometriosis (or endome -\ntrioma in specific) was mentioned by several women during the focus \ngroup as very valuable. Their experiences, effects on treatment and \nadvice were taken into account in the final treatment choice.\nIn addition, it was very striking that during all four focus groups, \nwomen indicated that they had felt that they were not ‘being heard’ by \nboth their partner and/or environment and the healthcare provider. \nWomen also mentioned that the relationships they maintained, both \nwith partners and with friends/family, had changed due to endometri -\nosis. They did not feel like the partner they wanted to be, for example \ndue to pain complaints. In addition, they indicated that they did not \nalways feel heard by colleagues or employers when they had to report \nsick due to their complaints. It was precisely ‘feeling heard’ by all people \ninvolved in the lives of these endometriosis patients that was essential \nfor their quality of life.\nDiscussion\nIn this qualitative study where we have explored motives in the \ntreatment decision-making process for women with symptomatic \nendometrioma, the following fixed themes were identified: “relief of \npain”, “fertility”, “adverse effects or complications”, “recurrence of pain \nof lesions” and “time untill treatment effect occurs”. These findings align \nwith previous research on women with deep endometriosis, who also \nprioritized fertility in treatment decisions [ 30 ]. Participants were \nrecruited via the Dutch Endometriosis Foundation, specialized centers, \nand the Leiden University Medical Center, showing similar results for \novarian endometrioma.\nAll these themes together should be included in the shared decision- \nmaking process. Beyond these themes, women emphasized the impor -\ntance of “feeling heard” by their caregivers, family, and workplace \nregarding their symptoms and treatment decisions, consistent with \nearlier studies [ 31–34 ]. This research highlights essential discussion \npoints for counseling, helping caregivers support women in making \npersonalized treatment choices while fostering a sense of being \nunderstood.\nStrengths and limitations\nA key strength of this study is its focus on women with ovarian \nendometriomas, rather than all forms of endometriosis. Additional \nstrengths include the diverse study population in age, education, and \nparental status, as well as achieving data saturation, ensuring no key \nperspectives were missed.\nA limitation is that all participants had already made retrospective \ntreatment decisions, which may have influenced their current prefer -\nences. However, we believe they accurately recalled the factors influ -\nencing their initial decisions. The shift to online focus groups due to \nCOVID-19 may also have affected dynamics, though no significant \nV.B. Veth et al.                                                                                                                                                                                                                                  European Journal of Obstetrics & Gynecology and Reproductive Biology 310 (2025) 113999 \n4 \n\nlimitations were reported by participants. Also, literature shows that \nfocus groups can also be conducted digitally and therefore we do not \nexpect any major bias in current study [ 35 ].\nConclusion\nThis study highlights the themes that women with ovarian endo -\nmetriomas consider when choosing a treatment: “ relief of pain ” , \n“ fertility ” , “ adverse effects or complications ” , “ recurrence of pain of \nlesions ” and “ time untill treatment effect occurs ” . These insights are \nvaluable for improving counseling and ensuring that treatment decisions \nare individualized, allowing for better outcomes and a more patient- \ncentered approach to care.\nDisclosure Statement\nThe Department of Reproductive Medicine of the Amsterdam UMC \nlocation VUmc has received several research and educational grants \nfrom Guerbet, Merck KGaA and Ferring not related to the submitted \nwork. V. Mijatovic reports grants from Guerbet, grants from Merck and \ngrants from Ferring outside the submitted work. All authors declare that \nthey have no competing interests concerning this publication.\nContribution to authorship\nAll authors have accepted responsibility for the entire content of this \nmanuscript and approved its submission.\nEthical approval\nThe study protocol was evaluated by the Medical Ethics Committee \nof the M ´axima Medical Center, Veldhoven (L19.067-N19.059) and \nethical approval was given.\nCRediT authorship contribution statement\nV.B. Veth: Writing – review & editing, Writing – original draft, \nVisualization, Project administration, Methodology, Investigation, \nFormal analysis, Data curation, Conceptualization. A. Keukens: Writing \n– review & editing, Writing – original draft, Methodology, Investigation. \nA.M.F. Schreurs: Supervision, Investigation. M.Y. Bongers: Supervi -\nsion. V. Mijatovic: Supervision. J.W.M. Maas: Writing – review & \nediting, Visualization, Validation, Resources, Conceptualization.\nInformed consent\nInformed consent was obtained from all individuals included in this \nstudy.\nFunding\nThis study is part of the SOMA-trial that is funded by ZonMw, a \nDutch organization for Health Research and Development, project \nnumber 80-85200-98-91041.\nDeclaration of competing interest\nThe authors declare the following financial interests/personal re -\nlationships which may be considered as potential competing interests: V. \nMijatovic reports a relationship with Guerbet, Merck KGaA and Ferring \nthat includes: speaking and lecture fees. If there are other authors, they \ndeclare that they have no known competing financial interests or per -\nsonal relationships that could have appeared to influence the work re -\nported in this paper.\nAcknowledgments\nWe really thank the patients for their time and effort in participating \nin this research and there honest and open attitude towards our ques -\ntions and to each other.\nReferences\n[1] Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, et al. ESHRE \nguideline: endometriosis. Hum Reprod Open 2022 Feb 26;2022(2):hoac009.\n[2] Giudice LC. Clinical practice. Endometriosis N Engl J Med 2010 Jun 24;362(25): \n2389 – 98 .\n[3] Eskenazi B, Warner ML. Epidemiology of endometriosis. Obstet Gynecol Clin North \nAm 1997 Jun;24(2):235 – 58 .\n[4] Meuleman C, Vandenabeele B, Fieuws S, Spiessens C, Timmerman D, D ’ Hooghe T. \nHigh prevalence of endometriosis in infertile women with normal ovulation and \nnormospermic partners. 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