The patient described provided written informed consent for the use and publication of medical data, operative video, and related images for educational and scientific purposes. The following protocol adheres to the human research ethics committee guidelines of Montefiore Medical Center and New York City Health and Hospitals Corporation.
Due to limitations of the available raw recording, not every step in the protocol could be fully documented in the video on this patient.
1. Preoperative evaluation
NOTE: Select patients who are candidates for a minimally invasive surgical resection. Preoperative evaluation is important to create a comprehensive surgical plan and facilitate a thorough informed consent discussion to delineate indications for, risks of, benefits and alternatives to surgical management.
<ol>
	<li>Obtain a thorough history.</li>
	<li>Perform an abdominal and pelvic exam.</li>
	<li>Screen the patient for features of malignancy or deep-infiltrating endometriosis (DIE), which may require pre-surgical coordination with other specialists such as colorectal, urological surgeons, or gynecologic oncologists.
	<ol>
		<li>Obtain abdominal-pelvic imaging with transvaginal ultrasonography (TVUS). Transvaginal ultrasonography is a standard imaging modality as it usually provides adequate visualization and enhanced resolution of the uterus, posterior cul-de-sac, right adnexa, and left adnexa.</li>
		<li>Consider obtaining magnetic resonance imaging (MRI) as shown in Figure 1 to evaluate for the presence of adnexal pathology, adenomyosis, hydronephrosis, and evidence of deeply infiltrating endometriosis (DIE). These findings may be reliably assessed by ultrasound when the study is performed with bowel preparation by an experienced radiologist. 
		NOTE: Hysterosalpingogram (HSG) may be performed to assess for tubal patency.</li>
	</ol>
	</li>
	<li>Determine whether the patient is an appropriate surgical candidate. Indications for surgical cystectomy include size greater than 4 cm with pain or infertility, or size less than 4 cm with medically refractory pain or concern for follicle count or accessibility during assisted reproduction. 
	NOTE: Tailor the approach to the patient&#39;s goals and preferences. Determine whether the patient desires complete removal of endometriosis or prefers more limited surgery. Consider post-surgical fertility plans and whether bilateral or unilateral adnexal resection is indicated. Incomplete resection of disease increases the risk of recurrence but may allow for shorter surgery and reduced morbidity and complications.</li>
	<li>Complete an informed consent discussion to discuss potential risks and benefits of the proposed surgery. Ensure that the patient has no other contraindications. 
	&#8203;NOTE: A more complete resection of ovarian disease often risks decline in ovarian reserve. The patient should be informed of management options regarding abnormal salpinges. In cases of deep infiltrating endometriosis, significant surgical morbidity and need for bowel resection must be addressed. Surgeons must discuss probable events and possible procedure-related complications, including bowel injuries, bleeding, genital-tract injuries, urologic injuries, return of pelvic pain, and post-operative infection.</li>
</ol>
2. Exam under anesthesia and diagnostic laparoscopy
NOTE: The preoperative evaluation and exam under anesthesia are crucial to safely entering the peritoneum and guide the diagnostic laparoscopy.
<ol>
	<li>Position the anesthetized patient in dorsal lithotomy position. The arms should be tucked in a neutral anatomical orientation and care should be taken to protect neurovascular areas.</li>
	<li>Perform an exam under anesthesia. Evaluate for the presence of abdominal wall hernias and scars to guide trocar placement, the size and position of pelvic organs, and for the presence of nodularity in rectovaginal septum as well as other possible sites of endometriosis not appreciated during prior pelvic exam.</li>
	<li>Prepare the surgical site.
	<ol>
		<li>Use appropriate agents (chlorhexidine gluconate in isopropyl alcohol for skin, povidone-iodine or chlorhexidine gluconate for the vagina) and allow the skin to dry. Cover the patient with sterile drapes.</li>
		<li>Place a urinary Foley catheter in the bladder for urine output monitoring and bladder decompression.</li>
	</ol>
	</li>
	<li>Create pneumoperitoneum using standard techniques with entry either peri-umbilically or at Palmer&#39;s Point (Figure 2). 
	NOTE: Use the smallest required trocars and the lowest insufflation pressures to decrease postoperative pain and facilitate patient ventilation.</li>
	<li>Place at least two additional lower abdominal ports as shown in Figure 2.</li>
	<li>Perform a diagnostic laparoscopy to exclude surgical injury during entry and to identify anatomy, adhesions and possible endometriotic implants in the peritoneal cavity (upper and lower abdomen). Evaluate for avascular sites free of adhesions for accessory port placement. 
	NOTE: Port placement should facilitate ergonomics and allow for full visualization and manipulation of pelvic tissue.</li>
	<li>Complete diagnostic laparoscopy. 
	NOTE: A combined approach with adhesiolysis (see steps 3.1-3.4) may be required to completely evaluate the pelvis. The surgeon may choose to defer complete adhesiolysis when balancing its higher surgical risk with the benefits of comprehensive pelvic assessment.
	<ol>
		<li>Place a uterine manipulator (see Table of Materials) and utilize a steep Trendelenburg position to optimize visualization of pelvic structures.</li>
		<li>Sweep mobile structures out of the pelvis with atraumatic graspers.</li>
	</ol>
	</li>
	<li>Systematically evaluate all pelvic structures and spaces. Biopsy any possible endometriotic lesions for diagnostic purposes. 
	NOTE: Endometriosis typically appears as red or white lesions; however, its appearance may be highly variable.
	<ol>
		<li>Use a 30&#176; laparoscope to aid visualization around structures, as needed.</li>
		<li>Obtain pelvic washings of free peritoneal fluid.</li>
	</ol>
	</li>
	<li>Score the extent of pelvic disease using a validated system. 
	&#8203;NOTE: The revised American Society for Reproductive Medicine (rASRM) system21 is most commonly used. However, the Endometriosis Fertility Index (EFI)22 is most appropriate for predicting fertility outcomes.</li>
</ol>
3. Lysis of adhesions
NOTE: This phase is critical for the exposure, restoration of neutral anatomical position, and subsequent enhancement of genital tract function. Ovarian adhesions may prevent follicular development and extrusion of a ruptured follicle with ovulation, while fimbrial adhesions may compromise sweeping of an ovum. Additionally, adequate adhesiolysis is crucial to assure tubal patency. Adhesions are created by inflammatory states, whether by prior surgeries, infection, or endometriosis. Adhesions interfere with adequate exposure, distort anatomy, and subsequently increase complication risk when handling tissue and attempting plane development. Due to distorted anatomical planes, major pelvic vessels and the ureter are frequently in close proximity to the sites of dissection. The surgeon must be prepared to perform retroperitoneal dissection and ureterolysis for safe identification of anatomy.
<ol>
	<li>Consider placement of additional ports at this time, as it will allow for more instruments to work in tandem along with the laparoscope.</li>
	<li>Once port placement is optimal, dissect adhesions to expose the adnexa. Divide &#34;kissing&#34; ovaries and lyse tubal adhesions to free the length of the entire salpinges, including fimbriae.
	<ol>
		<li>Start with the blunt dissection from the healthy tissue proximally, working towards dense adhesions and abnormal anatomy. Triangulate applied forces to allow for efficient dissection. 
		NOTE: Blunt dissection is not always possible with dense adhesions. It is best to start with filmy adhesions to mobilize pelvic and vascular structures to facilitate plane development between adherent structures which may require sharp dissection. The suction irrigator can bluntly dissect, push, sweep, hydrodissect, and aspirate from the surgical field without instrument exchanges. Use atraumatic graspers to apply traction to sensitive tissue and to push and spread.</li>
		<li>Continue along a dissection plane until it can no longer be easily developed bluntly, with care to avoid excessive force. Use scissors or energy devices with minimal lateral thermal spread such as ultrasonic shears to dissect dense adhesions, as these instruments minimize potential for inadvertent injury.</li>
		<li>Focused electrosurgery may be required to control bleeding.</li>
	</ol>
	</li>
	<li>Free the ovary from adjacent structures, such as the pelvic sidewall and cul-de-sac. Ensure full tubal length is freed from adhesions including fimbriae. 
