Last Reviewed: 4/25/2025

Reviewers: Aakriti Carrubba, Kacey Hamilton, Merima Ruhotina
Goal:
To develop advanced knowledge and clinical skills in applying Enhanced Recovery After Surgery (ERAS) principles to complex minimally invasive gynecologic procedures, with an emphasis on optimizing patient readiness, minimizing complications, and promoting rapid recovery.

Objectives:

By the end of training, fellows should be able to:

• Preoperative Management
  • Perform a comprehensive perioperative evaluation to optimize patient readiness for minimally invasive gynecologic surgery.
  • Know and implement ERAS protocols, including fluid management, antibiotic prophylaxis, VTE prophylaxis, management of preoperative anemia, medication adjustments, and multimodal analgesia.
  • Identify patients requiring specific preoperative interventions in complex clinical scenarios (e.g., strategies to reduce blood loss in patients with high fibroid burden, ureteral delineation in patients with distorted pelvic anatomy, bowel preparation in patients undergoing extensive endometriosis resection etc).
  • Identify patients at increased risk for intraoperative positioning injuries and develop strategies to minimize neurologic or musculoskeletal complications.
• Postoperative Management
  • Develop postoperative care pathways tailored to surgical complexity and patient-specific factors, including criteria for early discharge or escalation of care.
  • Perform routine postoperative management within ERAS pathways, with individualized adjustments to intravenous fluid management, diet progression, and pain control.

References:
Rebecca Stone et al. Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery: An AAGL White Paper, Journal of Minimally Invasive Gynecology, Volume 28, Issue 2, 2020, Pages 179-203.
Shields J, Lupo A, Walsh T, Kho K. Preoperative evaluation for gynecologic surgery: a guide to judicious, evidence-based testing. Curr Opin Obstet Gynecol. 2018 Aug;30(4):252-259.
Womack AS, et al. Perioperative pain management in minimally invasive gynecologic surgery. Curr Opin Obstet Gynecol. 2020 Aug;32(4):277-284.
Jimenez-Santana, JD, et al. Current Concepts in Intraoperative Ventilation during Anesthesia for Laparoscopic and Robot–Assisted Surgery – a Narrative Review. Curr Anesthesiol Rep 14, 534–550 (2024).
Cardaillac C, et al. Preoperative Mechanical Bowel Preparation for Gynecologic Surgeries: A Systematic Review with Meta-analysis. JMIG. 2023 Sep;30(9):695-704.
Steiner HL, Strand EA. Surgical-site infection in gynecologic surgery: pathophysiology and prevention. Am J Obstet Gynecol. 2017 Aug;217(2):121-128.
Addley S, et al. 'Well-leg' compartment syndrome associated with gynaecological surgery: a  perioperative risk-reduction protocol and checklist. BJOG. 2021 Aug;128(9):1517-1525.
Vilkins AL, et al. Effects of Shared Decision Making on Opioid Prescribing After Hysterectomy. Obstet Gynecol. 2019 Oct;134(4):823-833.

Last Reviewed: 4/25/2025

Reviewers: Elizabeth Banks, Dmitry Fridman, Kristin Patzkowsky
Goal:
To develop diagnostic, surgical, and decision-making expertise required to evaluate and manage a broad spectrum of adnexal pathologies, with an emphasis on safe surgical planning, fertility preservation, and minimally invasive approaches.

Objectives:
By the end of training, fellows should be able to:

• Describe the pathophysiology, risk factors and natural history of various adnexal pathologies.
• Recognize how age, reproductive status, menopausal state, pregnancy, and personal or family cancer history influence the differential diagnosis and management of adnexal masses.
• Interpret imaging findings and laboratory studies, including pelvic ultrasound, MRI, and serum tumor markers, to assess adnexal pathology and stratify malignancy risk in consultation with validated scoring systems (e.g., IOTA, ORADS, RMI).
• Formulate an individualized management plan based on patient symptoms, imaging findings, desire for future fertility, and local expertise.
• Perform minimally invasive surgical procedures for adnexal pathology—including cystectomy, oophorectomy, salpingectomy, adnexal detorsion, adhesiolysis, tubal reanastomosis, fimbrioplasty—using advanced laparoscopic and robotic techniques, with consideration for tissue containment, specimen extraction, minimizing tissue damage, fertility preservation and oncologic safety.
• Anticipate and manage unexpected intraoperative findings, including frozen pelvis, bowel involvement, conversion to open surgery, or the need for oncologic referral, while minimizing morbidity and preserving reproductive potential when appropriate.
• Counsel patients effectively on diagnosis, prognosis, treatment options, and long-term considerations of adnexal mass management, including recurrence, residual symptoms, and implications for fertility and cancer surveillance.
• Collaborate with multidisciplinary teams, including reproductive endocrinology, gynecologic oncology, colorectal and radiology, in the care of patients with complex or high-risk adnexal pathology.
• Discuss techniques to minimize injury to gynecologic and nearby structures and organ systems

References:
Evaluation and Management of Adnexal Masses. Practice Bulletin PB Number 174. November 2016.
Andreotti RF, Timmerman D, Strachowski LM, et al. O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee. Radiology. 2020 Jan;294(1):168-185.
Arden D, Lee T. Laparoscopic excision of ovarian remnants: retrospective cohort study with long-term follow-up. J Minim Invasive Gynecol. 2011 Mar-Apr;18(2):194-9.
Adnexal Torsion in Adolescents: ACOG Committee Opinion No, 783. Obstet Gynecol. 2019 Aug;134(2):e56-e63. Doi: 10.1097/AOG.0000000000003373. PMID: 31348225.
Cathcart AM, Nezhat FR, Emerson J, Pejovic T, Nezhat CH, Nezhat CR. Adnexal masses during pregnancy: diagnosis, treatment, and prognosis. Am J Obstet Gynecol. 2023 Jun;228(6):601-612 

Supplemental
Goje O, Markwei M, Kollikonda S, Chavan M, Soper DE. Outcomes of Minimally Invasive Management of Tubo-ovarian Abscess: A Systematic Review. J Minim Invasive Gynecol. 2021 Mar;28(3):556-564
7.Akdam A, Bor N, Fouks Y, Ram M, Laskov I, Levin I, Cohen A. Recurrent Ovarian Torsion: Risk Factors and Predictors for Outcome of Oophoropexy. J Minim Invasive Gynecol. 2022 Aug;29(8):1011-1018.
 

