Acute adnexal torsion before oocyte retrieval in an in vitro fertilization cycle

Abstract

The use of controlled superovulation protocols means that many otherwise healthy women spend some time with enlarged, multicystic ovaries that are at risk for torsion. A large series suggested that the incidence of adnexal torsion in IVF cycles is approximately 0.1% (1). Most such torsions occur after ET, usually in the setting of ovarian hyperstimulation syndrome. We report a case of adnexal torsion that occurred before oocyte retrieval in an IVF cycle. The patient was a 37-year-old nulligravid woman whose husband was azoospermic secondary to congenital bilateral absence of the vas deferens. Previous investigation by laparoscopy, hysteroscopy, and falloposcopy revealed normal findings. In three previous IVF cycles, normal fertilization was achieved with intracytoplasmic sperm injection with fresh epididymal sperm in a total of 33 (75%) of 44 oocytes; the fertilization rates were 82%, 83%, and 60% in the three cycles. During the study cycle, she underwent stimulation with 150 IU/d of recombinant human FSH (Gonal-F; Serono, Sydney, Australia). On day 12 of stimulation, sonography of the left ovary showed nine follicles of 18 mm in mean diameter and six smaller follicles (,16 mm in mean diameter); the right ovary had seven follicles of 18 mm in mean diameter and nine smaller follicles. An IM injection of 5,000 IU of hCG (Profasi; Serono) was administered at 9:00 P.M. on day 12 and oocyte retrieval was scheduled for 9:00 A.M. on day 14. Early on the morning of day 14, the patient had the sudden onset of severe lower left-sided abdominal pain with nausea but no emesis. On presentation at 8:00 A.M., she was tachycardic (104 beats/min) but afebrile and stable. Physical examination revealed lower abdominal tenderness that was worse on the left side and no signs of peritonitis. A differential diagnosis of either acute hemorrhage into, or torsion of, the left ovary was made, and oocyte retrieval proceeded at 9:00 A.M. Intraoperative sonography showed the left ovary positioned high in the midline; there was no free fluid or other abnormality. Unfortunately, Doppler ultrasound was not available. Transvaginal oocyte retrieval was undertaken in the hope that emptying the ovaries would allow the ovary with subacute torsion to return to its anatomic position. Seven oocytes were retrieved from the left ovary; the follicular fluid from all those follicles was densely bloodstained. Twelve oocytes were obtained from the right ovary; the follicular fluid from all those follicles was clear. After the procedure, the patient’s symptoms worsened; laparoscopy was performed 2 hours later and revealed torsion of the left ovary. The ovary was detorsed under laparoscopic control and peritoneal lavage with warmed saline solution was undertaken. During 15 minutes of observation, the left adnexal structures regained a more normal appearance. A comparison of the performance of the oocytes obtained from each ovary is presented in Table 1. The patient’s clinical symptoms resolved quickly and transcervical transfer of three embryos created from oocytes retrieved from the right ovary was performed on day 16. Luteal endocrine parameters were normal and 500-IU doses of hCG were given on days 18 and 21. Unfortunately, pregnancy did not ensue.