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. 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.
Case Report
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 × 10 3 /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.
Comment
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. 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%. 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 cases ; in one case, the infection became clinically apparent only after delivery ; the other 6 cases ended prematurely, with 5 fetal deaths, and the remaining case was followed up until the seventh gestational week.
| Author (year) | Onset (GA) | Symptoms | Risk factors | Surgical intervention | Bacterial study | Neonatal outcome | |
|---|---|---|---|---|---|---|---|
| Procedure | Time of intervention | ||||||
| Padilla (1993) | 22 d after TVOR | Abdominal pain, nausea, dizziness, fever, peritoneal irritation, leukocytosis | Endometrioma, pelvic surgery, pelvic adhesion | LSC drainage | 5 wks | Negative | Follow-up until GA 7 wks, IUP with presence of fetal heart activity |
| Zweemer et al (1996) | After delivery | No symptoms during pregnancy, and abdominal pain, fever, leukocytosis developed only after CS | Pelvic adhesion, pelvic surgery | Laparotomy | 6 wks after CS | Peptococcus | Healthy NB at GA 38 1/7 wks, CS |
| den Boon et al (1999) | 25 4/7 wks | Fever, abdominal pain, peritoneal irritation, leukocytosis | Endometrioma | Laparotomy-I and D | 26 wks | S aureus | Twin NB at GA 26 wks, second boy died 9 wks postpartum |
| Younis et al (1997) a | 22 d after TVOR | Fever, nausea, abdominal pain, tender adnexal mass, leukocytosis | Endometrioma, endometriosis | Not performed | NA | Healthy NB at term | |
| Jahan and Powell (2003) | 23 d after IVF | Fever, tachycardia, abdominal pain | Endometrioma | LSC drainage, twice | 4 wks and 5 wks | NA | NB with cardiac abnormality at 37 wks, CS |
| Matsunaga et al (2003) | 16 wks | Fever, abdominal pain, leukocytosis | Endometrioma, hydrosalpinx | Laparotomy LSO | 15 d after delivery | Staphylococcus | Delivered at GA 22 wks, and the baby died on the day of birth |
| Sharp et al (2006) | 13 wks | Painless vaginal discharge, fever, nausea, vomiting, malaise, leukocytosis | Endometrioma, endometriosis | Percutaneous drainage | 23 d after CS | S viridans, Escherichia coli , Bacteriodes , Peptostreptococcus | Twin NB at GA 31 wks |
| Al-Kuran et al (2008) | 9 wks | Fever, abdominal pain, urinary symptoms, vomiting, loss of appetite | None | Laparotomy, US-guided drainage and laparotomy | 10 wks, 19 wks, and 1 d after spontaneous pregnancy loss | E coli | Spontaneous pregnancy loss at GA 21 wks |
| Biringer et al (2009) | 16 wks | Leukocytosis, fever, abdominal pain | Pelvic surgery | Laparotomy-Lavage and drainage | 17 wks | Negative | 1st fetus-spontaneous pregnancy loss at GA 16 wks, second fetus healthy NB at GA 30 wks due to PPROM, preeclampsia, VD |
| Yalcinkaya et al (2011) | 5 d after TVOR | Abdominal pain, adnexal tenderness, leukocytosis, fever | None | US-guided drainage, posterior colpotomy, T-drain placement | Post-TVOR d 9 | N/A | Healthy NB at GA 38 wks, VD |
| Patounakis et al (2012) | 6 wks | Malaise, nocturnal fever, abdominal pain | Endometriosis | Laparotomy-LSO | 12 wks | S anginosus | Complete spontaneous pregnancy loss on postoperative d 1 |
| This case | 7 wks | Abdominal pain, leukocytosis | Previous vaginal infection, endometrioma | LSC-cyst enucleation | 14 wks and 3 d | Negative | Healthy NB at GA 37 3/7 wks, VD |
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