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Term delivery following tuboovarian abscess after in vitro fertilization and embryo transfer

2013; Elsevier BV; Volume: 208; Issue: 5 Linguagem: Inglês

10.1016/j.ajog.2013.01.040

1097-6868

Ji Won Kim, Woo Sik Lee, Tae Ki Yoon, Ji Eun Han,

Maternal and fetal healthcare

A tuboovarian abscess (TOA) during pregnancy following oocyte retrieval is extremely rare. We report a rare case of pregnancy complicated by the development of a TOA following in vitro fertilization-embryo transfer that was treated successfully with laparoscopy. We also review all similar cases reported in the English-language literature. A tuboovarian abscess (TOA) during pregnancy following oocyte retrieval is extremely rare. We report a rare case of pregnancy complicated by the development of a TOA following in vitro fertilization-embryo transfer that was treated successfully with laparoscopy. We also review all similar cases reported in the English-language literature. Transvaginal oocyte retrieval (TVOR) under ultrasound guidance is used worldwide for in vitro fertilization (IVF). However, this technique can involve complications, which, although rare, may even be life threatening. Infectious complications have been reported to occur in 0.03-0.5% of TVOR, and the development of a tuboovarian abscess (TOA) during pregnancy is even more unusual.1Aragona C. Mohamed M.A. Espinola M.S. et al.Clinical complications after transvaginal oocyte retrieval in 7,098 IVF cycles.Fertil Steril. 2011; 95: 293-294Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 2Sathananthan A.H. Ratnam S.S. Ng S.C. Tarin J.J. Gianaroli L. Trounson A. The sperm centriole: its inheritance, replication and perpetuation in early human embryos.Hum Reprod. 1996; 11: 345-356Crossref PubMed Scopus (174) Google Scholar, 3Moini A. Riazi K. Amid V. et al.Endometriosis may contribute to oocyte retrieval-induced pelvic inflammatory disease: report of eight cases.J Assist Reprod Genet. 2005; 22: 307-309Crossref PubMed Scopus (40) Google Scholar Although TOA is rare, clinicians should be aware of this complication to enable an accurate diagnosis and prompt intervention. We present a case of term delivery following TOA after in vitro fertilization-embryo transfer (IVF-ET), which was treated successfully with laparoscopy. A 33 year old woman visited our medical center to seek treatment for secondary infertility for 4 years. Her gynecological history included a left tubal pregnancy, bilateral tubal obstruction, and a 4.5-cm endometrioma on the right ovary. Before ovarian stimulation, she was treated with oral ciprofloxacin (250 mg orally twice daily for 5 days) because of vaginitis caused by Ureaplasma urealyticum and Mycoplasma hominis. She conceived during the first IVF cycle. Egg retrieval and embryo transfer were performed conventionally, with vaginal cleaning with saline. There was no evidence of aspiration or puncture of the endometrioma at the time of oocyte retrieval, and the patient routinely took doxycycline (100 mg orally twice daily for 4 days). An ultrasound examination confirmed a vital fetus in the fifth gestational week and enlargement of the right ovarian cyst (8.1× 5.7 cm), consistent with an endometrioma. The patient was well until 7 weeks' gestation, at which time she began to experience intermittent right lower abdominal pain. Ultrasound demonstrated 1 fetus appropriate for gestational age and growth of the mass (10.6 × 7.4 cm). The pain was thought to be due to mass compression, and we decided to observe the patient. She presented with right abdominal pain at 14 weeks' gestation and was diagnosed with acute appendicitis. On admission, her vital signs were normal. The initial laboratory results showed mild leukocytosis (10.33 × 