Referral Center For Reproductive Medicine Research Articles

2414 Endometriosis and the Prevalence of Infectious Agents within the Endometrium and Endo-Cervix

Study Objective The presence of endometriosis has been shown to be strongly associated with chronic endometritis, and, furthermore, chronic endometritis has been associated with infectious agents in the endometrial cavity (73% in published data). We planned to evaluate the prevalence of infectious agents within in the endometrial cavity and endo-cervix when endometriosis is present. Design Retrospective review of all patients that underwent diagnostic laparoscopy, diagnostic hysteroscopy, and the collection of sterile endometrial/endo-cervical cultures during surgical evaluation for suspected endometriosis and chronic endometritis. Setting Referral center for reproductive medicine and surgery in an academic medical center. Patients or Participants All patients diagnosed with endometriosis at the time of laparoscopy who underwent collection of endometrial/endo-cervical cultures from 2016 – 2018 (N=97). Interventions N/A. Measurements and Main Results Sterile endometrial/endo-cervical cultures were collected, per standardized protocol, prior to preparation of the vagina. Aerobic/anaerobic cultures; PCR for mycoplasma/ureaplasma/gonorrhea/chlamydia; viral cultures; and yeast cultures were performed. In patients diagnosed with endometriosis at the time of laparoscopy, 70% tested positive for an infectious agent on endometrial/endo-cervical culture. Organisms were found in 65% of individuals diagnosed laparoscopically with mild endometriosis (American Society for Reproductive Medicine Revised Classification of Endometriosis “ASRM Classification” Stage 1-2), and 75% diagnosed with severe endometriosis (ASRM Classification Stage 3-4). Gram positive organisms were the most common infectious agent cultured at 72%, and were primarily E. Faecalis (31%), Lactobacillus (17%), and Group B Strep (15%). Gram negative organisms (18%) were primarily E. coli (10%). Less commonly, yeasts (13%), anaerobes (3%), and ureaplasma (1%) were found. No gonorrhea, chlamydia, mycoplasma, or viruses were detected. No significant correlation was found between severity of endometriosis and prevalence of any single organism. Conclusion For individuals with endometriosis, regardless of severity, the presence of infectious organisms in the endometrium and endo-cervix is similar to published data on chronic infectious endometritis.

Impaired testicular signaling of vitamin A and vitamin K contributes to the aberrant composition of the extracellular matrix in idiopathic germ cell aplasia

To study pathogenic features of the somatic testicular microenvironment associated with idiopathic germ cell aplasia. Cross-sectional study. Tertiary referral center for reproductive medicine. Testicular specimens from men with idiopathic nonobstructive azoospermia (iNOA) prospectively submitted to microdissection testicular sperm extraction. Of 20 specimens used for histology, 10 were also available for proteomic analysis. Primary Sertoli cells with normal karyotype and phenotype were also used. Patients with iNOA were dichotomized according to a positive versus negative sperm retrieval at microdissection testicular sperm extraction, and on the isolated extracellular matrix (ECM) the proteomic analysis was performed. Proteomic analysis of the ECM from testicular specimens with positive versus negative sperm retrieval. Gene ontology enrichment was used to identify upstream regulators based on the 11 deregulated ECM proteins, which were validated by immunohistochemistry and quantitative polymerase chain reaction. Continuous variables were expressed as medians and interquartile range. Germ cell aplasia was characterized by an increased signaling of the retinoic acid in Sertoli cells and associated with decreased expression of the basal membrane markers nidogen-2 and heparan sulfate proteoglycan-2. Decreased levels of the interstitial matrisome-associated factor IX and its regulator VKORC1 were, instead, coupled with decreased signaling of vitamin K in Leydig cells. An altered expression of a further eight ECM proteins was also found, including laminin-4 and laminin-5. Peripheral levels of the two vitamins were within the reference range in the two cohorts of iNOA men. We identified the pathogenetic signature of the somatic human testicular microenvironment, providing two vitamin-related mechanistic insights related to the molecular determinants of the idiopathic germ cell aplasia.

AMH type II receptor and AMH gene polymorphisms are not associated with ovarian reserve, response, or outcomes in ovarian stimulation.