Goal: 
To develop diagnostic, imaging, surgical, and counseling expertise required to evaluate and manage uterine pathologies that impact fertility and pregnancy outcomes, with an emphasis on individualized treatment planning, fertility preservation, and minimally invasive surgical techniques.

Objectives: 
By the end of training, fellows should be able to:

• Obtain a comprehensive history, physical examination, and indicated laboratory and imaging studies to evaluate pathology that may impair fertility, implantation, or pregnancy outcomes.
• Interpret imaging modalities such as transvaginal ultrasound, saline infusion sonohysterography (SIS), hysteroscopy, and MRI to diagnose and characterize:
  • Congenital anomalies of the reproductive tract
  • Cesarean scar defects (isthmoceles)
  • Intrauterine adhesions
  • Dysmorphic uterine cavities
• Assess imaging features relevant to surgical planning, including cavity distortion, defect dimensions, residual myometrial thickness, and relationship to adjacent organs.
• Counsel patients on the impact of those pathologies on fertility, pregnancy outcomes, and delivery considerations. Counsel patients on expectations following surgical correction, including potential benefits, limitations, and the need for obstetric surveillance.
• Utilize a collaborative, multidisciplinary approach when appropriate, including consultation with reproductive endocrinology, maternal–fetal medicine, pediatric/adolescent gynecology, urology, or colorectal surgery.
• Congenital Uterine Anomalies
  • Cite indications for surgical management of congenital anomalies of the reproductive tract, including but not limited to imperforate hymen, vaginal agenesis, vaginal septum, uterine septum, unicornuate uterus with or without a non-communicating rudimentary horn
  • Describe surgical management techniques for congenital anomalies of the reproductive tract, including hysteroscopic, laparoscopic, and combined approaches.
• Cesarean Scar Defects (Isthmocele)
  • Describe the pathophysiology and clinical significance of cesarean scar defects, including factors influencing development and severity.
  • Identify clinical presentations and complications associated with cesarean scar defects, including abnormal uterine bleeding, pelvic pain, secondary infertility, cesarean scar pregnancy, and uterine rupture.
  • Develop individualized treatment plans incorporating medical and surgical management strategies, with consideration of patient symptoms, reproductive goals, and imaging findings.
  • Describe surgical management techniques for cesarean scar defect, including hysteroscopic, laparoscopic, vaginal and combined approaches. Counsel on risks, benefits, advantages and disadvantages of each approach.
• Intrauterine adhesions
  • Describe the pathophysiology and clinical significance of intrauterine adhesions.
  • Develop individualized treatment plans incorporating medical and surgical management strategies, with consideration of patient symptoms, reproductive goals, and imaging findings.
  • Describe surgical management techniques for intrauterine adhesions and perioperative strategies to reduce the risk of adhesion reformation.

ARTICLES

Bhagavath B, et al. Uterine Malformations: An Update of Diagnosis, Management, and Outcomes, Obstetrical & Gynecological Survey. 2017 June;6: 377-392.
Skinner B, Quint EH. Obstructive Reproductive Tract Anomalies: A Review of Surgical Management. J Minim Invasive Gynecol. 2017 Sep-Oct;24(6):901-908.
Skinner B, Quint EH. Nonobstructive Reproductive Tract Anomalies: A Review of Surgical Management. J Minim Invasive Gynecol. 2017 Sep-Oct;24(6):909-914.
Ludwin A, et al. Septate uterus according to ESHRE/ESGE, ASRM and CUME definitions: association with infertility and miscarriage, cost and warnings for women and healthcare
systems. Ultrasound Obstet Gynecol. 2019 Dec;54(6):800-814.
Acién P, Acién M. The presentation and management of complex female genital malformations. Hum Reprod Update. 2016 Jan-Feb;22(1):48-69.
Society for Maternal-Fetal Medicine (SMFM); Miller R, Gyamfi-Bannerman C; Publications Committee. Society for Maternal-Fetal Medicine Consult Series #63: Cesarean scar ectopic pregnancy. Am J Obstet Gynecol. 2022 Sep;227(3):B9-B20.
Murji A, et al; International Federation of Gynecology and Obstetrics (FIGO) Committee on Menstrual Disorders and Related Health Impacts. Cesarean scar defects and abnormal uterine bleeding: a systematic review and meta-analysis. Fertil Steril. 2022 Oct;118(4):758-766.
3.Jordans IPM, et al. Sonographic examination of uterine niche in non-pregnant women: a modified Delphi procedure. Ultrasound Obstet Gynecol. 2019 Jan;53(1):107-115.
Donnez O. Cesarean scar disorder: Management and repair. Best Pract Res Clin Obstet Gynaecol. 2023 Aug;90:102398.
Vitale SG, et al. From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis. Arch Gynecol Obstet. 2020 Jan;301(1):33-52.
Vitagliano A, et al. Isthmocele, not cesarean section per se, reduces in vitro fertilization success: a systematic review and meta-analysis of over 10,000 embryo transfer cycles. Fertil Steril. 2024 Feb;121(2):299-313.

Last Reviewed: 4/25/2025

Reviewers: Aakriti Carrubba, Kacey Hamilton, Merima Ruhotina
Goal:
To develop diagnostic, surgical, and decision-making expertise required to manage surgical care in special populations and to perform risk-reducing procedures, with an emphasis on individualized planning, interdisciplinary collaboration, and patient-centered counseling.

