Preoperative ovarian vascular parameters and perioperative factors associated with ovarian reserve marker decline after laparoscopic endometrioma cystectomy: a retrospective prediction study

Background Laparoscopic cystectomy is a commonly used surgical treatment for ovarian endometrioma, but postoperative reduction in ovarian reserve markers is a recognized concern. Preoperative identification of women at increased risk may support counseling and surgical planning. This study evaluated whether multidimensional ovarian vascular and hemodynamic ultrasound parameters are associated with subsequent decline in ovarian reserve markers. Objective To evaluate the association of preoperative multidimensional ultrasound parameters with postoperative ovarian reserve marker decline and to develop an exploratory perioperative prediction model. Methods A retrospective cohort of 280 reproductive-age women undergoing laparoscopic ovarian endometrioma cystectomy (May 2021-May 2024) was analyzed. Transvaginal color Doppler ultrasound on menstrual cycle days 2–5 yielded 2D morphological parameters [ovarian volume [OV], antral follicle count [AFC]], 3D vascular parameters [vascularization index [VI], flow index [FI], vascularization-flow index [VFI]], and spectral Doppler parameters (resistance index [RI], pulsatility index [PI], peak systolic velocity [PSV], end-diastolic velocity [EDV]). Serum AMH, FSH, LH, and E2 were measured. Ovarian reserve markers were reassessed at 3, 6, and 12 months. The primary 6-month outcome was a study-specific composite decline in ovarian reserve markers. Exploratory multivariable logistic regression was used to construct a perioperative model, and internal optimism was estimated by 1,000 bootstrap resamples. Apparent discrimination was assessed by ROC analysis. Results At 6 months, 118 of 280 patients (42.1%) met the study-specific composite outcome. Women meeting the outcome had lower preoperative VI, VFI, FI, PSV, and EDV and higher RI and PI (all P < 0.01). Pearson correlations showed moderate associations of vascular parameters with 6-month AMH and FSH levels. AMH decreased after surgery in both groups, with a greater reduction in patients meeting the composite outcome; significant effects of time, group, and group-by-time interaction were observed (all P < 0.001). The exploratory perioperative logistic model retained age, bilateral cysts, preoperative maximum cyst diameter, intraoperative r-AFS score, preoperative VI, and preoperative RI. Higher VI was associated with lower odds of the composite outcome, whereas higher RI was associated with greater odds. The composite model had an apparent AUC of 0.888 (95% CI 0.845–0.923), which was higher than that of VI (AUC=0.702) or RI (AUC=0.699) alone. Bootstrap internal validation yielded a corrected AUC of 0.878. At a probability cutoff of >0.57, sensitivity and specificity were 76.3% and 90.1%, respectively, with a PPV of 84.9% and an NPV of 83.9%. Because r-AFS is intraoperative and no external validation was performed, this is a perioperative rather than a strictly preoperative model and requires external validation before clinical application. Conclusions Preoperative ovarian vascular and hemodynamic ultrasound parameters, particularly VI and RI, were associated with postoperative decline in ovarian reserve markers. The composite model showed good apparent discrimination and modest optimism on internal bootstrap validation; however, external validation and comparison with models incorporating established baseline ovarian reserve markers are required before clinical implementation.