	NOTE: The ovary is often encased in adhesions, which may prevent ovum capture by the salpinges following ovulation.</li>
	<li>Perform retroperitoneal dissection and ureterolysis for safe identification of anatomy prior to dividing adherent structures. 
	&#8203;NOTE: This step ensures that the ureter is not inadvertently damaged. The retroperitoneum is best opened starting at a site of normal anatomy adjacent to the endometriosis and is commonly entered at the level of the pelvic brim by the pelvic sidewall.</li>
</ol>
4. Chromopertubation
<ol>
	<li>Inject dilute methylene blue (Table of Materials) through the uterine manipulator.</li>
	<li>Evaluate laparoscopically for the distension of the fallopian tube and spillage of dye from the fimbriae (Figure 4). If tubal patency is not demonstrated and the fimbriated end appears irreparable, then perform salpingectomy.</li>
	<li>If tubal patency is not demonstrated, perform the following steps.
	<ol>
		<li>Ensure adequate fimbriolysis.</li>
		<li>Use atraumatic graspers to occlude the patent tube proximally. 
		NOTE: Dye will most readily pass through the side with lower occlusion pressure. Use graspers to transiently occlude one&#160;patient side and favor passage of dye through the other.</li>
		<li>Replace the uterine manipulator with a dedicated catheter for HSG and re-attempt distension.</li>
	</ol>
	</li>
</ol>
5. Address tubal pathology
NOTE: Features of abnormal salpinges include irregular contours from adhesions or contents of hydro-, hemato-, or pyosalpinx. Salpinges are also pathologic if chromopertubation fails to demonstrate patency following adequate adhesiolysis. Abnormal salpinges are associated with poor spontaneous pregnancy rates and risk for ectopic pregnancy. Additionally, retrograde flow of tubal contents may reduce implantation rates. Bilateral salpingectomy or occlusion will necessitate in vitro fertilization for future fertility and must be explicitly defined in the surgical plan. Consider salpingectomy for irreparable salpinges when&#160;access to salpinges and mesosalpinx is feasible. Proximal tubal ligation to occlude retrograde flow of dilated tubal contents into the endometrial cavity is an acceptable alternative. Proximally occluded tubes may be left in situ.
<ol>
	<li>Identify the fallopian tube and the infundibulopelvic ligament.</li>
	<li>Expose and elevate the tube with graspers. 
	NOTE: The fimbriated ends should be maintained far from the ovary and the pelvic sidewall to avoid damage from inadvertent lateral thermal spread to either structure.</li>
	<li>Start the dissection of the tubal lumen from the mesosalpinx at the fimbriated end. Avoid infundibulopelvic ligament ligation and limit the amount of mesosalpinx excised to avoid damage to the anastomotic vascular connections that support ovarian blood supply. 
	NOTE: Preserve ovarian blood supply. These vascular sites may be of potential importance for maintaining ovarian reserve.</li>
	<li>Reaching the isthmus, transect across the full tubal lumen to complete the salpingectomy. 
	NOTE: The patient should be informed of her tubal status and the presence of any remaining tubal tissue after surgery as it may affect her risk of malignancy.</li>
	<li>Ensure adequate hemostasis.</li>
	<li>Perform on the contralateral side, if applicable.</li>
	<li>Remove specimens through the trocar or in a containment device.</li>
</ol>
6. Ovarian endometrioma cystectomy
NOTE: Cystectomy offers the lowest rate of endometrioma recurrence and has been demonstrated to improve pain outcomes and spontaneous pregnancy outcomes; however, it also removes more normal ovarian tissue than ablation (e.g., with CO2 laser). Endometrioma cyst walls are usually adherent from fibrosis and vascular at their base. The surgeon must balance removal of normal ovarian parenchyma and hemostasis with preservation of normal ovarian tissue. Cystectomy should only be attempted if the patient will be expected to have adequate ovarian reserve following the cystectomy. Removal of endometrioma in patients desiring fertility is generally restricted to lesions &#62;3 cm and only if removal improves accessibility of follicles or endometriosis-associated pain.
<ol>
	<li>Identify the ovary. Divide the remaining adhesions to allow to free the ovary. Elevate the structure with graspers to facilitate exposure of the cyst wall. 
	NOTE: Any disruption of the endometrioma cyst wall will yield chocolate-colored fluid.</li>
	<li>Elevate the ovary with graspers to facilitate the exposure of the lesion. Incise the thinnest portion of ovarian cortex to expose the endometrioma cyst wall (Figure 5). 
	NOTE: This incision is ideally made over the thinnest area of the endometrioma surface or at the antimesenteric border of the ovary. Avoid multiple incisions in the ovarian cortex as this is the area where follicles are located. Alternative approaches to develop the cleavage plane include injection of dilute vasopressin or normal saline.</li>
	<li>Utilize traction-counter traction to separate the cyst wall from normal ovarian parenchyma. Dissect efficiently using close placement of graspers with applied force perpendicular to the dissecting plane. 
	NOTE: As the surgical plane develops, regrasp both the endometrioma cyst wall and the healthy ovarian tissue to ensure traction forces continue to be applied close to the site of dissection (Figure 5).</li>
	<li>After complete excision, assess the operative bed for hemostasis. 
	NOTE: As the dissection reaches the ovarian medulla near the end, it can be challenging to continue because of the presence of utero-ovarian vessels and potential for more brisk bleeding.
	<ol>
		<li>Use copious irrigation and aspiration to remove hemoperitoneum and evaluate for active bleeding. 
		NOTE: Consider dropping the insufflation pressure to ascertain hemostasis.</li>
		<li>Observe the ovary for 1-3 min as the endogenous coagulation cascade is activated.</li>
		<li>If bleeding continues, apply topical hemostatic agents. Such agents avoid the need for application of energy to ovarian tissue and the potential for damaging ovarian follicles. Consider laparoscopically suturing an actively bleeding vascular lesion.</li>
		<li>If conservative or medical application fails, apply focused ultrasonic energy once assured of a safe margin from genitourinary and gastrointestinal structures. 
		NOTE: Select an energy source with the least potential to cause ovarian damage by lateral thermal spread. Lateral thermal spread is lowest with laser vaporization, which has a minimal depth of penetration, followed by ultrasonic energy, followed by bipolar electrosurgery, while monopolar electrosurgical application has the greatest potential for lateral thermal spread and inadvertent injury to adjacent structures. Electrosurgery should be avoided adjacent to the bowel or ureters and judiciously minimized on the ovary.</li>
	</ol>
	</li>
	<li>Gather all specimens for retrieval into a bag to reduce risk of port-site endometriosis. Specimen removal should be under direct visualization.</li>
</ol>
7. Address the remaining sites of endometriosis per surgical plan
NOTE: Endometriosis outside of the ovary or tubes may have limited impact on spontaneous conception rate, but excision may be particularly important for treating pain or dysfunctional symptoms. Resection of implants should be site-directed. Peritoneal sites of endometriosis as well as other deep infiltrative sites should be addressed at this point. Retroperitoneal dissection is often required. Consider the morbidity of such procedures and patient goals when determining the necessity of such steps.
<ol>
	<li>Address peritoneal implants.
	<ol>
		<li>Select biopsy sites.</li>
		<li>Strip or ablate all visible peritoneal implants.
		<ol>
			<li>Use ultrasonic energy to divide the peritoneum adjacent to the implant.</li>
			<li>Mobilize tissue adjacent to implant. Remove implants en bloc.</li>
			<li>Remove endometriosis from the pelvic sidewall. This may require retroperitoneal dissection of the relevant avascular planes and identification of the branches of the internal iliac artery and the course of the ureter. 
			NOTE: Ureterolysis should be performed with blunt dissection using the push and spread technique to create a safe margin and preserve vascular supply to the ureter.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Address deep infiltrating endometriosis (DIE) per the surgical plan. 
	&#8203;NOTE: Common sites of endometrial implants include the posterior-cul-de-sac and uterosacral ligaments. Removal of disease that cannot be shaved or safely ablated may require coordination with specialists such as urologic or colorectal surgeons.</li>
</ol>
8. Closure
<ol>
	<li>Confirm hemostasis at the operative bed.</li>
	<li>Close any fascial defects larger than 1 cm.</li>
	<li>Close the skin intracutaneously.</li>
</ol>

