Any evaluation of a patient with an ovarian cyst should include a thorough medical history and a complete physical examination in the search of warning signs of malignancy. The medical history should focus of risk factors and red flags for malignancy. Symptoms such as abdominal bloating, abdominal and pelvic pain, and early satiety and appetite changes should alert the physician to the presence of malignancy and the appropriate steps should be taken [17,18] . It is also important to search for symptoms suggesting endometriosis, especially in this cohort of patients—reproductive-age women with infertility [19] .

The physical examination should include an abdominal and pelvic examination including a bimanual pelvic examination. One should look for alerting signs such as an irregular, solid, fixed and nodular mass or a bilateral finding. The presence of ascites should warn us about the possibility of malignancy.

The physician should remember that physical examination has poor sensitivity for detecting ovarian masses (15% - 51%) [18,20] . In addition, one should remember that in this age group it is not uncommon to find the above warning sign with benign conditions such as endometriosis which can present with bilateral findings and irregularity on pelvic examination and ascites.

In the settings of a benign ovarian mass in a reproductive-age group, there is no added value in measuring CA-125 [21-23] . CA-125 in the reproductive-age group rises in numerous conditions such as fibroids, endometriosis, adenomyosis and pelvic infections and during normal menstrual cycle. This makes CA-125 an unreliable marker for differentiating benign from malignant masses and not helpful at all in the differential diagnosis of benign cysts [21-23] .

Serum levels of CA-125 are not necessary when the Sonographic appearance of the cyst is simple-thin walled, clear fluid, no intracystic structures and lees then 50 mm in diameter [23-26] .

Anti-mullerian hormone (AMH) is a relatively new marker of ovarian reserve and considered the most accurate one available today. A serum AMH level above 0.5 ng/mL is consistent with good ovarian reserve, while lower levels suggest the presence of a depleted ovarian follicle pool. Levels of serum AMH may provide guidance as to the appropriate management of the patient with an ovarian cyst [27-31] .

Reduced ovarian reserve as measure by serum levels of AMH may contraindicate surgical management in the specific patient.

Pre-operative and post-operative AMH levels may be used as a tool for evaluating ovarian damage after surgery [27-31] .

The most widely used imaging modality is gray-scale, high frequency transvaginal ultrasonography. In asymptomatic and reproductive age group, this is the imaging modality of choice [32] .

Ultrasonographic examination will provide us with the size, consistency, laterality and intracystic structures (septations, nodules, papillary extensions) of the cyst. These findings, in correlations with the physical examination will provide us with a deeper insight as to correct diagnosis.

Benign cystic teratoma (Dermoid) in characterized by fat-fluid level and intracystic floating balls, shadowing echogenicity, diffuse or regional high amplitude echoes, dermoid mesh and tip of the iceberg sign [33]. When two or more characteristic sign are present, the diagnosis of dermoid cyst can be made with a high positive predictive value [33].

Endometrioma is sonographicaly characterized by ground glass echogenicity and one to four compartments and no papillary structures with detectable blood flow [34] .

Color Doppler alone does not improve diagnostic evaluation [35-37] , but the combination of color flow mapping with 3D imaging may improve sensitivity in complex masses [38,39] .

The role of computed tomography (CT) scan and magnetic resonance imaging (MRI) in the evaluation of a suspected mass in reproductive-age women is reserved for cases in which suspicion for malignancy arises.

Conservative management can be undertaken with women with small and simple ovarian cysts (less than 50 mm in diameter, thin walled, clear fluid, no itracystic structures). This group of women need no follow up, since the cysts are almost invariably physiological and will regress spontaneously within 3 menstrual cycles [40] .

A consensus statement published by the Society of Radiologists in Ultrasound concluded that asymptomatic simple cysts with a diameter of 30 - 50 mm in diameter do not require any follow-up, cysts with a diameter of 50 - 70 mm require follow-up, and cysts more than 70 mm in diameter should be considered for either further imaging or surgical intervention due to difficulties in examining the entire cyst [41] .

The course of pregnancy of patients with dermoid and other benign ovarian cysts, including perinatal outcomes, is favorable. The cysts should be managed conservatively if possible with routine ultrasound follow-up during the pregnancy since complications are extremely rare [42] .

The use of combined oral contraceptives has been proposed for the treatment of functional ovarian cysts. According to the Cochrane review of the effects of the oral contraceptive pill in the treatment of functional ovarian cysts, there was no earlier resolution in the treatment group compared to the control group [43]. However, these trials were small with significant heterogeneity. It has been shown that the use of combined oral contraceptives may reduce the risk of cyst occurrence [43-45] . Therefore, combined oral contraceptives are still a possible treatment option for already existing functional cyst.

There is no medical treatment for benign cystic teratoma (dermoid) except for expectant follow up.

Medical treatment for endometriosis includes oral contraceptives, progesterone, GnRH agonists or antagonists. The problem with this treatment options is that they impair fertility and though are counter-effective in patients seeking fertility treatments [46]. Some of the treatments are useful prior to starting stimulation for IVF, increase in the implantation rate in stages III and IV endometriosis [15, 46-49] .

Surgical management should be offered when tissue diagnosis is necessary or when the ovarian cyst interferes with oocyte retrieval or ovarian stimulation. When considering surgery in reproductive-age patient, the ovarian reserve should be assessed prior to the procedure and if severely reduced surgery may be deferred in order to further explore other treatment options.

Before performing surgery, we should discuss with the patient the issue of ovarian reserve compromise after surgery and its implication on future fertility.

Ovarian cysts that persist or increase in size after several menstrual cycles are unlikely to be functional [50- 52] , for example mature cystic teratoma (dermoid cysts) has been shown to grow over time, increasing the risk of pain and ovarian accidents (torsion, rupture) [10,53] . Surgical management is therefore usually appropriate in these settings. 

When encountering an endometrioma in women undergoing ART, the new ESHRE guidelines conclude that surgery should not be performed before ART only in the aim of improving pregnancy rate but for symptoms improvement. Surgery should be considered before ART for tissue diagnosis, reducing the risk of infection after oocyte retrieval and improve accessibility of follicles. The guidelines also conclude that if surgery is performed, cystectomy is the best option of treatment rather than aspiration or ablation  ADDIN EN.CITE  ADDIN EN.CITE.DATA [13,14] .

When surgical management is indicated, the laparoscopic approach should be undertaken. Laparoscopic surgery for ovarian masses presumed to be benign is associated with lower postoperative morbidity and shorter recovery time and is preferred to laparotomy in suitable patients [54-57] . In a systematic review, that included six randomized controlled trials comparing the laparoscopic approach to laparotomy for ovarian cysts has shown reduced febrile morbidity, less postoperative pain, lower rates of postoperative complications, earlier discharge from hospital and lower overall cost [58] . It is also costeffective because reduced hospitalization time and earlier return to work [59] .

When performing laparoscopic surgery for the management of a benign ovarian cyst, complete removal of the capsule should be performed. Aspiration alone, either laparoscopicaly or vaginaly, is less effective and carries a high rate of recurrences (46% - 84%) [60,61] .