Qs re endometriosis excision - which progestin to use post-op and how you’d assess risk of leaving small endometriomas vs excising and lowering already low ovarian reserve

39F, 5’3”, 120 lb, chronic migraine/cluster with mri changes (emgality and sumatriptan, magnesium, B2, melatonin, D3), asthma (symbicort), Raynaud’s, psoriasis (occasional topicals), endometriosis (slynd), uterine fibroids, iron deficiency anemia (periodic infusions), positive ANA, positive anti-RNA polymerase III (no diagnosis, just interesting enough when combined with raynaud’s to be followed by rheum), mild pulmonary valve regurgitation, thickened mitral leaflets, history of peptic ulcer from nsaid use (now resolved), non smoker, do not drink, tretinoin, Aczone, ipratropium bromide (headache-related rhinitis), fexofenadine. I am having a laparoscopic endometriosis excision and hysteroscopic myomectomy/uterine septum revision next week. Two qs: 1. Do you have advice about which progestin to use post-op? Kyleena made me bleed for eight months straight and cry at nothing, it also caused unwanted hair growth and intense acne despite having been on tretinoin and Aczone for 7 years. Switched for a Mirena and not only continued to bleed daily but also had two recognizable periods 14 days apart, continued mood/skin changes. Removed it after a month, finally got diagnosed with endometriosis based on MRI, switched to Slynd. Slynd has less intense mood and skin changes (I know it’s weird to have fewer body wide effects from an oral contraceptive than the IUDs, but the IUDs definitely made more intense mood and skin changes for me than Slynd. Lap surgeon also doing hysteroscopic myomectomy (small intracavitary fibroid at fundus) and uterine septum revision (2 cm). In an ideal world I’d be able to get an IUD again (prior to all this had copper IUD for seven years without any major issue). Is there any reason for me to hope that Mirena would have different side effects after removing the septum and fibroid and endo? Did I just not give it enough time? I get that the bleeding could be affected, but I’m mostly worried about the mood and skin changes. also open to other suggestions! 2. MRI shows a bunch of endo that I’m excited to evict, but there are also bilateral sub-4cm endometriomas and I‘d value your advice on how to think about the value of excising them vs risk of reducing ovarian reserve. My AMH (.8) and AFC (6 measured on Slynd, day 15ish after 1st day last period, which I get despite taking Slynd continuously) are already not great. I dont want to leave the endometriomas in the hope of ever having a kid if that is a pipe dream. I know I’m 39, but please be gentle. This decision is wrecking me. Thank you.