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(2), (2008).</li><li>Vignali, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+excision+of+ovarian+endometriomas:+Does+it+truly+impair+ovarian+reserve?+Long+term+anti-M&#252;llerian+hormone+(AMH)+changes+after+surgery.">Surgical excision of ovarian endometriomas: Does it truly impair ovarian reserve? Long term anti-M&#252;llerian hormone (AMH) changes after surgery.</a> Journal of Obstetrics and Gynaecology Research. 41 (11), 1773-1778 (2015).</li><li>Revised American Society for Reproductive Medicine. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Revised+American+Society+for+Reproductive+Medicine+classification+of+endometriosis.">Revised American Society for Reproductive Medicine classification of endometriosis.</a> Fertility and Sterility. 67 (5), 817-821 (1997).</li><li>Adamson, G. D., Pasta, D. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endometriosis+fertility+index:+the+new,+validated+endometriosis+staging+system.">Endometriosis fertility index: the new, validated endometriosis staging system.</a> Fertility and Sterility. 94 (5), 1609-1615 (2010).</li><li>Endometriosis and infertility Committee. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endometriosis+and+infertility:+A+committee+opinion.">Endometriosis and infertility: A committee opinion.</a> Fertility and Sterility. 98 (3), (2012).</li><li>Miller, C. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+endometrioma+treatment+paradigm+when+fertility+is+desired:+A+systematic+review.">The endometrioma treatment paradigm when fertility is desired: A systematic review.</a> Journal of Minimally Invasive Gynecology. 28 (3), 575-586 (2021).</li><li>Muzii, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Histologic+analysis+of+specimens+from+laparoscopic+endometrioma+excision+performed+by+different+surgeons:+Does+the+surgeon+matter.">Histologic analysis of specimens from laparoscopic endometrioma excision performed by different surgeons: Does the surgeon matter.</a> Fertility and Sterility. 95 (6), (2011).</li><li>Kotlyar, A., Gingold, J., Shue, S., Falcone, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effect+of+salpingectomy+on+ovarian+function.">The effect of salpingectomy on ovarian function.</a> Journal of Minimally Invasive Gynecology. 24 (4), 563-578 (2017).</li></ol>