PurposeGenetic variation may influence women’s response to ovarian stimulation therapy. The purpose of this study was to investigate any effects of genetic variants in the anti-Müllerian hormone (AMH) and AMH type II receptor genes on ovarian response/treatment outcomes and on current markers of ovarian reserve in individuals undergoing in vitro fertilisation (IVF) treatment.MethodsIn this prospective observational study, we genotyped the AMH c.146G>T, p.(Ile49Ser) and AMHR2 -482A>G variants in 603 unrelated women undergoing their first cycle of controlled ovarian stimulation for IVF and ICSI (intracytoplasmic sperm injection) using gonadotrophins at a tertiary referral centre for reproductive medicine. Pelvic ultrasound and blood hormone levels were taken on days 2–3 of the cycle. Genotypes were determined using TaqMan allelic discrimination assay. Regression analysis was performed to assess the relationship between the genotypes and the ovarian reserve markers (FSH, AMH, antral follicle count) and the early outcomes of response (number of oocytes retrieved and gonadotropin dose) as well as the treatment outcome (live birth).ResultsThere were no significant associations between the variants AMH c.146G>T and AMHR2 -482A>G with ovarian response in terms of number of oocytes retrieved (p = 0.08 and p = 0.64, respectively), live births (p = 0.28 and p = 0.52) and/or markers of ovarian reserve.ConclusionsGenotyping of the AMH c.146G>T and AMHR2 -482A>G polymorphisms does not provide additional useful information as a predictor of ovarian reserve or ovarian response and treatment outcomes.

A single nucleotide polymorphism of bone morphogenic protein-15 is not associated with ovarian reserve or response to ovarian stimulation.

Is there any effect of the -9C>G variant in the bone morphogenic protein-15 (BMP15) gene on ovarian response and/or current markers of ovarian reserve in patients undergoing in vitro fertilization (IVF) treatment? No significant associations of BMP15 genotypes with ovarian response (number of oocytes retrieved) and/or markers of ovarian reserve were detected in our cohort of women undergoing IVF treatment. There is evidence that genetic variation influences patients' response to ovarian stimulation therapy. BMP15 plays a role in the recruitment of primordial follicles. Therefore, variation in BMP15 could predict ovarian reserve and response to ovarian stimulation. Two previous studies have determined a significant correlation between the BMP15 -9C>G variant and over-response to ovarian stimulation. No studies to date have correlated this variant with ovarian reserve markers. In this prospective observational study, we genotyped the BMP15 -9C>G single nucleotide polymorphism in 239 unrelated women undergoing their first cycle of controlled ovarian stimulation for IVF and ICSI (intra-cytoplasmic sperm injection) using gonadotrophins at a tertiary referral centre for reproductive medicine between March 2009 and August 2010. Baseline pelvic ultrasound and blood tests were taken on Days 2-3 of the cycle for assessment of baseline hormones and for DNA extraction. Genotypes were determined using TaqMan allelic discrimination assay. Regression analysis was performed to assess the effect of the BMP15 genotype on the ovarian reserve markers, serum anti-Müllerian hormone (s-AMH), follicle stimulating hormone (s-FSH) and antral follicle count (AFC), with adjustment for age and body mass index (BMI), and on the primary outcomes of response (number of oocytes retrieved and gonadotrophin dose) with adjustment for age, BMI and treatment received. There was no evidence of any statistically significant (P < 0.05) difference in basal s-FSH, s-AMH and AFC between individuals with different BMP15 genotypes. The number of oocytes retrieved and gonadotrophin dose used were also comparable between the individuals with different genotypes. A larger sample size would be required in order to determine if the BMP15 genotype has a small effect on ovarian reserve or response. When considering the development of integrative clinical algorithms for individual FSH doses, our analysis suggests that the genotyping of BMP15 -9C>G does not provide additional useful information as a predictor of ovarian reserve or response to ovarian stimulation. The study was funded by the Manchester Biomedical Research Centre. The authors have no competing interests to declare.

Thyroglobulin Autoantibodies: Is There Any Added Value in the Detection of Thyroid Autoimmunity in Women Consulting for Fertility Treatment?