Objectives:

By the end of training, fellows should be able to:

• Surgery in Special Populations
  • Understand potential physiologic changes relevant to surgical management in morbidly obese, pregnant, adolescent, LGBTQ+, and geriatric patients.
  • Anticipate and mitigate perioperative, intraoperative, and postoperative risks unique to each population.
  • Identify case scenarios requiring interdisciplinary consultation (e.g., bariatric surgery, genetics, reproductive endocrinology) and coordinate care accordingly.
  • Modify surgical approaches based on patient-specific considerations, including anatomy, comorbidities, and reproductive goals.
  • Implement patient-specific perioperative measures, including but not limited to VTE prophylaxis, antibiotic selection, airway protection strategies, and postoperative hormone therapy.
• Risk-Reducing Surgery
  • Elicit a comprehensive personal and family history to assess risk for hereditary gynecologic cancer syndromes.
  • Describe the impact of familial cancer syndromes on the lifetime risk of gynecologic cancer and counsel patients accordingly.
  • Order and interpret relevant preoperative testing to guide surgical decision-making.
  • Recognize indications for endometrial sampling in high-risk patients.
  • Counsel patients on non-surgical, evidence-based management and surveillance options.
  • Explain the indications, optimal timing, and expected impact of risk-reducing surgeries (e.g., salpingectomy, oophorectomy, hysterectomy) on individual risk profiles and genetic predispositions.
  • Describe and perform risk-reducing surgeries, modifying surgical approaches based on the unique clinical needs of the intended population.
  • Address implications of early oophorectomy and counsel patients on oocyte preservation, hormone replacement therapy, and referral for multidisciplinary care in the setting of hereditary cancer syndromes.
  • Demonstrate ethical and patient-centered counseling in shared decision-making for risk-reducing surgery, including discussion of fertility, quality of life, and long-term health outcomes.

References:
Casey J, Yunker A, Anderson T. Gynecologic Surgery in the Pediatric and Adolescent Populations: Review of Perioperative and Operative Considerations. JMIG. (2016) 23, 1033–1039.
Dizon AM, Carey ET. Minimally invasive gynecologic surgery in the pregnant patient: considerations, techniques, and postoperative management per trimester. Curr Opin Obstet Gynecol. 2018 Aug;30(4):267-271.
Louie M, Toubia T, Schiff LD. Considerations for minimally invasive gynecologic surgery in obese patients. Curr Opin Obstet Gynecol. 2016 Aug;28(4):283-9.
Marfori CQ, et al. Hysterectomy for the Transgendered Male: Review of Perioperative Considerations and Surgical Techniques. J Minim Invasive Gynecol. 2018 Nov-Dec;25(7):1149-1156.
Erekson EA, et al. Gynecologic surgery in the geriatric patient. Obstet Gynecol. 2012 Jun;119(6):1262-9.
Chalermchockcharoenkit A, et al. Safety and caregiver satisfaction associated with TLH among young patients with intellectual disability. Int J Gynaecol Obstet. 2015 Aug;130(2):183-6.
Risk reducing surgery ACOG Practice Bulletin No. 182. Hereditary Breast and Ovarian Cancer Syndrome. September 2017.
Committee on Gynecologic Practice. CO #774: Opportunistic Salpingectomy as a Strategy for Epithelial Ovarian Cancer Prevention. April 2019.
Lancaster JM, et al; SGO Clinical Practice Committee. Society of Gyn Onc statement on risk assessment for inherited gynecologic cancer predispositions. Gynecol Oncol. 2015 Jan;136(1):3-7.
Schmeler KM, et al. Prophylactic surgery to reduce the risk of gynecologic cancers in the Lynch syndrome. N Engl J Med. 2006 Jan 19;354(3):261-9.

Last Reviewed: 3/11/2026

Reviewers: Elizabeth Banks, Liza Berkowitz, Aakriti Carrubba, Laura Douglas, Dmitry Fridman, Meena Misal, Merima Ruhotina
Goal:

To develop advanced diagnostic, surgical, and decision-making expertise required to evaluate and manage non-tubal ectopic pregnancies, with an emphasis on safe surgical planning, fertility preservation, minimally invasive surgical approach, and interdisciplinary collaboration.

Objectives:
By the end of training, fellows should be able to:

• Describe pathophysiology, risk factors, and natural history of non-tubal ectopic pregnancies (e.g., cesarean scar, interstitial, cervical, ovarian, abdominal, and heterotopic).
• Interpret sonographic and other imaging findings to accurately diagnose non-tubal ectopic pregnancies and distinguish them from mimics, with a focus on early and accurate diagnosis.
• Formulate an individualized management plan based on patient symptoms, imaging findings, desire for future fertility, and local expertise.
• Evaluate medical, surgical treatment, and interventional management options, including the role of systemic and local methotrexate (with or without potassium chloride), uterine artery embolization, expectant management, and other interventions.
• Perform surgical management and assist in non-surgical intervention of non-tubal ectopic pregnancies using minimally invasive approaches when feasible (e.g., laparoscopic resection of interstitial pregnancy, hysteroscopic management of cesarean scar pregnancies), while mitigating potential complications such as hemorrhage or uterine rupture.
• Anticipate and manage intraoperative and postoperative complications, including massive hemorrhage, injury to adjacent organs, and retained trophoblastic tissue.
• Counsel patients effectively on diagnosis, prognosis, treatment options, risks to current and future pregnancies, and fertility implications in a sensitive and evidence-informed manner.
• Collaborate with multidisciplinary teams, including interventional radiology, maternal-fetal medicine, and reproductive endocrinology, when planning care for patients with complex or unstable presentations.
• Integrate current literature and evolving surgical techniques into clinical decision-making, while identifying limitations in available evidence and tailoring care to patient goals and preferences.

References:

1. Farren J, Al Wattar BH, Jurkovic D. The diagnosis and management of extrauterine and uterine ectopic pregnancy. Hum Reprod Update. 2026 Jan 1;32(1):2-32. doi: 10.1093/humupd/dmaf024. PMID: 41061761; PMCID: PMC12922837.