103/μL) and elevated C-reactive protein (2.51 mg/dL). Ultrasound and magnetic resonance imaging (MRI) revealed a viable fetus with an enlarged right ovarian mass, right hydronephrosis, and a normal appendix (Figure). Her condition did not improve over the following 2 days, and laparoscopy was performed. The bowels were adherent to the pelvic wall, uterus, and both adnexa. A large pelvic mass, arising from the right adnexa, was adherent to the posterior wall of the uterus, right pelvic side wall, and sigmoid colon. The abscess was encapsulated within the ovary and there was no pus within the pelvis. A large amount of pus was drained on incising the capsule. The mass was enucleated, and the peritoneal cavity was washed with normal saline. A drain was placed through the abdominal wall in the pouch of Douglas; it was removed on the second postoperative day. Intravenous cefotiam (1 g every 12 hours for 10 days) and metronidazole (500 mg every 8 hours for 5 days) were continued postoperatively. Cultures obtained from the specimen were negative. Her clinical condition improved gradually, and she was discharged 10 days after the laparoscopy. Repeated outpatient ultrasound examinations confirmed a vital fetus with appropriate biometry. Amniocentesis was performed because of an abnormal integrated test for Down syndrome (1:5) at 19 gestational weeks and revealed a normal karyotype. She spontaneously delivered a healthy female (2320 g, Apgar scores 7 and 9 at 1 and 5 minutes, respectively) at 37 weeks and 3 days of gestation without any complications. The mother was discharged 2 days after delivery in stable condition. Written informed consent was obtained from the patient and this report was approved by the Institutional Review Board of CHA Gangnam Medical Center. Although TVOR is the gold standard for IVF therapy, this technique is not without risks, such as hemorrhage, pelvic infection, pelvic injury, and endometrioma rupture.4El-Shawarby S. Margara R. Trew G. Lavery S. A review of complications following transvaginal oocyte retrieval for in vitro fertilization.Hum Fertil. 2004; 7: 127-133Crossref Scopus (71) Google Scholar Pelvic infection is a rare complication of TVOR, although it is the second most common complication. TOA is a serious sequela of pelvic infection; the reported incidence of pelvic abscess after TVOR is 0.38%.5Dicker D. Dekel A. Orvieto R. Bar-Hava I. Feldberh D. Ben-Rafael Z. Ovarian abscess after ovum retrieval for in vitro fertilization.Hum Reprod. 1998; 13: 1813-1814Crossref PubMed Scopus (20) Google Scholar The development of TOA during pregnancy is even more unusual, with only 11 previously reported cases of tuboovarian or pelvic abscess complicating TVOR with a concurrent pregnancy (Table). Of these, full-term infants were delivered in 4 cases6Jahan T. Powell M.C. Laparoscopic management of an ovarian abscess complicating in vitro fertilisation pregnancy.J Obstet Gynaecol. 2003; 23: 324PubMed Google Scholar, 7Yalcinkaya T.M. Erman-Akar M. Jennell J. Term delivery following transvaginal drainage of bilateral ovarian abscesses after oocyte retrieval: a case report.J Reprod Med. 2011; 56: 87-90PubMed Google Scholar, 8Younis J.S. Ezra Y. Laufer N. Ohel G. Late manifestation of pelvic abscess following oocyte retrieval, for in vitro fertilization, in patients with severe endometriosis and ovarian endometriomata.J Assist Reprod Genet. 1997; 14: 343-346Crossref PubMed Scopus (88) Google Scholar, 9Zweemer R.P. Ssheele F. Verheijen R.H. Hummel P. Schats R. Ovarian abscess during pregnancy mimicking a leiomyoma of the uterus: a complication of transvaginal ultrasound-guided oocyte aspiration.J Assist Reprod Genet. 