Thyroid autoimmunity (TAI) is frequent in infertile women, but to what extent thyroglobulin autoantibodies (Tg-Abs) contribute to TAI is unclear in the literature. The aims of the present study were to determine the prevalence of TAI in women consulting for fertility problems and to investigate the impact of isolated Tg-Abs, isolated thyroid peroxidase autoantibodies (TPO-Abs), and the presence of both autoantibody types on thyroid function. Furthermore, thyroid function was compared between women with and without TAI and between infertile and fertile women. A cross-sectional data analysis nested within an ongoing prospective cohort study was performed in order to determine the prevalence of TAI in unselected women consulting our tertiary referral center for reproductive medicine (CRM). The women underwent a determination of serum thyrotropin (TSH), free thyroxine (FT4), TPO-Abs, and Tg-Abs. The cause of infertility, age, body-mass index (BMI), and smoking habits were recorded. The prevalence of TAI was 16% (163/992). In 8% of cases, both types of autoantibodies were present, in 5% isolated positive Tg-Abs were found, and 4% had isolated positive TPO-Abs (p=0.025 and p=0.003 respectively). The prevalence of TAI was significantly higher in infertile women as compared to that in fertile controls (19% vs. 13%; p=0.047). The median serum TSH level was significantly higher in the women with TAI and with isolated positive Tg-Abs compared to that in women without TAI (1.83 [1.44] and 1.90 [0.85] vs. 1.47 [0.94] mIU/L; p<0.001 respectively). The median FT4, age, BMI, and smoking habits were comparable between the study groups. The prevalence of TAI was higher in infertile women as compared to fertile women consulting our CRM. Five percent of the women had isolated positive Tg-Abs and a significantly higher serum TSH compared to that in women without TAI.

FSH receptor genotype does not predict metaphase-II oocyte output or fertilization rates in ICSI patients

The objective of this study was to assess the role of the variant p.Asn680Ser in the FSH receptor gene (FSHR) in determining oocyte maturity. It also assessed the relationship between this FSHR variant with metaphase-II oocyte output rate (MOR) and the fertilization rate. This was a prospective observational study based at a tertiary referral centre for reproductive medicine. Women (n=212) undergoing their first cycle of ovarian stimulation for IVF with intracytoplasmic sperm injection (ICSI) were included in the study. Baseline pelvic ultrasound and blood tests were taken on day 2 or 3 of the cycle for assessment of baseline hormones and for DNA extraction. Genotypes for FSHR p.Asn680Ser was determined using TaqMan allelic discrimination assay. The outcome measures were the total dose of exogenous gonadotrophins used, antral follicle count (AFC), number of mature (metaphase-II) oocytes retrieved, MOR and fertilization rate. No statistically significant differences were found between the number of mature oocytes retrieved, MOR or fertilization rates among the patients with different p.Asn680Ser FSHR genotypes. No significant difference was noted in the clinical pregnancy rates per transfer. There is no evidence that the p.Asn680Ser FSHR genotype predicts oocyte maturity.IVF is a complex treatment for infertility requiring costly drugs and carrying significant risk of complications. The procedure aims to stimulate the ovaries to produce more eggs, and conventional methods include a combination of hormones to induce follicle growth, from which eggs are collected. Before beginning the first IVF cycle, knowledge of individual ovarian activity may help predict the response to stimulation and allow clinicians to tailor treatments. Over the last 50years, it has become evident that studying the genetic mechanisms behind variations in drug response in can help control and minimise adverse effects of drugs and their related actions. Hypothetically, a genetic test looking at the variations in the FSH receptor gene may help identify the dosage required and can predict the quality of egg and embryo. One of these variants (at position 680 of exon 10) has been linked to differences in FSH action during ovarian stimulation. None of the studies to date have looked at the role of these genetic markers in the prediction of the quality of eggs and fertilization. We undertook a large prospective study and did not see a relationship between a FSH receptor gene variation and the dosage of gonadotrophins used, quality of eggs or fertilization rates. We surmise that the outcome of ovarian stimulation could be dependent on several factors – both genetic and non-genetic – in a complex multi-factorial model. In the future, genome-wide screening strategies may allow the discovery of further genetic variants associated with ovarian response to stimulation.