All the authors report no disclosures or conflicts of interest.

Patients with diagnosed endometriosis commonly report pain or implant-related organ dysfunction, including infertility. Up to 50% of patients with endometriosis meet criteria for infertility23. Ovarian reserve, measured via AMH levels, FSH levels around menses or an antral follicle count, is used to predict patient response to gonadotropin stimulation. Surgical management of endometrioma is known to decrease ovarian reserve23. However, ovarian reserve continues to decline in patients with endometriomas even with conservative management14. Management of women with endometrioma remains debated and shared-decision making is crucial. Many patients opt for surgical resection of their disease for a variety of indications, including improvement of pain and to optimize post-surgical fertility outcomes.
In infertile women with mild/moderate endometriosis (rASRM stage I/II classification21), surgeons should excise or ablate endometriosis lesions and perform adhesiolysis to improve pregnancy rates17. Although studies are limited, research suggests that removal of the endometrioma capsule can aid spontaneous and even facilitate assisted reproduction. Endometriomas have the potential to interfere with assisted reproduction as they may preclude development of an adequate cohort of antral follicles and may incur the risk of infection if the endometrioma were to rupture at the time of oocyte retrieval1. Professional societies and expert opinions support ovarian cystectomy for endometriomas above a certain size among symptomatic patients with significant pain symptoms (&#62;4 cm), medically refractory pain (&#60;4 cm), and those planning assisted reproductive conception (ART) with concern for poor antral follicle count or possible cyst rupture during oocyte retrieval (&#60;4 cm)1,24. Additionally, resection of endometrioma is favored compared with drainage and ablation due to lower rates of recurrence of dysmenorrhea and dyspareunia post-operatively.
Nonetheless, in patients who only desire fertility and report no other symptoms, many can avoid surgery, as pregnancy is often possible through assisted reproduction. Conservative non-surgical management should particularly be considered for patients with diminished ovarian reserve who are planning assisted reproduction, as even a successful surgery may affect their potential to obtain adequate oocytes from ovarian stimulation. For patients with endometrioma desiring surgical management, gynecological surgeons are urged to create surgical plans to minimize iatrogenic damage to ovarian reserve and optimize post-surgical fertility outcomes.
One of the critical advantages of surgery is it provides the opportunity to evaluate and treat identified lesions which may hamper future fertility2. The amount of normal ovarian tissue removed together with the endometrioma is related to the experience of the operator and is decreased with experience25. Stripping technique is our preference for ovarian cystectomy as it limits the use of electrosurgery on healthy ovarian tissue and thereby reduces the potential for lateral thermal spread. Similarly, all efforts should be made to limit damage to the anastomotic ovarian blood supply. Intraoperative bleeding from the ovarian tissue following endometrioma excision is a common complication. This protocol outlines the use of sparing ultrasonic application and use of hemostatic agents. All ovarian and related vasculature tissue should be managed as conservatively as possible to preserve ovarian reserve. Although not detailed in this video, alternative hemostatic techniques, including use of plasma energy, laser vaporization, and suturing, should be considered over electrosurgery application whenever feasible.
Adhesions and inflammatory-related sequelae of endometriosis are particularly prone to damage the salpinges, but the decision to remove them is often individualized. If chromopertubation after maximum adhesiolysis demonstrates genital tract obstruction, spontaneous conception via the affected tube is unlikely and salpingectomy may reduce the risk of ectopic pregnancy. However, salpingectomy appears to have a small but detectable detrimental effect on ovarian response to controlled ovarian hyperstimulation26. The decision to remove affected salpinges is more clear-cut for treatment of hydrosalpinx or hematosalpinx, as reflux of this fluid into the endometrial cavity appears to directly compromise implantation and early pregnancy rates.
In conclusion, this protocol visually reviews techniques for ovarian cystectomy and highlights important surgical principles during dissection and excision of endometrioma to reduce loss of ovarian reserve. A fertility-preserving resection of ovarian endometrioma also includes restoration of normal anatomy through adhesiolysis, evaluation of tubal patency and excision of irreparable tissue and removal of extraovarian endometriosis.

Endometriosis is a chronic inflammatory condition defined by ectopic endometrial tissue1. Patients with endometriosis commonly present with pain-related complaints and organ dysfunction related to the site of ectopic implantation, which may be anywhere in the body though is typically within the pelvis2,3. Ovarian endometrioma, in which a cyst of endometriosis forms within the ovary, contributes to subfertility by multiple means, including depletion of the ovarian follicle pool, promoting an inflammatory environment, progesterone resistance, and impaired ovum release and capture4. Affected patients frequently have diminished ovarian reserve upon presentation, and the follicle pool is further depleted following surgery5,6. Cyclic bleeding in sites with ectopic endometrial tissue leads to inflammation and significant adhesions, which may impair ovum pick-up and transport, fertilization, and embryo passage7,8,9. The abnormal inflammatory environment may also impair folliculogenesis and early embryonic development10,11.
At a practical surgical level, the resultant adhesions frequently obliterate normally avascular surgical planes, placing patients at elevated risk of prolonged operative times, blood loss, and surgical injury. Surgical management of patients desiring future fertility presents additional challenges, most notably risk of iatrogenic damage to the tubes and ovaries, compromising tubal patency or ovarian reserve12,13,14. However, surgical resection of endometriosis also presents a unique opportunity to potentially diagnose, evaluate, and treat identified lesions, including optimizing fertility15.
We detail our approach to the treatment of ovarian endometriomas in patients desiring future fertility. We strongly favor a laparoscopic approach over laparotomy for enhanced post-operative results, including less pain, shorter hospital stay, and quicker recovery16. This protocol prioritizes excision of ovarian endometrioma over drainage and ablation as it provides a more favorable outcome with respect to cyst recurrence, pain recurrence, and spontaneous pregnancies17,18,19,20. Additionally, it allows for the specimen retrieval for histology. We excise ovarian endometrioma via a stripping technique with limited electrosurgical energy application. Nonetheless, many specialized tools have been described for the management of ovarian endometrioma and multiple acceptable surgical approaches exist for patients desiring future fertility. Regardless of any specific technique employed, the considerations and surgical principles described in this protocol are applicable to all patients with endometriosis desiring fertility-optimizing surgery.
The protocol described below was employed for the care of a 32-year-old woman with chronic pelvic pain and histologically proven endometriosis identified during a prior laparoscopy, during which endometriosis was incompletely resected. She endorsed pain refractory to the first-line medical management and was interested in future fertility, although had not actively attempted spontaneous conception. She was deemed a candidate for minimally invasive surgical resection and underwent an exam under anesthesia, diagnostic laparoscopy, lysis of adhesions, ovarian cystectomy, chromopertubation, and salpingectomy. Her surgery and recovery were uncomplicated.

