SummaryA review of transvaginally guided punctures is presented. The aim of these procedures is to perform the various treatments using the guidance of a high resolution ultrasound image generated by the high frequency probes of the vaginal transducer. The goal is to avoid a more extensive risky surgical intervention and still achieve a similar outcome. The technique of the transvaginally guided punctures is described using the manual needle placement as well as the automated spring loaded puncture device which is mated to the handle of the transvaginal probe. Each puncture procedure is described in detail, however special attention is given to the multifetal pregnancy reductions and the puncture treatment of various ectopic gestations.