A common Asn680Ser polymorphism in the follicle-stimulating hormone receptor gene is not associated with ovarian response to gonadotropin stimulation in patients undergoing in vitro fertilization

To assess the role of the variant p.Asn680Ser in the follicle-stimulating hormone receptor (FSHR) gene in determining ovarian response in patients undergoing in vitro fertilization (IVF) treatment. Prospective observational study. Tertiary referral center for reproductive medicine. Women (n = 421) undergoing their first cycle of controlled ovarian stimulation for IVF and 83 healthy, ethnically matched controls. Baseline pelvic ultrasound and blood tests taken on days 2 to 3 of the cycle for assessment of baseline hormones and for DNA extraction. Genotypes for FSHR p.Asn680Ser determined using TaqMan allelic discrimination assay, and ovarian response to gonadotropin treatment classified as normal, poor, or overresponse based on the number of oocytes retrieved. The FSHR p.Asn680Ser genotype frequencies were similar in IVF patients and controls. The number of oocytes retrieved was comparable between patients with different FSHR receptor genotypes. The total amount of gonadotropin used was also similar in all the genotype groups. A logistic regression analysis showed nonstatistically significant twofold difference in the distribution of genotypes between the groups with poor and normal ovarian response. The variant FSHR p.Asn680Ser was not shown to be predictive of ovarian response, but clinically relevant differences cannot be ruled out.

Follicle-stimulating hormone receptor gene polymorphisms are not associated with ovarian reserve markers

To evaluate the association between variants in the FSHR receptor (FSHR) gene and current markers of ovarian reserve (antimüllerian hormone, antral follicle count, FSH). Prospective observational study. Tertiary referral center for reproductive medicine. Women (n = 421) undergoing their first cycle of controlled ovarian stimulation for IVF. Baseline pelvic ultrasound and blood tests were taken on day 2-3 of the cycle for assessment of baseline hormones and for DNA extraction. Genotypes for FSHR p.Asn680Ser and p.Thr307Ala variants were determined using TaqMan allelic discrimination assays. Association of FSHR single nucleotide polymorphisms with markers of ovarian reserve. There was no evidence of any difference in basal FSH, antimüllerian hormone, or antral follicle count between the patients with different genotypes, with or without an adjustment for age or body mass index. No associations of FSHR genotypes with markers of ovarian reserve were detected in our cohort.

The likelihood of live birth and multiple birth after single versus double embryo transfer at the cleavage stage: a systematic review and meta-analysis

To determine whether a policy of elective single-embryo transfer (e-SET) lowers the multiple birth rate without compromising the live birth rate. Systematic review and meta-analysis. Tertiary referral center for reproductive medicine and IVF unit. None. Searches of the Cochrane Controlled Trials Register, Meta-register for Randomized Controlled Trials (RCTs), EMBASE, MEDLINE, and SCISEARCH with no limitation on language and publication year, 1974 to 2008. randomized, controlled trials comparing e-SET with double-embryo transfer (DET) for live birth and multiple birth rates after in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI). Nonrandomized trials and studies that included only patients who had blastocyst transfer were excluded. The likelihood of live birth per patient and multiple birth per total number of live births. Other outcomes included implantation rate, pregnancy rate, miscarriage and ectopic pregnancy rates, clinical pregnancy rate, ongoing pregnancy rate per patient, and preterm delivery rate per live birth. Six trials (n=1354 patients) were included in the meta-analysis. Compared with DET, the e-SET policy was associated with a statistically significant reduction in the probability of live birth (RR 0.62; 95% CI, 0.53-0.72) and multiple birth (RR 0.06; 95% CI, 0.02-0.18). Elective-SET of embryos at the cleavage stage reduces the likelihood of live birth by 38% and multiple birth by 94%. Evidence from randomized, controlled trials suggests that increasing the number of e-SET attempts (fresh and/or frozen) results in a cumulative live birth rate similar to that of DET. Offering subfertile women three cycles of IVF will have a major impact on the uptake of an e-SET policy.

Circulating basal anti-Müllerian hormone levels as predictor of ovarian response in women undergoing ovarian stimulation for in vitro fertilization