<table><tbody><tr><td>&lt;strong&gt;Basic laparoscopy&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>1L bag 0.9% NaCl solution</td><td></td><td></td><td>Suction irrigation, hemostasis, lysis of adhesions</td></tr><tr><td>1-10% povidone-iodine</td><td></td><td></td><td>Sterile prep</td></tr><tr><td>2% chlorhexidine gluconate in 70% isopropyl alcohol for skin</td><td></td><td></td><td>Sterile prep</td></tr><tr><td>4% chlorhexidine gluconate</td><td></td><td></td><td>Sterile prep</td></tr><tr><td>5mm laparoscopic trocar and sleeve x 3</td><td>Covidien</td><td>ONB5STF</td><td>Diagnostic laparoscopy</td></tr><tr><td>12mm laparoscopic trocar and sleeve</td><td>Covidien</td><td>ONB12STF</td><td>Diagnostic laparoscopy and larger size facilitates specimen retrieval bag</td></tr><tr><td>CO2 insufflator</td><td>Stryker</td><td>620-040-504</td><td>Diagnostic laparoscopy</td></tr><tr><td>CO2 insufflator tubing</td><td>Stryker</td><td>620-030-201</td><td>Diagnostic laparoscopy</td></tr><tr><td>Electrosurgical generator</td><td>Covidien</td><td>VLFT10GEN</td><td>Diagnostic laparoscopy</td></tr><tr><td>Foley kit and urometer bag</td><td>Bard</td><td>153214</td><td>Diagnostic laparoscopy</td></tr><tr><td>Laparoscopic scope, 5mm 0 degree</td><td>Olympus</td><td>WA4KL500</td><td>Diagnostic laparoscopy</td></tr><tr><td>Laparoscopic scope, 5mm 30 degree</td><td>Olympus</td><td>WA4KL530</td><td>Diagnostic laparoscopy</td></tr><tr><td>Laparoscopic suction irrigation pool tip</td><td>Stryker</td><td>250-070-406</td><td>Suction irrigation, hemostasis, lysis of adhesions</td></tr><tr><td>StrykeFlow II suction irrigator</td><td>Stryker</td><td>250-070-500</td><td>Suction irrigation, hemostasis, lysis of adhesions</td></tr><tr><td>Suction tubing</td><td>Stryker</td><td>250-070-403</td><td>Suction irrigation, hemostasis, lysis of adhesions</td></tr><tr><td>Suction/vacuum source</td><td></td><td></td><td>Suction irrigation, hemostasis, lysis of adhesions</td></tr><tr><td>&lt;strong&gt;Cystectomy and Salpingectomy&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>10mm tissue retrieval bag</td><td>Covidien</td><td>173050G</td><td>Specimen retrieval bag to be used in 12mm laparoscopic trocar site</td></tr><tr><td>Atraumatic laparoscopic bowel graspers</td><td>Stryker</td><td>250-080-319</td><td>Lysis of adhesions, cystectomy, salpingectomy</td></tr><tr><td>Bipolar Cord</td><td>Stryker</td><td>250-040-016</td><td>Lysis of adhesions, cystectomy, salpingectomy</td></tr><tr><td>Endopeanut laparoscopic retractor</td><td>Covidien</td><td>173019</td><td>Lysis of adhesions, cystectomy, salpingectomy</td></tr><tr><td>Harmonic ACE +7 ultrasonic shears</td><td>Ethicon</td><td>HARH23</td><td>Lysis of adhesions, cystectomy, salpingectomy</td></tr><tr><td>Laparoscopic bipolar grasping forceps</td><td>Karl Storz</td><td>38951 MD</td><td>Lysis of adhesions, cystectomy, salpingectomy</td></tr><tr><td>Laparoscopic curved Metzenbaum scissors</td><td>Stryker</td><td>250-080-267</td><td>Lysis of adhesions, cystectomy, salpingectomy</td></tr><tr><td>Ultrasonic generator unit</td><td>Ethicon</td><td>GEN11</td><td>Lysis of adhesions, cystectomy, salpingectomy</td></tr><tr><td>Vasopressin solution (20 units in 50 to 100cc of injectable saline)</td><td></td><td></td><td>Cystectomy</td></tr><tr><td>&lt;strong&gt;Chromopertubation&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>10mg methylene blue in 150mL 0.9% NaCl solution</td><td></td><td></td><td>Pigmented solution for chromopertubation</td></tr><tr><td>ZUMI uterine manipulator/injector</td><td>Cooper Surgical</td><td>ZSI1151</td><td>Chromopertubation, diagnostic laparoscopy, lysis of adhesions</td></tr><tr><td>&lt;strong&gt;Hemostatic agents&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Arista absorbable hemostatic particles 3g</td><td>Bard Davol</td><td>SM0002-USA</td><td>Hemostatic agent</td></tr><tr><td>Floseal gelatin thrombin matrix 5ml</td><td>Baxter</td><td>ADS201844</td><td>Hemostatic agent</td></tr></tbody></table>

surgical techniques to optimize ovarian reserve during laparoscopic cystectomy for ovarian endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis.
We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

Table 1 shows results of our patient example. Total operation time was 251 min from anesthetic induction to extubation, with an estimated blood loss of 200 mL. The recovery period was uncomplicated. As she desired future pregnancy remote from the time of surgery, she began oral contraceptives. Histopathological examination revealed a right hydrosalpinx with paratubal cyst, bilateral endometriomas (4.5 cm and 3.7 cm), and ovarian tissue.
The surgery utilized a combination of fertility-sparing and fertility-optimizing approaches to laparoscopic cystectomy for ovarian endometrioma. Endometriomas previously visualized on imaging such as ultrasound or MRI (Figure 1) were removed from the ovary. Abdominal trocar placement (Figure 2) enabled visualization of all key pelvic anatomical structures, with demonstrated independent mobility of the uterus, fallopian tubes and ovaries and separation of these structures from the bladder, rectum, and pelvic sidewalls at the conclusion of the surgery. Fallopian tubal patency was characterized (Figure 3). Tubal adhesions were lysed and damaged/irreparable tubes were removed once this was demonstrated.
Endometrioma excision was achieved with a minimum amount of additional healthy ovarian cortex excised (Figure 4) at the same time thanks to efficient use of the stripping technique (Figure 5). All structures were confirmed to be hemostatic at the end of the case. The ovary was comprehensively evaluated, and any bleeding was addressed using the least damaging intervention possible.
At the completion of the surgery, this patient with bilateral ovarian endometriomas and significant tubal disease was treated for her pain, optimized for spontaneous conception and positioned to pursue assisted reproduction with a minimal decline in ovarian reserve.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/62742/62742fig01.jpg" /> 
Figure 1: Pre-operative MRI imaging. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/62742/62742fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/62742/62742fig02v2.jpg" /> 
Figure 2: Suggested abdominal port placement. Circles represent minimum three-port placement. Consider placing up to two additional ports as marked by the encircled x. U represents umbilicus and P represents Palmer&#39;s point.&#160;&#160;<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/62742/62742fig02largev2.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/62742/62742fig03.jpg" /> 
Figure 3: Chromopertubation. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/62742/62742fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/62742/62742fig04.jpg" /> 
Figure 4: Exposing the endometrioma. The endometrioma (pale, translucent object) is exposed after making an incision over the thinnest area of the endometrioma surface. Additional blunt dissection with a probe and suction irrigator free the adherent ovarian cortex from the endometrioma. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/62742/62742fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/62742/62742fig05.jpg" /> 
Figure 5: Efficient use of traction-counter traction forces. (A) Dissecting the endometrioma from the normal ovary. Two graspers are used to place downward traction on the endometrioma cyst wall. In parallel, graspers stabilize and elevate the ovary to facilitate dissection. (B) Placement of graspers in closer proximity to the dissection plane (arrowhead) would result in a more efficient dissection. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/62742/62742fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Number</td>
		</tr>
		<tr>
			<td>Operative timea (min)</td>
			<td>251</td>
		</tr>
		<tr>
			<td>Estimated blood loss (mL)</td>
			<td>200</td>
		</tr>
		<tr>
			<td>Length of stay (days)</td>
			<td>0</td>
		</tr>
		<tr>
			<td>Post-operative complications</td>
			<td>0</td>
		</tr>
		<tr>
			<td colspan="2">aOperative time is the number of minutes between intubation and extubation.</td>
		</tr>
	</tbody>
</table>
Table 1. Results of fertility-sparing surgical resection.

