We report the results of a first exploratory study testing the use of vaginal microbiome transplantation (VMT) from healthy donors as a therapeutic alternative for patients suffering from symptomatic, intractable and recurrent bacterial vaginosis (ClinicalTrials.gov NCT02236429). In our case series, five patients were treated, and in four of them VMT was associated with full long-term remission until the end of follow-up at 5-21 months after VMT, defined as marked improvement of symptoms, Amsel criteria, microscopic vaginal fluid appearance and reconstitution of a Lactobacillus-dominated vaginal microbiome. One patient presented with incomplete remission in clinical and laboratory features. No adverse effects were observed in any of the five women. Notably, remission in three patients necessitated repeated VMT, including a donor change in one patient, to elicit a long-standing clinical response. The therapeutic efficacy of VMT in women with intractable and recurrent bacterial vaginosis should be further determined in randomized, placebo-controlled clinical trials.Bacterial vaginosis (BV) is a form of vaginal microbial community alteration in which the microbiome normally dominated by Lactobacillus species switches to one characterized by the emergence of anaerobes [1][2][3][4] . BV is prevalent in women of reproductive age, affecting from one-fourth to one-third of women 5 . It ranges from an asymptomatic finding in most cases to a clinically symptomatic entity characterized by an abnormal, often malodorous vaginal discharge in 16% of women diagnosed with BV, summing up to a prevalence of 4.4% for symptomatic BV in women aged 14-49 years 5 . BV may be associated with risk of upper genital tract infection 6 , complications of pregnancy (particularly preterm birth and lower success in fertility treatments [7][8][9][10] ) and susceptibility to sexually transmitted infections 11 . At the clinically severe end of the BV spectrum, treatment with antibiotics (either systemic or vaginal) is associated with a 30% relapse rate within 3 months of initial treatment and a relapse rate of up to 50-70% within 1 year 12 . Therapeutic options are very limited in the subpopulation of women who experience persistent or recurrent BV despite multiple antibiotic treatment attempts [13][14][15] . Maintenance antimicrobial treatment 16,17 is often the treatment suggested in these cases, but it can predispose to vaginal candidiasis 18 and resistant infections 19,20 . Importantly, probiotic treatment of symptomatic patients with oral and/or vaginal administration of bacterial Lactobacillus strains has produced mixed results 21,22 , suggesting that the microbiome as a whole, rather than a single bacterial species, may be necessary for an effective cure at the clinically

Gynecologist and plastic surgeons pioneered the application of lasers in medicine and surgery almost 5 decades ago, initially used to treat cervical and vaginal pathologies. Ever since, energy-based devices have been deployed to treat pelvic pathologies and improve fertility. Recent technological developments triggered an unprecedented wave of publications, assessing the efficacy of fractional laser, and radiofrequency on the vaginal wall in reversing natural aging processes. Studies have shown that a certain degree of thermal energy deposited on the vaginal wall stimulates proliferation of the glycogen-enriched epithelium, neovascularization, and collagen formation in the lamina propria, and improves natural lubrication and control of urination. This review aimed to review such data and to guide future research. A unique assembly of experts from around the globe, compiled and edited this manuscript based on a thorough literature review and personal experience. Lasers Surg. Med. 49:137–159, 2017.

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