To evaluate the clinical value of basal anti-Müllerian hormone (AMH) measurements compared with other available determinants, apart from chronologic age, in the prediction of ovarian response to gonadotrophin stimulation. Prospective cohort study. Tertiary referral center for reproductive medicine and an IVF unit. Women undergoing their first cycle of controlled ovarian hyperstimulation (COH) for in vitro fertilization (IVF). Basal levels of FSH and AMH as well as antral follicle count (AFC) were measured in 165 subjects. All patients were followed prospectively and their cycle outcomes recorded. Predictive value of FSH, AMH, and AFC for extremes of ovarian response to stimulation. Out of the 165 women, 134 were defined as normal responders, 15 as poor responders, and 16 as high responders. Subjects in the poor response group were significantly older then those in the other two groups. Anti-Müllerian hormone levels and AFC were markedly raised in the high responders and decreased in the poor responders. Compared with FSH and AFC, AMH performed better in the prediction of excessive response to ovarian stimulation-AMH area under receiver operating characteristic curve (ROC(AUC)) 0.81, FSH ROC(AUC) 0.66, AFC ROC(AUC) 0.69. For poor response, AMH (ROC(AUC) 0.88) was a significantly better predictor than FSH (ROC(AUC) 0.63) but not AFC (ROC(AUC) 0.81). AMH prediction of ovarian response was independent of age and PCOS. Anti-Müllerian hormone cutoffs of >3.75 ng/mL and <1.0 ng/mL would have modest sensitivity and specificity in predicting the extremes of response. Circulating AMH has the ability to predict excessive and poor response to stimulation with exogenous gonadotrophins. Overall, this biomarker is superior to basal FSH and AFC, and has the potential to be incorporated in to work-up protocols to predict patient's ovarian response to treatment and to individualize strategies aiming at reducing the cancellation rate and the iatrogenic complications of COH.

The use of estradiol for luteal phase support in in vitro fertilization/intracytoplasmic sperm injection cycles: a systematic review and meta-analysis

To investigate the effect of luteal E(2) supplementation on the pregnancy rate of IVF/intracytoplasmic sperm injection (ICSI) cycles. A systematic review and meta-analysis of all the randomized controlled trials (RCTs). Tertiary referral center for reproductive medicine and IVF. Women undergoing IVF or ICSI using the GnRH agonist or GnRH antagonist protocol with hMG or FSH for controlled ovarian hyperstimulation. Progesterone (P4) alone or combined with estradiol valerate for luteal phase support. Pregnancy and clinical pregnancy rates per ET. An electronic search was conducted targeting all reports published between January 1960 and March 2007. Ten RCTs met the criteria for inclusion in the meta-analysis. There were no statistically significant differences with regard to the main outcome measures, ongoing pregnancy rate per ET, or implantation rate between the group of women who had combined E(2) and P4 therapy and those who had P4 supplementation alone. The addition of E(2) to P4 for luteal phase support in IVF/ICSI cycles has no beneficial effect on pregnancy rates. The data in the literature are, however, limited and heterogeneous, precluding the extraction of clear and definite conclusions. A large multicenter, properly designed RCT is needed to further clarify the role of luteal E(2) supplementation in IVF.

Ovarian response to gonadotropins after laparoscopic salpingectomy or the division of fallopian tubes for hydrosalpinges

To compare the effect of prophylactic laparoscopic salpingectomy versus division of the fallopian tubes on ovarian response to gonadotropins in women undergoing IVF. Retrospective study. National Health Service-based tertiary referral center for reproductive medicine. One hundred sixty-eight women with tubal factor infertility. Sixty-five women with hydrosalpinges had either salpingectomy (n = 40, group A) or proximal tubal division (n = 25, group B), while the remaining women with tubal disease but without hydrosalpinges acted as the control group (n = 103, group C). Prophylactic laparoscopic salpingectomy or proximal division of the fallopian tubes and ovarian stimulation with gonadotropins for IVF. Day 2 serum FSH levels before surgery and 3 months after surgery but before ovarian stimulation, ovarian response assessed as total dose of hMG administered, serum E2 concentrations on day 3 and day 8 of stimulation and on the day of hCG injection, number of follicles, and number of oocytes retrieved and fertilized. In group A, baseline FSH levels were significantly raised after surgery compared with before surgery. Postsurgery FSH concentrations were significantly higher in group A compared with group B. The number of follicles (15-20 mm) was significantly lower in group A compared with group B and group C. The serum E2 levels on day 8 of stimulation were lower in group A compared with group B, and on the day of hCG injection it was significantly reduced in group A compared with groups B and C. The number of oocytes retrieved per cycle was significantly lower in group A compared with group B. There were no significant differences in pregnancy rates and miscarriage rates among the three groups. These findings suggest that prophylactic salpingectomy in women with hydrosalpinx may compromise ovarian response to stimulation without affecting pregnancy rates. A randomized control trial is recommended to determine the most appropriate laparoscopic procedure in the management of hydrosalpinx before IVF.

Is systematic screening for thyroid disorders indicated in subfertile men?