1996; 13: 81-85Crossref PubMed Scopus (13) Google Scholar; in one case, the infection became clinically apparent only after delivery9Zweemer R.P. Ssheele F. Verheijen R.H. Hummel P. Schats R. Ovarian abscess during pregnancy mimicking a leiomyoma of the uterus: a complication of transvaginal ultrasound-guided oocyte aspiration.J Assist Reprod Genet. 1996; 13: 81-85Crossref PubMed Scopus (13) Google Scholar; the other 6 cases ended prematurely, with 5 fetal deaths,10Al-Kuran O. Beitawi S. Al-Mehaisen L. Pelvic abscess complicating an in vitro fertilization pregnancy and review of the literature.J Assist Reprod Genet. 2008; 25: 341-343Crossref PubMed Scopus (14) Google Scholar, 11Biringer K. Zubor P. Visnovsky J. Danko J. Delayed delivery following unusual flare-up pelvic abscess after in vitro fertilization and embryo transfer.Fertil Steril. 2009; 91: 1956.e5-1956.e7Abstract Full Text Full Text PDF Scopus (6) Google Scholar, 12den Boon J. Kimmel C.E. Nagel H.T. van Roosmalen J. Pelvic abscess in the second half of pregnancy after oocyte retrieval for in-vitro fertilization: case report.Hum Reprod. 1999; 14: 2402-2403Crossref PubMed Scopus (31) Google Scholar, 13Matsunaga Y. Fukushima K. Nozaki M. et al.A case of pregnancy complicated by the development of a tubo-ovarian abscess following in vitro fertilization and embryo transfer.Am J Perinatol. 2003; 20: 277-282Crossref PubMed Scopus (43) Google Scholar, 14Patounakis G. Krauss K. Nicholas S.S. Baxter J.K. Rosenblum N.G. Berghella V. Development of pelvic abscess during pregnancy following transvaginal oocyte retrieval and in vitro fertilization.Eur J Obstet Gynecol Reprod Biol. 2012; 164: 116-117Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 15Sharpe K. Karovitch A.J. Claman P. Suh K.N. Transvaginal oocyte retrieval for in vitro fertilization complicated by ovarian abscess during pregnancy.Fertil Steril. 2006; 86: 219.e11-219.e13Abstract Full Text Full Text PDF Scopus (37) Google Scholar and the remaining case was followed up until the seventh gestational week.16Padilla S.L. Ovarian abscess following puncture of an endometrioma during ultrasound-guided oocyte retrieval.Hum Reprod. 1993; 8: 1282-1283PubMed Google ScholarTABLEClinical features in 12 cases of pelvic abscess during pregnancy following TVOR for IVFAuthor (year)Onset (GA)SymptomsRisk factorsSurgical interventionBacterial studyNeonatal outcomeProcedureTime of interventionPadilla (1993)16Padilla S.L. Ovarian abscess following puncture of an endometrioma during ultrasound-guided oocyte retrieval.Hum Reprod. 1993; 8: 1282-1283PubMed Google Scholar22 d after TVORAbdominal pain, nausea, dizziness, fever, peritoneal irritation, leukocytosisEndometrioma, pelvic surgery, pelvic adhesionLSC drainage5 wksNegativeFollow-up until GA 7 wks, IUP with presence of fetal heart activityZweemer et al (1996)9Zweemer R.P. Ssheele F. Verheijen R.H. Hummel P. Schats R. Ovarian abscess during pregnancy mimicking a leiomyoma of the uterus: a complication of transvaginal ultrasound-guided oocyte aspiration.J Assist Reprod Genet. 1996; 13: 81-85Crossref PubMed Scopus (13) Google ScholarAfter deliveryNo symptoms during pregnancy, and abdominal pain, fever, leukocytosis developed only after CSPelvic adhesion, pelvic surgeryLaparotomy6 wks after CSPeptococcusHealthy NB at GA 38 1/7 wks, CSden Boon et al (1999)12den Boon J. Kimmel C.E. Nagel H.T. van Roosmalen J. Pelvic abscess in the second half of pregnancy after oocyte retrieval for in-vitro fertilization: case report.Hum Reprod. 1999; 14: 2402-2403Crossref PubMed Scopus (31) Google Scholar25 4/7 wksFever, abdominal pain, peritoneal irritation, leukocytosisEndometriomaLaparotomy-I and D26 wksS aureusTwin NB at GA 26 wks, second boy died 9 wks postpartumYounis et al (1997)8Younis J.S. Ezra Y. Laufer N. Ohel G. Late manifestation of pelvic abscess following oocyte retrieval, for in vitro fertilization, in patients with severe endometriosis and ovarian endometriomata.J Assist Reprod Genet. 