Background <p>Fertility-sparing surgery (FSS) is commonly performed in patients with borderline ovarian tumors (BOT) due to their favorable prognosis. However, the long-term prognosis and pregnancy outcomes for these patients remain uncertain. This study aims to assess the feasibility of ovarian cystectomy (OC) and evaluate both oncologic and reproductive outcomes in BOT patients.</p> Methods <p>A retrospective analysis of oncologic and reproductive outcomes was conducted on BOT patients who underwent OC at our department between July 1, 2007, and April 30, 2024, using univariate and multivariate analyses and survival curves.</p> Results <p>Among 85 patients in the study, 12 experienced recurrence post-ovarian cystectomy. High-risk indicators included ultrasound findings, CA-125 levels, extent of surgery, and histological type. Of the 45 who attempted pregnancy, 38 conceived successfully, though no specific factors significantly influenced pregnancy outcomes. Among patients with micropapillary serous borderline ovarian tumors (MP-sBOT), 8 did not receive chemotherapy, while 6 did. Recurrence (2/8 vs. 1/6, <i>p</i> = 0.707) and fertility outcomes (1/8 vs. 2/6, <i>p</i> = 0.347) were not significantly different between those who received adjuvant chemotherapy and those who did not.</p> Conclusions <p>OC is the preferred fertility-preserving treatment for BOT patients, with laparoscopic ovarian cystectomy recommended for most young, reproductive-aged patients. Early conception and close monitoring are advised for those with bilateral or high-risk tumors, though more research is needed on managing pregnancy-associated BOT.</p>