Data on the prevalence of thyroid disorders in male subfertility remain scarce. To investigate the prevalence of thyroid dysfunction and thyroid autoimmunity in men with normal and abnormal semen characteristics. Tertiary referral center for reproductive medicine of the University Hospital AZ-VUB, Brussels, Belgium. Two hundred and ninety-two men were stratified according to the presence of normal (group 1; n = 39) or abnormal (group 2; n = 253) semen characteristics. Thyroid function was assessed by serum thyrotropin (TSH) and free thyroxine (FT4), and thyroid peroxidase antibodies (TPO-Ab) for thyroid autoimmunity (TAI or TPO-Ab > 34 kU/l); both were correlated with semen characteristics. Semen characteristics were determined by World Health Organisation criteria (rapid + slow motility > or = 50% and concentration > or = 20 x 10(6)) and Kruger criteria (morphology > or = 14% normal cells). In group 1, the mean (+/- s.d.) age was 33 +/- 4 years; serum TSH was 1.6 (0.3-29.6) mU/l (median (range)) and FT4 was 12.2 (8.8-15.6) ng/l. In group 2, the mean age was 33 +/- 5 years, serum TSH was 1.3 (0.3-5.2) mU/l and FT4 was 12.5 (8.4-17.5) ng/l; (compared with group 1 P = 0.008 for TSH and P = 0.037 for FT4). In both groups, one patient had increased TSH (2.6% and 0.4%; P = not significant (ns)). In group 1, one patient had TAI and in group 2 twelve patients had TAI (2.6% compared with 4.7%; P = ns). FT4 was an independent determinant for semen characteristics. The prevalence of thyroid dysfunction and autoimmunity is comparable between men with normal and abnormal semen characteristics. On the basis of these data, we do not advise systematic screening for thyroid disorders in subfertile men consulting a tertiary referral center for reproductive medicine.

Cryopreserved-thawed embryo transfer in natural or down-regulated hormonally controlled cycles: a retrospective study

To assess the implantation, pregnancy, and live birth rates after the transfer of frozen-thawed embryos (FET) in a natural or hormonal control cycle. Retrospective study. National Health Service tertiary referral center for reproductive medicine in Manchester, United Kingdom. Two comparable groups of women with regular menstrual cycles: Group A (n = 212) had FET in a natural cycle after spontaneous ovulation; group B (n = 205) had FET in a pituitary-desensitized hormonally controlled cycle. In group B, GnRH agonist was commenced in the midluteal phase of the previous cycle and discontinued 3 days before embryo transfer. Oral estradiol valerate and vaginal progesterone pessary were used to prepare the endometrium. Embryo transfer was carried out 3 days after detection of the endogenous LH surge in group A and on day 3 of progesterone administration in group B. Implantation, pregnancy, and live birth rates per cycle and per embryo transfer (ET). In the 212 women who had natural-cycle FET, 172 ETs were performed and 247 embryos replaced. The implantation rate was 14.1% (35/247). Twenty clinical pregnancies (20/172, 11.6%) were achieved. In the 205 women who had down-regulated hormone replacement-cycle FET, 173 embryo transfers were performed and 243 embryos replaced. The implantation rate was 13.5% (33/243). Eighteen clinical pregnancies (18/173, 10.2%) were achieved. There were no significant differences between the two groups with regard to the implantation, clinical pregnancy, or live birth rates per cycle or per ET. These findings suggest that both FET protocols are equally effective in terms of implantation rate and pregnancy outcome in women with regular menstrual cycles.

Operative transvaginal hydrolaparoscopy of a large ovarian endometrioma

Objectives The purpose of this case report is to describe the feasibility of transvaginal underwater surgery for reconstruction of the ovary with a large endometrioma. Design Descriptive study. Setting Tertiary referral centre for reproductive medicine. Interventions Transvaginal hydrolaparoscopy and bipolar surgery were used as the techniques for access and surgery of a large ovarian endometrioma. Results A two-step procedure was performed with the first step under general anaesthesia and the second under conscious sedation. Transvaginal hydrolaparoscopy allowed easy access, bloodless dissection of the adhesions and marsupialization and coagulation of the endometrioma. Conclusions The report proves the feasibility of reconstruction of the ovary with a large endometrioma using the new technique of transvaginal hydrolaparoscopy. The technique has the advantage of easy access to the endometrioma and accurate dissection and coagulation of adhesions. The low morbidity makes a two-step technique more acceptable to the patient.