Watch this Scientific Journal Video about Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma at JoVE.com

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...

surgical-techniques-to-optimize-ovarian-reserve-during-laparoscopic

Nanyang Technological University

Research

JoVE Journal

Medicine

14.0K Views.  Montefiore Medical Center. Chirurgische technieken om de ovariële reserve te optimaliseren tijdens laparoscopische cystectomie voor ovarium endometrioom. Dit protocol beschrijft verschillende vruchtbaarheidssparende technieken die worden uitgevoerd tijdens cystectomie voor ovarium-endometrioom. Deze technieken demonstreren manieren om chirurgische schade aan het eierstokweefsel te beperken, een volledige evaluatie van de bekkenanatomie mogelijk te maken en genitale tractuspathologie te identificeren en te behandelen.

Video: Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Orthotopic Ovarian Transplantation Procedures to Investigate the Life- and Health-span Influence of Ovarian Senescence in Female Mice

Ovarian transplantation was first conducted at Utah State University in 1963. In more recent work, heterochronic transplantation of mammalian ovaries is being used to investigate the health-protective effects of young ovaries in young females. The current procedures employ an orthotopic transplantation method, where allogenic ovaries are transplanted back to their original position in the ovarian bursa. This is in contrast to the more commonly used heterotopic transplantation of ovaries/ovarian tissue subcutaneously or under the kidney capsule. All three locations provide efficient revascularization of the transplanted tissues. However, orthotopic transplantation provides the ovary with the most natural signaling environment and is the only procedure that provides the opportunity for the animal to reproduce naturally post-operatively. One must take care to remove all endogenous ovarian tissue during the ovariectomy procedure. If any endogenous tissue remains or if only one ovary is removed, the transplanted tissue will remain dormant until the existing tissue becomes senescent. While revascularization of the transplanted ovaries occurs very quickly, the transplant recipient can take a considerable amount of time to adapt to a new hypothalamic/pituitary/gonadal/adrenal (HPG/A) axis signaling regime associated with the transplanted tissue. This normally takes about 100 days in the mouse. Therefore, transplantation experiments should be designed to accommodate this adaptation period. Typical results with ovarian transplantation will include changes in the health of the recipient that reflect the age of the transplanted ovary, rather than the chronological age of the recipient.

Described here are orthotopic ovarian transplantation protocols for modifying ovarian influence on the physiology of the recipient mouse. This surgical procedure is used to expose female mice to various types of ovarian influence and may include heterochronic transplantations and transplantation of ovaries that have undergone various ex vivo treatments.

Ovarian transplantation was first conducted at Utah State University in 1963. In more recent work, heterochronic transplantation of mammalian ovaries is ...

Developmental Biology

Assessing Ovarian Reserve in Young Patients Using Z-Scores for Follicle Density

Z-Scores for Assessing Ovarian Reserve in Young Patients Undergoing Fertility Preservation

Women are born with a non-renewable pool of ovarian follicles, referred to as the ovarian reserve. This reserve consists of primordial follicles in the ovaries and can be affected by many factors, such as genetic and endocrine disorders, medical interventions, and endocrine disruptors. Fertility preservation is recommended when gonadotoxic treatments are necessary. The preferred options for women are oocyte and embryo cryopreservation. However, in very young, sexually immature patients, ovarian tissue cryopreservation is the only option. Knowing the follicular density of cryopreserved tissue samples is essential in fertility counseling for young patients. This protocol demonstrates the use of Z-scores for cortical follicle density as a tool to evaluate the quality of ovarian tissue in girls and young women aged 25 years and below who are undergoing fertility preservation. Follicle density in patient samples is compared to age-normalized reference standards, developed by Hassan et al. to estimate possible deviations from the standard. The follicle density is measured through histological quantification. For this, a small piece of ovarian cortical tissue (~2 mm x 2 mm x 2 mm) is fixed in either Bouin&#39;s or formaldehyde solution, embedded in paraffin, sectioned at 4 &#181;m thickness, stained with hematoxylin and eosin, and digitized using a slide scanner. Follicular stages present in the cortex range from primordial to primary follicles. The cortical area was 1 mm from the surface epithelium on histological sections. Follicle density is calculated using a modified formula presented by Schmidt et al., and the Z-score is determined using the reference mean and standard deviation. The Z-score indicates how much the measured value deviates from the reference mean, determining&#160;reduced (&#60;-1.7 Z-score) ovarian reserve. With this method, follicle densities can be used as a valuable measure of ovarian reserve for young patients requiring fertility preservation.

Author Spotlight: Advancing Fertility Assessment with Z-Score-Based Follicle Density Evaluation in Cryopreserved Ovarian Tissue

The present protocol describes a method for assessing ovarian reserve in patients under 25 years old who require fertility preservation through ovarian tissue cryopreservation. This method involves: (1) histological assessment of ovarian reserve in cortical samples, (2) comparison to a reference dataset, and (3) calculation of Z-scores.

Women are born with a non-renewable pool of ovarian follicles, referred to as the ovarian reserve. This reserve consists of primordial follicles in the ...

Introduction of Intracapsular Rotary-cut Procedures (IRCP): A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation

Uterine fibroids are common benign tumors in the female reproductive system. A hysterectomy is the most effective treatment for symptomatic fibroids. For patients desiring pregnancy, laparoscopic intracapsular myomectomy (LM) is an alternative surgery option. Although LM is widely accepted to treat fibroids, it is technically demanding with risk of excessive bleeding and difficult suturing, especially in cases with large fibroids or tumors in unusual locations. Therefore, we developed an intracapsular rotary-cut procedure (IRCP) as a modification of laparoscopic intracapsular myomectomy, with the intention to minimize risks of LM and help uterine healing. A summary of the improvements to the IRCP is described: 1) making an incision at the site of the fibroid with a length of one-third to one-half of the fibroid&#39;s diameter at a depth reaching the fibroid&#39;s surface; 2) holding the fibroid stably and making rotary cuts on the fibroid at a depth of 0.5&#8211;1 cm within its pseudo-capsule while pulling it outward slightly, making sure not to cut off any pieces of the fibroid; and 3) repeating the cutting-and-pulling until the longest dimension of the fibroid is outside the incision. The multiple cuts are to minimize the diameter and extend the length of the fibroid. When the multiple cuts cause half of the fibroid body to &#34;shrink&#34;, the fibroid is squeezed out by contraction of the surrounding myometrium. Evaluation of the outcomes of IRCP showed that the time of enucleation and suturing, intraoperative bleeding, and decline of hemoglobin were significantly lower in the IRCP group than the LM group. As for reproductive outcomes, the full-term live birth rate of the IRCP group was significantly higher than that of LM group. However, there was no difference in delivery modes between the two groups. In conclusion, IRCP significantly benefits fertility preservation by minimizing damage to the uterus, protecting myofibers of the pseudo-capsule, and resulting in a shallower residual cavity, which eases stitching and causes less bleeding. It is worthwhile to adopt IRCP in younger patients who desire preservation of their fertility.