Cervical pregnancy:

1. Stoyanova N, Yordanov A, Popovski N. Current Trends in the Treatment of Cervical Pregnancy: A Narrative Review. Medicina (Kaunas). 2025 Nov 20;61(11):2072. doi: 10.3390/medicina61112072. PMID: 41303906; PMCID: PMC12654775. https://pubmed.ncbi.nlm.nih.gov/41303906/ 
2. Timor-Tritsch IE, Monteagudo A, Bennett TA, Foley C, Ramos J, Kaelin Agten A. A new minimally invasive treatment for cesarean scar pregnancy and cervical pregnancy. Am J Obstet Gynecol. 2016 Sep;215(3):351.e1-8. doi: 10.1016/j.ajog.2016.03.010. Epub 2016 Mar 12. Erratum in: Am J Obstet Gynecol. 2020 Jun;222(6):618. doi: 10.1016/j.ajog.2019.09.034. PMID: 26979630.
3. Di Lorenzo G, Mirenda G, Springer S, Mirandola MT, Mangino FP, Romano F, Ricci G. Hysteroscopic Treatment of Cervical Pregnancy: A Scoping Review of the Literature. J Minim Invasive Gynecol. 2022 Mar;29(3):345-354.e1. doi: 10.1016/j.jmig.2021.09.712. Epub 2021 Sep 29. PMID: 34600146. https://pubmed.ncbi.nlm.nih.gov/34600146/

Cesarean scar pregnancy:

1. Miller R, Timor-Tritsch IE, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #49: Cesarean scar pregnancy. Am J Obstet Gynecol. 2020 May;222(5):B2-B14. doi: 10.1016/j.ajog.2020.01.030. Epub 2020 Jan 21. Erratum in: Am J Obstet Gynecol. 2021 Jan;224(1):106. doi: 10.1016/j.ajog.2020.08.036. PMID: 31972162.
2. Barakat E, Riemma G, Laganà AS, Nehme L, Khazzaka A, Noventa M, Lukanovic D, Hakimi S, Sleiman Z. Laparoscopic treatment of cesarean scar pregnancy: A scoping review. Eur J Obstet Gynecol Reprod Biol. 2025 Apr;307:154-163. doi: 10.1016/j.ejogrb.2025.02.006. Epub 2025 Feb 6. PMID: 39929117.
3. Ban Y, Shen J, Wang X, Zhang T, Lu X, Qu W, Hao Y, Mao Z, Li S, Tao G, Wang F, Zhao Y, Zhang X, Zhang Y, Zhang G, Cui B. Cesarean Scar Ectopic Pregnancy Clinical Classification System With Recommended Surgical Strategy. Obstet Gynecol. 2023 May 1;141(5):927-936. doi: 10.1097/AOG.0000000000005113. Epub 2023 Apr 5. PMID: 37023450; PMCID: PMC10108840. https://pmc.ncbi.nlm.nih.gov/articles/PMC10108840/

Interstitial pregnancy:

1. Moawad NS, Mahajan ST, Moniz MH, Taylor SE, Hurd WW. Current diagnosis and treatment of interstitial pregnancy. Am J Obstet Gynecol. 2010 Jan;202(1):15-29. doi: 10.1016/j.ajog.2009.07.054. PMID: 20096253.
2. Finlinson AR, Bollig KJ, Schust DJ. Differentiating pregnancies near the uterotubal junction (angular, cornual, and interstitial): a review and recommendations. Fertil Res Pract. 2020 May 4;6:8. doi: 10.1186/s40738-020-00077-0. PMID: 32391161; PMCID: PMC7199330.

Supplemental references:

1. Verberkt, C., et al. (2023). Effectiveness, complications, and reproductive outcomes after cesarean scar pregnancy management: a retrospective cohort study. AJOG Global Reports, 3(2).Hameed MSS, Wright A, Chern BSM. Cesarean Scar Pregnancy: Current Understanding and Treatment Including Role of Minimally Invasive Surgical Techniques. Gynecol Minim Invasive Ther. 2023;12(2):64–71
2. Dolinko AV, Vrees RA, Frishman GN. Non-tubal Ectopic Pregnancies: Overview and Treatment via Local Injection. J Minim Invasive Gynecol. 2018 Feb;25(2):287-296. doi: 10.1016/j.jmig.2017.07.008. Epub 2017 Jul 20. PMID: 28734972.

Last Reviewed: 3/11/2026

Reviewers: Aakriti Carrubba, Dmitry Fridman, Kacey Hamilton, Meenal Misal
Goal:

• To develop advanced diagnostic and interpretive skills in pelvic imaging that support surgical planning, intraoperative decision-making, and patient counseling—emphasizing accurate identification of endometriosis, adenomyosis, fibroids, intrauterine pathology, pelvic adhesions, adnexal pathology, and uterine anomalies using standardized imaging models and techniques.
• To understand the limitations of particular imaging studies and how to determine the best imaging study for the clinical scenario or disease state. 

Objectives:
By the end of training, fellows should be able to:

1. Counsel patients effectively based on imaging findings, including explanation of normal variants, suspicious features, and relevant clinical implications.
2. Recognize the limitations of imaging in gynecologic surgery, including operator dependence, variability in resolution, and technological limitations.
3. Correlate imaging findings with surgical anatomy to anticipate operative complexity and select the most appropriate approach to achieve surgical goals.
4. Utilize and interpret appropriate abdominal and pelvic imaging for the diagnosis and management of mullerian anomalies.
5. Apply standardized imaging frameworks for the evaluation of abnormal uterine bleeding, including MUSA criteria for adenomyosis and fibroids, as well as the FIGO fibroid classification system.
6. Apply validated imaging-based risk stratification models for adnexal masses, including IOTA ADNEX and O-RADS.
7. Understand sensitivity, specificity, and limitations of various imaging modalities for the diagnosis of deep invasive endometriosis for each pelvic compartment.
8. Understand how to perform pelvic ultrasound for the evaluation of deep infiltrating endometriosis, including the application of the IDEA Criteria and/or UBESS framework. 
9. Understand components of a standardized Magnetic resonance imaging (MRI) endometriosis protocol for diagnosis of deep invasive endometriosis, with attention to common sites of involvement.
10. Perform and interpret ultrasound in high-risk surgical patients to identify adhesive disease and understand implications for surgical planning.
11. Perform and/or interpret saline infusion sonohysterography (SIS) to evaluate the endometrial cavity for pathology — including polyps, fibroids, adhesions, and cesarean scar defects — and assess tubal patency, integrating findings into preoperative planning.