1997; 14: 343-346Crossref PubMed Scopus (88) Google ScholaraIn this case, the patient was treated with intravenous antibiotics.22 d after TVORFever, nausea, abdominal pain, tender adnexal mass, leukocytosisEndometrioma, endometriosisNot performedNAHealthy NB at termJahan and Powell (2003)6Jahan T. Powell M.C. Laparoscopic management of an ovarian abscess complicating in vitro fertilisation pregnancy.J Obstet Gynaecol. 2003; 23: 324PubMed Google Scholar23 d after IVFFever, tachycardia, abdominal painEndometriomaLSC drainage, twice4 wks and 5 wksNANB with cardiac abnormality at 37 wks, CSMatsunaga et al (2003)13Matsunaga Y. Fukushima K. Nozaki M. et al.A case of pregnancy complicated by the development of a tubo-ovarian abscess following in vitro fertilization and embryo transfer.Am J Perinatol. 2003; 20: 277-282Crossref PubMed Scopus (43) Google Scholar16 wksFever, abdominal pain, leukocytosisEndometrioma, hydrosalpinxLaparotomy LSO15 d after deliveryStaphylococcusDelivered at GA 22 wks, and the baby died on the day of birthSharp et al (2006)15Sharpe K. Karovitch A.J. Claman P. Suh K.N. Transvaginal oocyte retrieval for in vitro fertilization complicated by ovarian abscess during pregnancy.Fertil Steril. 2006; 86: 219.e11-219.e13Abstract Full Text Full Text PDF Scopus (37) Google Scholar13 wksPainless vaginal discharge, fever, nausea, vomiting, malaise, leukocytosisEndometrioma, endometriosisPercutaneous drainage23 d after CSS viridans, Escherichia coli, Bacteriodes, PeptostreptococcusTwin NB at GA 31 wksAl-Kuran et al (2008)10Al-Kuran O. Beitawi S. Al-Mehaisen L. Pelvic abscess complicating an in vitro fertilization pregnancy and review of the literature.J Assist Reprod Genet. 2008; 25: 341-343Crossref PubMed Scopus (14) Google Scholar9 wksFever, abdominal pain, urinary symptoms, vomiting, loss of appetiteNoneLaparotomy, US-guided drainage and laparotomy10 wks, 19 wks, and 1 d after spontaneous pregnancy lossE coliSpontaneous pregnancy loss at GA 21 wksBiringer et al (2009)11Biringer K. Zubor P. Visnovsky J. Danko J. Delayed delivery following unusual flare-up pelvic abscess after in vitro fertilization and embryo transfer.Fertil Steril. 2009; 91: 1956.e5-1956.e7Abstract Full Text Full Text PDF Scopus (6) Google Scholar16 wksLeukocytosis, fever, abdominal painPelvic surgeryLaparotomy-Lavage and drainage17 wksNegative1st fetus-spontaneous pregnancy loss at GA 16 wks, second fetus healthy NB at GA 30 wks due to PPROM, preeclampsia, VDYalcinkaya et al (2011)7Yalcinkaya T.M. Erman-Akar M. Jennell J. Term delivery following transvaginal drainage of bilateral ovarian abscesses after oocyte retrieval: a case report.J Reprod Med. 2011; 56: 87-90PubMed Google Scholar5 d after TVORAbdominal pain, adnexal tenderness, leukocytosis, feverNoneUS-guided drainage, posterior colpotomy, T-drain placementPost-TVOR d 9N/AHealthy NB at GA 38 wks, VDPatounakis et al (2012)14Patounakis G. Krauss K. Nicholas S.S. Baxter J.K. Rosenblum N.G. Berghella V. Development of pelvic abscess during pregnancy following transvaginal oocyte retrieval and in vitro fertilization.Eur J Obstet Gynecol Reprod Biol. 2012; 164: 116-117Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar6 wksMalaise, nocturnal fever, abdominal painEndometriosisLaparotomy-LSO12 wksS anginosusComplete spontaneous pregnancy loss on postoperative d 1This case7 wksAbdominal pain, leukocytosisPrevious vaginal infection, endometriomaLSC-cyst enucleation14 wks and 3 dNegativeHealthy NB at GA 37 3/7 wks, VDTwelve cases including present case were reviewed and summarized.CS, cesarean section; GA, gestational age; I and D, incision and drainage; IVF, in vitro fertilization; IUP, intrauterine