Introduction of Intracapsular Rotary-cut Procedures IRCP: A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation

Here, we present a protocol for performing an intracapsular rotary-cut procedure (IRCP), a modified laparoscopic intracapsular myomectomy that promotes fertility preservation.

Uterine fibroids are common benign tumors in the female reproductive system. A hysterectomy is the most effective treatment for symptomatic fibroids. For ...

Endoscopy Guided Photoablation of Endometrial Cysts using a 980 nm Laser with a Contact Fiber in Mares

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. Historical treatments were invasive and had adverse effects on the endometrium. Hysteroscopically guided laser therapy is easy and effective for endometrial cysts resection, with no deleterious effects for the endometrium.
A 110 cm long and 1.0 cm wide endoscope is sterilely introduced in the uterus through the open cervix of an estrous mare after vulvar cleaning. The uterus is slowly infused with less than 1 L of physiologic solution and the laser fiber is inserted in the biopsy canal of the endoscope. Cysts are then cauterized with the 980 nm diode laser with a contact fiber set at 20&#8210;2 5W in continuous mode. Each cyst is punctured&#160;until complete voiding of the cyst and shrinking of the cyst wall around the fiber. Uterine lavages with sterile saline solution are performed directly after the surgery and for one or two days as non-inflammatory fluid can be observed.
This procedure is easy and quickly performed, with no obvious deleterious effects. Cysts resection makes ultrasound pregnancy diagnosis easier and, in some cases, could restore proper embryo migration in the uterine horns between day 6.5 and 17. However, this treatment does not improve the underlying histological lesions related to endometriosis. These considerations should be clearly expressed to the breeder before this procedure.

The aim of this report is to describe the photoablation of endometrial cysts in the mare using an endoscopic laser device, and to discuss the interest and limitations of this new approach to deal with low fertility issues.

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. ...

OP-IVM: Combining In vitro Maturation after Oocyte Retrieval with Gynecological Surgery

The use of in vitro maturation (IVM) before gynecological operation (OP-IVM) is an extension of conventional IVM that combines IVM following oocyte retrieval with routine gynecological surgery. OP-IVM is suitable for patients undergoing benign gynecological surgery who have the need for fertility preservation (FP) or infertility treatments such as in vitro fertilization and embryo transfer (IVF-ET). In the operating room, patients undergoing benign gynecological surgery are first anesthetized and receive ultrasound-guided immature follicle aspiration (IMFA) treatment. As the subsequent gynecological surgery is performed, the cumulus-oocyte complexes (COCs) are examined, and the immature COCs are transferred into the IVM medium and cultured for 28-32 hours in the IVF laboratory. After assessment, mature oocytes in the MII stage will be selected and cryopreserved in liquid nitrogen for FP or fertilized by intracytoplasmic sperm injection (ICSI) for IVF-ET. By combining IVM with gynecological surgery, immature oocytes that would have been discarded can be saved and used for assisted reproductive technology (ART). The procedure, significance and critical aspects of OP-IVM are described in this article.

In vitro maturation (IVM) before gynecological operation (OP-IVM) combines IVM following oocyte retrieval with routine gynecological surgery and serves as an extension of conventional IVM applications for fertility preservation.

The use of in vitro maturation (IVM) before gynecological operation (OP-IVM) is an extension of conventional IVM that combines IVM following oocyte ...

Fertility Preservation Through Oocyte Vitrification: Clinical and Laboratory Perspectives

Preserving female fertility is crucial in a multifunctional healthcare system that takes care of patients' future quality of life. Oocyte cryopreservation is recognized by several international scientific societies as the gold standard for fertility preservation in postpubertal women, for both medical and non-medical indications. The main medical indications are oncologic diseases, gynecologic diseases such as severe endometriosis, systemic diseases compromising the ovarian reserve, and genetic conditions involving premature menopause. This paper describes the whole clinical and laboratory work-up of a fertility preservation treatment by outlining recommendations for objective and evidence-based counseling. Furthermore, it focuses on the effectiveness of the procedure and describes the most appropriate strategies to fully exploit the ovarian reserve and maximize the number of oocytes retrieved in the shortest possible time. The evaluation of the ovarian reserve, the definition of an ideal stimulation protocol, as well as oocyte retrieval, denudation, and vitrification procedures have been detailed along with approaches to maximize their efficacy, efficiency, and safety.

Oocyte cryopreservation is recognized by several international scientific societies as the gold standard for fertility preservation in postpubertal women. Appropriate clinical and laboratory strategies ensure maximum efficacy, efficiency, and safety of fertility preservation treatments.

Preserving female fertility is crucial in a multifunctional healthcare system that takes care of patients' future quality of life. Oocyte cryopreservation ...

Fertility Preservation in Patients with Severe Ovarian Dysfunction

Ovarian function progressively declines during aging and in some pathophysiological conditions including karyotype abnormality, autoimmune diseases, chemo- and radiation-therapies, as well as ovarian surgeries. In unmarried women with severe ovarian dysfunction, fertility preservation is important for future pregnancies. Although oocyte cryopreservation is an established method for fertility preservation, these patients could only preserve a limited number of oocytes even after ovarian hyperstimulation, leading to repeated stimulations to ensure sufficient oocytes to guarantee future pregnancy. To solve this issue, we have recently developed a drug-free in vitro activation (IVA) procedure, which enable us to stimulate early stages of ovarian follicles to develop to the preantral follicle stage. These preantral follicles can respond to the unique protocol of gonadotropin stimulation, resulting in increased number of retrieved oocytes per ovarian stimulation for cryopreservation. The drug-free IVA comprised from the surgical approach and ovarian stimulation. We removed a part of cortex from one or both ovaries from patients under laparoscopic surgery. The ovarian cortical tissues were cut into small cubes to disrupt the Hippo signaling pathway and stimulate the development of early stage follicles. These cubes were grafted orthotropically into remaining ovaries as well as beneath the serosa of both Fallopian tubes. We have already published the surgical procedure of the drug-free IVA and the protocol of subsequent ovarian stimulation, but herein we present the details of laboratory methods required for drug-free IVA.