References:

1. Guerriero S, Condous G, van den Bosch T, Valentin L, Leone FP, Van Schoubroeck D, Exacoustos C, Installé AJ, Martins WP, Abrao MS, Hudelist G, Bazot M, Alcazar JL, Gonçalves MO, Pascual MA, Ajossa S, Savelli L, Dunham R, Reid S, Menakaya U, Bourne T, Ferrero S, Leon M, Bignardi T, Holland T, Jurkovic D, Benacerraf B, Osuga Y, Somigliana E, Timmerman D. Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound Obstet Gynecol. 2016 Sep;48(3):318-32. doi: 10.1002/uog.15955. Epub 2016 Jun 28. PMID: 27349699. https://pubmed.ncbi.nlm.nih.gov/27349699/
2. Leonardi M, Condous G. How to perform an ultrasound to diagnose endometriosis. Australas J Ultrasound Med. 2018 Apr 22;21(2):61-69. doi: 10.1002/ajum.12093. PMID: 34760504; PMCID: PMC8409846. https://pmc.ncbi.nlm.nih.gov/articles/PMC8409846/ 
3. Guerriero S, Condous G, Rolla M, Hudelist G, Ferrero S, Alcazar JL, Ajossa S, Bafort C, Van Schoubroeck D, Bourne T, Van den Bosch T, Singh SS, Abrao MS, Szabó G, Testa AC, Di Giovanni A, Fischerova D, Tomassetti C, Timmerman D. Addendum to consensus opinion from International Deep Endometriosis Analysis (IDEA) group: sonographic evaluation of the parametrium. Ultrasound Obstet Gynecol. 2024 Aug;64(2):275-280. doi: 10.1002/uog.27558. Epub 2024 Jun 30. PMID: 38057967. https://pubmed.ncbi.nlm.nih.gov/38057967/ 
4. Harmsen MJ, Van den Bosch T, de Leeuw RA, Dueholm M, Exacoustos C, Valentin L, Hehenkamp WJK, Groenman F, De Bruyn C, Rasmussen C, Lazzeri L, Jokubkiene L, Jurkovic D, Naftalin J, Tellum T, Bourne T, Timmerman D, Huirne JAF. Consensus on revised definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: results of modified Delphi procedure. Ultrasound Obstet Gynecol. 2022 Jul;60(1):118-131. doi: 10.1002/uog.24786. PMID: 34587658; PMCID: PMC9328356. https://pubmed.ncbi.nlm.nih.gov/34587658/
5. Andreotti RF, Timmerman D, Strachowski LM, Froyman W, Benacerraf BR, Bennett GL, Bourne T, Brown DL, Coleman BG, Frates MC, Goldstein SR, Hamper UM, Horrow MM, Hernanz-Schulman M, Reinhold C, Rose SL, Whitcomb BP, Wolfman WL, Glanc P. O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee. Radiology. 2020 Jan;294(1):168-185. doi: 10.1148/radiol.2019191150. Epub 2019 Nov 5. PMID: 31687921. https://pubmed.ncbi.nlm.nih.gov/31687921/
6. Van Calster B, Van Hoorde K, Froyman W, Kaijser J, Wynants L, Landolfo C, Anthoulakis C, Vergote I, Bourne T, Timmerman D. Practical guidance for applying the ADNEX model from the IOTA group to discriminate between different subtypes of adnexal tumors. Facts Views Vis Obgyn. 2015;7(1):32-41. PMID: 25897370; PMCID: PMC4402441. https://pubmed.ncbi.nlm.nih.gov/25897370/

In Development

Last Reviewed: 4/25/2025

Reviewers: Dmitry Fridman, Meena Misal, Kristin Patzkowsky
Goal:
To develop advanced diagnostic, surgical, and decision-making expertise in operative hysteroscopy, with an emphasis on managing complex intrauterine pathology, optimizing fertility outcomes, preventing recurrence, and minimizing complications through evidence-based and innovative techniques.

Objectives:
By the end of training, fellows should be able to:

• Preoperative Evaluation
  • Obtain a comprehensive history and targeted physical examination to evaluate patient candidacy for, and potential challenges of, a hysteroscopic approach.
  • Select and interpret appropriate imaging modalities (e.g., saline infusion sonohysterography, 3D ultrasound, MRI) to characterize the size, location and characteristics  of the target pathology
  • Counsel patients on risks, benefits, alternatives, and cost-effectiveness of operative hysteroscopy, with individualized discussion regarding feasibility of an office based procedure based on anticipated complexity and patient comorbidities.
• Surgical Technique
  • Demonstrate proficiency in advanced operative hysteroscopic procedures, including:
  • Myomectomy of large, multiple, or deeply embedded submucosal fibroids (FIGO types 0–3)
  • Lysis of synechiae in Asherman’s syndrome
  • Metroplasty for Müllerian anomalies impacting fertility
  • Treatment of cesarean scar defects
  • Removal of retained products or foreign bodies in distorted uterine cavities
  • Rollerball endometrial ablation
  • Understand techniques to facilitate cervical dilation and considerations for a stenotic os.
  • Utilize techniques to maintain hemostasis and optimize intraoperative visualization during hysteroscopy.
  • Understand differences between the advanced hysteroscopic modalities (mechanical, monopolar, bipolar, bipolar-mechanical) and choose a device appropriate for pathology and surgical goals.
  • Integrate hysteroscopic management into broader surgical planning for patients with concurrent pelvic pathology, fertility considerations, or need for combined minimally invasive approaches.
• Postoperative Care & Recurrence Prevention
  • Apply strategies to improve outcomes, including recurrence reduction strategies for intrauterine adhesions, use of intrauterine barriers, postoperative hormonal therapy, and staged procedures for high-volume disease.
  • Recognize and manage early and delayed complications such as perforation, hemorrhage, gas embolism, fluid overload, and intrauterine adhesions, using both immediate intraoperative and postoperative interventions.