pregnancy; LSC, laparoscopy; LSO, left SO; NB, newborn; NA, not available; S anginosus, Streptococcus anginosus; SO, salpingo-oophorectomy; TVOR, transvaginal oocyte retrieval; US, ultrasound; VD, vaginal delivery.Kim. TOA during pregnancy following IVF-ET. Am J Obstet Gynecol 2013.a In this case, the patient was treated with intravenous antibiotics. Open table in a new tab Twelve cases including present case were reviewed and summarized. CS, cesarean section; GA, gestational age; I and D, incision and drainage; IVF, in vitro fertilization; IUP, intrauterine pregnancy; LSC, laparoscopy; LSO, left SO; NB, newborn; NA, not available; S anginosus, Streptococcus anginosus; SO, salpingo-oophorectomy; TVOR, transvaginal oocyte retrieval; US, ultrasound; VD, vaginal delivery. Kim. TOA during pregnancy following IVF-ET. Am J Obstet Gynecol 2013. The etiology of pelvic infection after TVOR includes the inoculation of vaginal microorganisms into the ovary, reactivation of a preexisting infection, infection in a previous ovarian cyst, or direct contiguous organ injury.4El-Shawarby S. Margara R. Trew G. Lavery S. A review of complications following transvaginal oocyte retrieval for in vitro fertilization.Hum Fertil. 2004; 7: 127-133Crossref Scopus (71) Google Scholar Microorganisms of the vagina are believed to be the etiological pathogens in pelvic abscesses when TVOR is performed.17Dicker D. Ashkenazi J. Feldberg D. Levy T. Dekel A. Ben-Rafael Z. Severe abdominal complications after transvaginal ultrasonographically guided retrieval of oocytes for in vitro fertilization and embryo transfer.Fertil Steril. 1993; 59: 1313-1315Abstract Full Text PDF PubMed Scopus (122) Google Scholar, 18Bennett S.J. Waterstone J.J. Cheng W.C. Parsons J. Complications of transvaginal ultrasound-directed follicle aspiration: a review of 2670 consecutive procedures.J Assist Reprod Genet. 1993; 10: 72-77Crossref PubMed Scopus (157) Google Scholar Reactivation of old pelvic inflammation can result from ovarian puncture, and anatomical damage from previous inflammation can increase the susceptibility to subsequent pelvic infection.18Bennett S.J. Waterstone J.J. Cheng W.C. Parsons J. Complications of transvaginal ultrasound-directed follicle aspiration: a review of 2670 consecutive procedures.J Assist Reprod Genet. 1993; 10: 72-77Crossref PubMed Scopus (157) Google Scholar Although our patient was treated for vaginitis before ovarian stimulation, it is a plausible mechanism in this case. Moreover, our patient had an endometrioma on the right ovary, which might have increased our patient's susceptibility because endometrioma is another risk factor for abscess development.8Younis J.S. Ezra Y. Laufer N. Ohel G. Late manifestation of pelvic abscess following oocyte retrieval, for in vitro fertilization, in patients with severe endometriosis and ovarian endometriomata.J Assist Reprod Genet. 1997; 14: 343-346Crossref PubMed Scopus (88) Google Scholar, 19Chen M.J. Yang J.H. Yang Y.S. Ho H.N. Increased occurrence of tubo-ovarian abscesses in women with stage III and IV endometriosis.Fertil Steril. 2004; 82: 498-499Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 20Paul Dmowski W. Braun D.P. Immunology of endometriosis.Best Pract Res Clin Obstet Gynaecol. 2004; 18: 245-263Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar Blood content in an endometrioma can facilitate bacterial growth after transvaginal inoculation. Furthermore, the altered immune system of a patient with endometriosis might fail to overcome the inoculated bacteria. Although least likely, infection can occur via direct needle puncture of the bowel, with inflammatory or infectious spillage.21Peters A.J. Hecht B. Durinzi K. Deleon F. Wentz A.C. Salpingitis or oophoritis: what causes fever following oocyte aspiration and embryo transfer?.Obstet Gynecol. 