Tubo-ovarian abscess (TOA), a serious sequela of pelvic inflammatory disease, occurs usually in women of ages 20 to 40. Up to 59% of these women are nulliparous. Traditionally, pregnancy rates after TOA are estimated to be 15% or less. Current proposed management algorithms for TOA do not include a separate pathway for women of reproductive age who may desire future pregnancies. A MEDLINE search and extensive review of published literature was undertaken to study management options for patients with TOA, and to compare rates of responders, pregnancies and complications associated with each management option. If intra-abdominal rupture is suspected, and patients are treated with fertility-preserving, conservative surgery, reported pregnancy rate is 25%. If no rupture is suspected and patients are treated with medical management alone, reported pregnancy rates vary between 4% and 15%. If no rupture is suspected, and the treatment is medical management with immediate laparoscopic drainage within 24 hours, reported pregnancy rates vary between 32% and 63%. Laparoscopy should be considered to all patients with TOA who desire future conception. Overall, the advantages of immediate laparoscopy allow for an accurate diagnosis, effective treatment under magnification with minimal complications, possibly faster response rates with shorter hospitalization times and decreased infertility.