We present details of laboratory procedures for drug-free in vitro activation (IVA) of ovarian follicles for patients with severe ovarian dysfunction. This method could increase the number of retrievable oocytes per ovarian hyperstimulation and benefit fertility preservation for those patients.

Ovarian function progressively declines during aging and in some pathophysiological conditions including karyotype abnormality, autoimmune diseases, ...

Fertility Sparing Procedure using Carbon Dioxide Fiber Laser Vaporization of Ovarian Endometrioma

The surgical management of endometrioma is still a matter of debate. Cystectomy, which is recognized as the standard technique, seems to be associated with a potential reduction in the ovarian reserve due to the inadvertent removal and thermal damage of healthy ovarian tissue. New ablative techniques with reduced tissue penetration depth and less thermal spread to the surrounding parenchyma may represent a viable alternative to cystectomy. For these reasons, the aim of this manuscript is to demonstrate the ablation of the endometrioma capsule using a CO2 fiber laser technique and discuss the clinical outcomes. Once the cyst has been drained and washed, a biopsy is taken. After cyst eversion, vaporization of the inner surface of the cyst is performed using a CO2 fiber laser. The technique is simple and reproducible as even young surgeons without any surgical experience were more confident in performing laser CO2 vaporization instead of cystectomy. The positive effects of CO2 technology are reported in a randomized controlled trial, where the postoperative changes in the antral follicular count (AFC) and antimullerian hormone (AMH) levels were compared between patients who had their endometrioma excised (cystectomy) and those who had undergone endometrioma vaporization with CO2 laser. The patients treated with CO2 laser showed significantly increased AFC without a reduction in serum AMH levels as compared to the cystectomy group, in which both parameters were significantly reduced. The postoperative pregnancy rate was also assessed, and comparable pregnancy rates were found after both treatments. On the contrary, patients treated with the CO2 fiber laser technique had more favorable in-vitro fertilization (IVF) outcomes compared to cystectomy.
In conclusion, the CO2 fiber laser technique may represent a viable alternative to cystectomy in the surgical treatment of endometrioma in terms of ovarian preservation, pregnancy rates, and IVF outcomes. Moreover, it has the advantage of being independent of the surgeon's skills and personal experience.

In this protocol, CO2 fiber laser technique is demonstrated for the surgical treatment of ovarian endometriosis, which represents a viable alternative in terms of fertility preservation with the major advantage of not being dependent on the surgeon's skills and personal experience.

The surgical management of endometrioma is still a matter of debate. Cystectomy, which is recognized as the standard technique, seems to be associated ...

Laparoscopic Oocyte Retrieval and Cryopreservation during Vaginoplasty for Treatment of Mayer-Rokitansky-Kuster-Hauser Syndrome

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, we propose that a concomitant laparoscopic oocyte retrieval for cryopreservation is performed. Oocyte retrieval is pursued at the beginning of the laparoscopy. Right and left 5 mm trocars are positioned, through which a 17 G ovum aspiration needle is used for puncture of the right and left ovaries, respectively. To facilitate exposure of the follicles, the ovaries are mobilized and held with laparoscopic forceps.
When aspirating multiple follicles near each other, the needle tip is retained in the ovary to reduce the number of times that the ovarian cortex is transfixed and due to the inherent risk of bleeding. Subsequent steps are unchanged compared to the Davydov laparoscopic modified technique for vaginoplasty. Prior to surgery, controlled ovarian stimulation is performed with a gonadotropin hormone-releasing hormone (Gn-RH) antagonist protocol, and the concomitant procedure of oocyte retrieval and vaginoplasty is scheduled 36 h after the final follicular maturation trigger. Follicular fluid is collected in the same 10 mL sterile tubes used during transvaginal oocyte retrieval and transferred in a warming block (37 &#176;C) to the assisted reproduction laboratory, where mature (metaphase II) oocytes are vitrified.
In this case, a series of 23 women with MRKH, oocytes were successfully retrieved and cryopreserved in all patients; vaginoplasty was subsequently conducted without modifications, and the inpatient and outpatient postoperative care (day of urinary catheter removal, day of hospital discharge, dilator use, and comfort at follow-up) remained unaffected. One postoperative complication occurred in one patient (fever developing on day 5 post surgery and intraperitoneal fluid detection on transabdominal ultrasound) and resolved after conservative treatment. Rather than performing surgical vaginoplasty and delaying oocyte retrieval in MRKH patients, this approach combines both procedures in a single laparoscopy, thereby minimizing surgical invasiveness and anesthesiologic risks.

A dedicated team can offer Mayer-Rokitansky-Kuster-Hauser patients the option to perform controlled ovarian stimulation and oocyte cryopreservation at the time of laparoscopic vaginoplasty.

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, ...

Noninvasive Monitoring of Lesion Size in a Heterologous Mouse Model of Endometriosis

Here, we describe a protocol for the implementation of a heterologous mouse model in which progression of endometriosis can be assessed in real time through noninvasive monitoring of fluorescence emitted by implanted ectopic human endometrial tissue. For this purpose, biopsies of human endometrium are obtained from donor women ongoing oocyte donation. Human endometrial fragments are cultured in the presence of adenoviruses engineered to express cDNA for the reporter fluorescent protein mCherry. Upon visualization, labeled tissues with an optimal rate of fluorescence after infection are subsequently chosen for the implantation in recipient mice. One week prior to the implantation surgery, recipient mice are oophorectomized, and estradiol pellets are placed subcutaneously to sustain the survival and growth of lesions. On the day of surgery mice are anesthetized, and peritoneal cavity accessed through a small (1.5 cm) incision by the linea-alba. Fluorescently labeled implants are tweezed, briefly soaked in glue and attached to the peritoneal layer. Incisions are sutured, and animals left to recover for a couple of days. Fluorescence emitted by endometriotic implants is usually non-invasively monitored every 3 days for 4 weeks with an in vivo imaging system. Variations in the size of endometriotic implants can be estimated in real time by quantification of the mCherry signal and normalization against the initial time-point showing maximal fluorescence intensity.
Traditional preclinical rodents of models of endometriosis do not allow non-invasive monitoring of lesion in real time but rather allow evaluation of the effects of drugs assayed at the end point. This protocol allows one to track lesions in real time and is more useful to explore the therapeutic potential of drugs in preclinical models of endometriosis. The main limitation of the model thus generated is that non-invasive monitoring is not possible over long periods of time due to the episomal expression of Ad-virus.

Here, we present a protocol for live-imaging of fluorescently labeled human endometrial fragments grafted in mice. The method allows studying the effects of drugs of choice on endometriotic lesion size through monitoring and quantification of fluorescence emitted by the fluorescent reporter on real time

Here, we describe a protocol for the implementation of a heterologous mouse model in which progression of endometriosis can be assessed in real time ...

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

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