References:
AAGL Advancing Minimally Invasive Gynecology Worldwide, Munro MG, Storz K, Abbott JA, Falcone T, Jacobs VR, Muzii L, Tulandi T, Indman P, Istre O, Jacobs VR, Loffer FD, Nezhat CH, Tulandi T. AAGL Practice Report: Practice Guidelines for the Management of Hysteroscopic Distending Medi J Minim Invasive Gynecol. 2013 MarApr;20(2):137-48.
Cholkeri-Singh A, Sasaki KJ. Hysteroscopy for infertile women: a review. J Minim Invasive Gynecol. 2015 Mar-Apr;22(3):353-62. doi: 10.1016/j.jmig.2014.12.163. Epub 2014 Dec 29. PMID: 25553895.
Orlando MS, Bradley LD. Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology. Obstet Gynecol. 2022 Sep 1;140(3):499-513.
The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology: ACOG Committee Opinion, Number 800. Obstet Gynecol. 2020 Mar;135(3):e138-e148.
Yin X et al. Hysteroscopic tissue removal systems for the treatment of intrauterine pathology: a systematic review and meta-analysis. Facts Views Vis Obgyn. 2018 Dec;10(4):207-213.
Vitale SG et al. Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a network meta-analysis of randomized controlled trials. Am J Obstet Gynecol. 2022 Apr;226(4):487-498.e8
Mazzon, Ivan et al. Step-by-step hysteroscopic treatment of International Federation of Gynaecology and Obstetrics type 3 myoma with the cold loop technique Fertility and Sterility, Volume 123, Issue 4, 727 - 729

Last Reviewed: 4/25/2025

Reviewers: Laura Douglas, Meena Misal, Merima Ruhotina 
Goal:
To demonstrate expert-level proficiency in advanced laparoscopic and robotic surgical performance for complex benign gynecologic conditions.

Objectives:
By the end of training, fellows should be able to:

• Develop detailed diagnostic and surgical plans for patients with complex benign gynecologic disease (e.g., advanced stage endometriosis, large fibroids, extensive adhesions, prior abdominal surgery), integrating current evidence and individualized patient considerations.
• Identify and manage relative and absolute contraindications to laparoscopy or robotic surgery, adapting surgical approaches for patients with high-risk comorbidities including obesity, pregnancy, and significant cardiopulmonary disease.
• Recognize and address physiologic changes related to pneumoperitoneum and Trendelenburg positioning, incorporating cardiopulmonary implications into surgical and anesthetic planning for high-complexity cases.
• Give individualized preoperative counseling addressing surgical complexity, possible intraoperative findings, risk mitigation strategies, recovery expectations, and viable alternative treatment options.
• Execute precise patient positioning to maximize exposure and minimize complications; perform safe and efficient abdominal entry using multiple advanced access techniques, with the ability to troubleshoot and manage entry-related complications.
• Tailor ancillary port selection, type (e.g., single-port, multiport, hand-assist), and configuration (ipsilateral, suprapubic, alternative trajectories) to anticipated surgical complexity, pathology, and patient anatomy, demonstrating flexibility for challenging operative fields.
• Demonstrate preoperative planning and intraoperative management of surgical cases to promote efficiency of cases, including efficient management of specimen extraction, suture management, instrument exchange, and management of surgical assistants.
• Apply evidence-based intraoperative adhesion prevention and reduction methods, understanding the risks, benefits, and cost-effectiveness of various barrier agents and surgical techniques.
• Select appropriate cases for robotic-assisted laparoscopy based on pathology, anatomy, and anticipated surgical demands; demonstrate mastery of robotic system (X, XI, DV5) setup, port placement, and troubleshooting to optimize efficiency and precision.

References:

Yunker, A. Principles of Laparoscopy, Chapter 9. Telinde’s Operative Gynecology, 13th Edition.
Taskforce for Abdominal Entry: Principles of safe laparoscopic entry. Eur J Obstet Gynecol Reprod Biol. 2016 Jun;201:179-88.
Alkatout I et al. Abd anatomy in the context of port placement and trocars. J Turk Ger Gynecol Assoc. 2015 Nov 2;16(4):241-51.
O'Malley C, Cunningham AJ. Physiologic changes during laparoscopy. Anesthesiol Clin North Am. 2001 Mar;19(1):1-19.
Scheib SA et al. Laparoscopy in the morbidly obese: physiologic considerations and surgical techniques to optimize success. J Minim Invasive Gynecol. 2014 Mar-Apr;21(2):182-95.
Dizon AM, Carey ET. Minimally invasive gynecologic surgery in the pregnant patient: considerations, techniques, and postoperative management per trimester. Curr Opin Obstet Gynecol. 2018 Aug;30(4):267-271.
Practice Committee of the ASRM. Postoperative adhesions in gynecologic surgery: a committee opinion. Fertil Steril. 2019 Sep;112(3):458-463. Essentials of Robotic Surgery
Advancing Minimally Invasive Gynecology Worldwide. AAGL position statement: Robotic‐assisted laparoscopic surgery in benign gynecology. JMIG. 2013 Jan‐Feb;20(1):2
AAGL Advancing Minimally Invasive Gynecology Worldwide. Guidelines for privileging for robotic-assisted gynecologic laparoscopy. JMIG. 2014 Mar-Apr;21(2):157-67.
Capozzi VA et al. Update of Robotic Surgery in Benign Gynecological Pathology: Systematic Review. Medicina (Kaunas). 2022 Apr 17;58(4):552.