1993; 81: 876-877PubMed Google Scholar The interval between retrieval and symptom onset is highly variable. In 7 reported cases, the infection developed in the first trimester, whereas in the other cases, the abscess was diagnosed between the 13th gestational and sixth postpartum weeks (Table). The symptoms are variable, but fever, abdominal pain, and peritoneal irritation are common. Consequently, a pelvic abscess during pregnancy must be differentiated from other conditions, including appendicitis, torsion of an adnexal tumor, and threatened incomplete abortion.22Jafari K. Vilovic-Kos J. Webster A. Stepto R.C. Tubo-ovarian abscess in pregnancy.Acta Obstet Gynecol Scand. 1977; 56: 1-4Crossref PubMed Scopus (16) Google Scholar A detailed clinical history, a physical examination, laboratory investigations, and the use of various imaging studies are necessary to make an accurate diagnosis. In our case, appendicitis was suspected, but MRI demonstrated a normal appendix, which ruled out acute appendicitis. The treatment of a pelvic abscess varies with the clinical situation but can be complicated by pregnancy. Medical treatment alone is successful in 34-87.5% of patients with pelvic abscess.23Kelada E. Ghani R. Bilateral ovarian abscesses following transvaginal oocyte retrieval for IVF: a case report and review of literature.J Assist Reprod Genet. 2007; 24: 143-145Crossref PubMed Scopus (23) Google Scholar Ultrasound-guided drainage of a pelvic abscess is an alternative to surgery; however, the reported incidence of a residual abscess requiring further surgery despite repeated ultrasound-guided aspiration is 6.6%.24Gjelland K. Ekerhovd E. Granberg S. Transvaginal ultrasound-guided aspiration for treatment of tubo-ovarian abscess: a study of 302 cases.Am J Obstet Gynecol. 2005; 193: 1323-1330Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar Surgical intervention, using laparotomy or laparoscopy with drainage of the abscess and excision of infected tissue, is generally performed in cases of diagnostic uncertainty or when medical therapy is inadequate. Recent reviews suggest a laparoscopic approach to ovarian abscesses.25Rosen M. Breitkopf D. Waud K. Tubo-ovarian abscess management options for women who desire fertility.Obstet Gynecol Surv. 2009; 64: 681-689Crossref PubMed Scopus (48) Google Scholar Laparoscopy was performed in only 2 reported cases. In the first case, the patient underwent laparoscopic abscess drainage and was followed up until the seventh gestational week.16Padilla S.L. Ovarian abscess following puncture of an endometrioma during ultrasound-guided oocyte retrieval.Hum Reprod. 1993; 8: 1282-1283PubMed Google Scholar In the second, laparoscopic abscess drainage was performed at 4 weeks' gestation, but 5 days later, the size of abscess had increased, and the patient underwent a second laparoscopy.6Jahan T. Powell M.C. Laparoscopic management of an ovarian abscess complicating in vitro fertilisation pregnancy.J Obstet Gynaecol. 2003; 23: 324PubMed Google Scholar Our patient was managed successfully managed using laparoscopy with enucleation of the infected tissue as well as drainage. To our knowledge, our case is the second term delivery following TOA complicating TVOR that was treated successfully with laparoscopy. Pregnancy is said to protect against pelvic infections; therefore, clinicians are unlikely to suspect TOA as the cause of an acute abdomen in pregnancy. A delayed presentation and advanced gestational age can lead to severe sequelae, such as several operations, preterm birth, or perinatal morbidity and mortality. Clinicians should consider TOA in the differential diagnosis of abdominal pain, fever, and leukocytosis after TVOR for IVF, even if the patient is pregnant.