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 0.57, 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.