Last Reviewed: 4/25/2025

Reviewers: Elizabeth Banks, Aakriti Carrubba, Meena Misal, Kristin Patzkowsky, Merima Ruhotina
Goal:
To provide comprehensive evaluation, counseling, and surgical treatment for patients with endometriosis that optimizes disease management, symptom relief, and fertility, while respecting patient-specific goals and expectations.

Objectives:
By the end of training, fellows should be able to:

• Background
  • Describe the symptomatology of endometriosis.
  • Describe the theories of pathogenesis of endometriosis and the supporting evidence for each (retrograde menstruation, coelomic metaplasia, induction theory, lymphatic or hematogenous dissemination).
  • Describe the various visual appearances and phenotypes of endometriosis (superficial, deeply infiltrative, and endometrioma).
  • Describe the endometriosis classification systems and articulate their strengths and limitations.
  • Describe the effects of endometriosis on  fertility and systemic health, including non-gynecologic organ systems
  • Describe the incidence of and risk factors for malignant transformation of endometriosis.
• Evaluation and Diagnosis
  • Elicit a comprehensive medical history including but not limited to symptoms such as dysmenorrhea, noncyclic pelvic pain, dyspareunia, dysuria, dyschezia, and subfertility.
  • Perform a focused physical exam, including evaluation of pelvic floor musculature, trigger points, and focal tenderness of pelvic organs. Evaluate for signs suggestive of deeply infiltrating endometriosis (DIE) (such as nodularity in the cul-de-sac, uterosacral thickening, rectovaginal septum masses, or reduced uterine mobility). Incorporate extrapelvic assessment when indicated, including abdominal wall scars for nodules, thoracic exam for breath sounds or chest wall tenderness with cyclic pain, and neurologic screening for lower-extremity radicular symptoms.
  • Select and interpret imaging modalities (pelvic ultrasound, specialized deep pelvic ultrasound, and/or MRI), assess the sensitivity and specificity of each for detecting endometriosis in each pelvic compartment.
  • Describe the limitations of non-invasive laboratory tests and other biomarkers in the diagnosis of endometriosis
• Medical and Surgical Management
  • Discuss evidence-based recommendations on the role of medical therapy for endometriosis-associated pain and physical disease manifestations.
  • Counsel patients on multiple lines of therapy options, integrate current guideline-based recommendations, and discuss their benefits, side effects and limitations.
  • Identify and manage common coexisting etiologies of pelvic pain, such as pelvic floor dysfunction, painful bladder syndrome, etc.
  • Describe the current evidence for surgical treatment of early-stage disease, including excision versus ablation of peritoneal lesions, expected symptom outcomes, fertility outcomes and considerations, recurrence and reoperation rates, and the role of adjunctive medical therapy.
  • Describe the current evidence for surgical treatment of advanced disease (deeply infiltrating lesions,  extra-pelvic endometriosis and endometriosis involving other organ systems), expected symptom outcomes,  fertility outcomes and considerations, recurrence and reoperation rates, and the role of adjunctive medical therapy.
  • Discuss hysterectomy, with and without oophorectomy, as a treatment for different stages and types of endometriosis, with focus on treatment expectations including pain relief, recurrence of endometriosis, need for additional intervention, long-term health implications, and role/risks of menopausal hormone therapy in the setting of endometriosis.
  • Provide comprehensive counseling for patients undergoing conservative surgery for ovarian endometrioma, including the effect of cystectomy on ovarian reserve, indications for oophorectomy and/or salpingectomy, risk of recurrence, role of adjunctive medical therapy, fertility considerations, and expectations for surgical treatment of concurrent pelvic disease.
  • Describe the treatment considerations and surgical techniques for less common forms of endometriosis and deeply infiltrating disease:
    • Abdominal wall endometriosis
    • Diaphragmatic endometriosis
    • Thoracic endometriosis
  • Gastrointestinal endometriosis, including bowel shaving, discoid excision, and segmental bowel resection
  • Genitourinary endometriosis, including transmural bladder involvement, ureteral disease, including obstruction and need for reimplantation, and implications on kidney function 
  • Discuss surgical techniques for operating in a frozen pelvis, including safe retroperitoneal dissection, normalization of distorted anatomy, and preservation of vital structures such as the hypogastric plexus.
  • Describe the indications and limitations of neuropelveology procedures, including presacral neurectomy, nerve decompression, laparoscopic uterosacral nerve ablation, and laparoscopic implantation of neuroprosthesis (LION).
• Counseling and Long-Term Considerations
  • Provide longitudinal counseling that integrates reproductive planning, fertility preservation, pain control, medical suppression, and surgical staging into a cohesive care strategy. 

References:

Stratton P, Berkley KJ. Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications. Hum Reprod Update. 2011 May-Jun;17(3):327-46.
Taylor H.S., Giudice L. C., Lessey B. A. et al., Treatment of Endometriosis-Associated Pain with Elagolix, an Oral GnRH Antagonist. New England Journal of Medicine 2017 Vol. 377 Issue 1 Pages 28-40
Agarwal, S. K., Chapron, C., Giudice, L. C., Laufer, M. R., Leyland, N., Missmer, S. A., Singh, S. S. and Taylor, H. S. 2019. Clinical diagnosis of endometriosis: a call to action. Am J Obstet Gynecol 220 (4) 354.e1-354.e12
Zondervan KT et al. Endometriosis. N Engl J Med 2020; 382:1244-125
Taylor HS, Kotlyar AM, Flores VA. Endometriosis is a chronic systemic disease: clinical challenges and novel innovations. Lancet. 2021 Feb 27;397(10276):839-852. Doi: 10.1016/S0140-6736(21)00389-5. PMID: 33640070.
Bazot M, Daraï E. Diagnosis of deep endometriosis: clinical examination, ultrasonography, magnetic resonance imaging, and other techniques. Fertil Steril. 2017 Dec;108(6):886-894. (from CPP)
Burks C, et al. Excision versus Ablation for Management of Minimal to Mild Endometriosis: A Systematic Review and Meta-analysis. JMIG. 2021 Mar;28(3):587-597.
Younis JS, et al. Endometrioma surgery-a systematic review and meta-analysis of the effect on antral follicle count and anti-Müllerian hormone. Am J Obstet Gynecol. 2022 Jan;226(1):33-51.e7.
Working group of ESGE, ESHRE, and WES, Keckstein J, Becker CM, Canis M, Feki A, Grimbizis GF, Hummelshoj L, et al. Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis. Hum Reprod Open. 2020 Feb 12.
Pelvic denervation procedures for dysmenorrhea. C. Ramirez & N. Donnellan. Curr Opin Obstet Gynecol. 2017. 29(4):225-230 
Chen I, et al. Pre- and postsurgical medical therapy for endometriosis surgery. Cochrane Database Syst Rev. 2020 Nov 18;11(11):CD003678. DIE/Extrapelvic disease
Andres MP, Arcoverde FVL, Souza CCC, Fernandes LFC, Abrão MS, Kho RM. Extrapelvic Endometriosis: A Systematic Review. J Minim Invasive Gynecol. 2020 Feb;27(2):373-389.
Leonardi M, Espada M, Kho RM, Magrina JF, Millischer AE, Savelli L, Condous G. Endometriosis and the Urinary Tract: From Diagnosis to Surgical Treatment. Diagnostics (Basel). 2020 Sep 30;10(10):771.
Abrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C. Deep endometriosis infiltrating the recto‐ sigmoid: critical factors to consider before management. Hum Reprod Update. 2015 May‐ Jun;21(3):329‐3
Leonardi M, et al. When to Do Surgery and When Not to Do Surgery for Endometriosis: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol. 2020 Feb;27(2):390-407.e3.
Orr NL, Huang AJ, Liu YD, Noga H, Bedaiwy MA, Williams C, Allaire C, Yong PJ. Association of Central Sensitization Inventory Scores With Pain Outcomes After Endometriosis Surgery. JAMA Netw Open. 2023 Feb 1;6(2):e230780. Doi: 10.1001/jamanetworkopen.2023.0780. PMID: 36848090; PMCID: PMC9972194.
 

Last Reviewed: 4/25/2025

Reviewers: Elizabeth Banks, Kacey Hamilton, Meena Misal, Kristin Patzkowsky

Goal: 

To gain expertise in the recognition, evaluation and management of menstrual cycle disorders—such as abnormal uterine bleeding, endometriosis, adenomyosis,  uterine fibroids and anovulation— and offer interventions, with understanding of the pathophysiology, to optimize treatment success. 

Objectives:
By the end of training, fellows should be able to:

• Demonstrate in-depth understanding of the neuroendocrine regulation of the menstrual cycle, including the hypothalamic-pituitary-ovarian (HPO) axis.
• Describe the cyclic hormonal changes and their effects on ovarian and endometrial physiology that occur over the reproductive lifespan.
• Correlate physiologic changes with the menstrual cycle phases (follicular, ovulation, luteal, and menstruation).
• Demonstrate an understanding of hormonal and physiologic changes that occur at the end of the reproductive life span (perimenopause-menopause) and apply to this knowledge to offer symptom specific therapies
• Correlate menstrual physiology with common gynecologic pathologies (e.g., abnormal uterine bleeding, endometriosis, PCOS).
• Interpret imaging and endometrial sampling results in the context of menstrual cycle irregularities. 
• Apply knowledge of menstrual cycle physiology to optimize timing and planning of surgical interventions and medical therapies in gynecologic patients.
• Apply knowledge of hormonal physiology to troubleshoot side effects, mitigate risk and improve adverse effects of hormonal therapies. 
• Formulate individualized, patient-centered diagnostic and management plans for AUB, incorporating medical therapy, office procedures, and minimally invasive surgical options.

References: 

Menstrual Cycle Physiology
Farage MA, et al. Physiological changes associated with the menstrual cycle: a review. Obstet Gynecol Surv.2009 Jan;64(1):58-72.
Ferries-Rowe E, et al. Primary Dysmenorrhea: Diagnosis and Therapy. Obstet Gynecol. 2020 Nov;136(5):1047-1058.
Critchley HOD. Physiology of the Endometrium and Regulation of Menstruation. Physiol Rev. 2020;100(3):1149-1179.
The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022 Jul 1;29(7):767-794.
Critchley HOD, et al. Menstruation: science and society. Am J Obstet Gynecol. 2020 Nov;223(5):624-664.

Abnormal Uterine Bleeding
Munro MG, et al. FIGO Menstrual Disorders Committee. The two FIGO systems for normal and AUB symptoms and classification of causes of AUB in the reproductive years: 2018 Revisions. Int J Gynaecol Obstet. 2018 Dec;143(3):393-408.
James AH. HMB: work-up and management. Hematology Am Soc Hematol Educ Program. 2016 Dec 2;2016(1):236-242.
Bradley LD, Gueye NA. The medical management of abnormal uterine bleeding in reproductive-aged women. Am J Obstet Gynecol. 2016 Jan;214(1):31-44.
Neblett MF, et al. Oral GnRH Antagonists for the Treatment of Uterine Leiomyomas. Obstet Gynecol. 2023 May 1;141(5):901-910.
Bofill Rodriguez M, et al. Interventions for HMB; overview of Cochrane reviews and network meta-analysis. Cochrane Database Syst Rev. 2022 May 31;5(5):CD013180.