{"paper_id":"3f04b9e8-130d-465a-a9cb-41996f84170b","body_text":"Case Report  | JOGCR. 2025; 10(7): 582-587 \n     Volume 10, July 2025       Journal of Obstetrics, Gynecology and Cancer Research \n Journal of Obstetrics, Gynecology and Cancer Research | ISSN: 2476-5848 \n \nSuccessful Pregnancy Following Ovarian Vein Embolization in a Patient with \nPelvic Congestion Syndrome and Deep Infiltrating Endometriosis: A Case \nReport \n \nBayu Agung Sangkara Putra1* , Ashon Sa'adi1 , Sri Ratna Dwiningsih1 ,  \nHimawan Limanto2  \n \n1. Department of Obstetrics and Gynecology, Dr. Soetomo General Hospital, Faculty of Medicine, Airlangga University, \nSurabaya, Indonesia \n2. Department of Thoracic Cardiovascular Surgery, Dr. Soetomo General Hospital, Faculty of Medicine, Airlangga \nUniversity, Surabaya, Indonesia \nArticle Info  ABSTRACT \n  \n   10.24200/jogcr.10.7.582 \n \n \n \nChronic Pelvic Pain (CPP) is defined as persistent pain in the pelvic region that \npersists for a duration of six months or more. A prevailing cause of CPP is \nendometriosis, affecting 10-15% of women of reproductive age. The present report \ndetails the case of a 32 -year-old female patient who was initially diagnosed with \nadenomyosis and subsequently found to have CPP and infertility. Imaging revealed the \npresence of endometriosis and Pelvic Congestion Syndrome (PCS). Following the \nimplementation of ovarian vein embolization to address Pelvic Cavity Syndrome (PCS) \nand hormonal therapy for deep -infiltrating endometriosis, the patient exhibited a \nsubstantial decrease in pain. After the discontinuation of hormonal therapy, the patient \nunderwent a pregnancy that resulted in a successful outcome. This case underscores the \nimportance of accurate diagnosis and treatment of endometriosis and PCOS in women \nwith CPP and infertility, emphasizing a multidisciplinary approach for optimal care. \nKeywords: Pelvic congestion syndrome, Deep infiltrating endometriosis, \nEmbolization, Secondary infertility, Pregnancy  \n \nReceived: 2025/03/04 \nAccepted: 2025/04/07 \nPublished Online: 30 Jun. 2025  \nCorresponding Information:  \nBayu Agung Sangkara Putra, \nDepartment of Obstetrics and Gynecology, \nFaculty of Medicine, Universitas Airlangga, \nUniversitas Airlangga Hospital, Surabaya, \nIndonesia \n \nEmail: bayusangkara@gmail.com \n \n \n \n \nCopyright © 2025, This is an original open -access article distributed under the terms of the Creative Commons Attribution-noncommercial \n4.0 International License which permits copy and redistribution of the material just in noncommercial usages with proper citation . \n \n \n1. Introduction\nChronic Pelvic Pain (CPP) is defined as non -cyclic \npain that persists for a duration of six months or more \nin the pelvic region, resulting in functional impairment \nor necessitating medical intervention (1). The etiology \nof CPP is multifactorial, with prominent contributors \nincluding endometriosis, adenomyosis, and Pelvic \nCongestion Syndro me (PCS). Endometriosis, a \ncondition affecting 10-15% of women of reproductive \nage, is a recognized etiology of CPP (2). A study \nconducted in Vietnam demonstrated that endometriosis \ncontributes to approximately 17% of infertility cases \namong women (3).  \nDeep Infiltrating Endometriosis (DIE) is a severe \nform of endometriosis characterized by the presence of \nlesions extending deeper than 5 mm below the \nperitoneum (4). PCS is frequently misdiagnosed as DIE \nand accounts for 16-31% of CPP cases, which often co-\noccurs with endometriosis and impacts fertility (5). \nThere is not enough data regarding the incidence of \nPCS in Indonesia, but studies in other developing \ncountries have demonstrated significant variations in \nits prevalence. The prevalence of PCOS in Thailand \ncan reach 43.2%, while in India and Pakistan, it was \n5.2% and 8.8%, respectively (5). \nThis study reported a 32 -year-old woman with PCS \nand DIE treated with embolization who successfully \nbecame pregnant after stopping hormonal therapy. \n \n \n2. Case Presentation \nA 32 -year-old female patient was referred to our \noutpatient clinic with a diagnosis of adenomyosis and \nsecondary infertility. The primary complaint was \npainful menstruation, which significantly impeded \ndaily activities. Previously, the patient had been \ndiagnosed with adenomyosis at another medical \nfacility. The patient received hormonal therapy, which \nprovided some relief from pain; however, the \ntherapeutic effect was deemed minimal. \nA thorough medical examination was conducted, and \nthe patient's vital signs were within normal parameters. \nThe physical examination yielded no significant \n\n\n583 Pregnancy in Advance Epithelial Ovarian Cancer \n      Volume 10, July 2025       Journal of Obstetrics, Gynecology and Cancer Research \nfindings. Initial sonography prompted the \nrecommendation of additional radiological imaging. \nThere was a contrast MRI that showed multiple \nendometriosis with DIE (deep infiltrating \nendometriosis) in the left sacrouterine ligament and \npelvic congestion syndrome (Figure 1). \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nFigure 1. Contrast MRI showed multiple deep endometriosis infiltrating the left sacrouterine ligament. There was also \npelvic congestion syndrome and left ovarian vein dilatation. \n \nFurther Computed Tomography Angiography (CTA) \nrevealed dilatation of the left ovarian vein with reflux \non the left ovarian vein. The patient was scheduled for \nleft ovarian plain embolization, a procedure in which a \nsmall tube is inserted into the vein to b lock the blood \nflow. The embolization was successful, with no acute \ncomplications (Figure 2). The patient was discharged \nthree days after the procedure.  \nThree months following the procedure, the patient \nindicated that there had been no reduction in the \nseverity of the pain. The Visual Analogue Scale (VAS) \nremained at a score of 5, consistent with preoperative \nVAS. However, the patient reported a decrease in the \nfrequency of pain attacks. Postoperatively, the patient \nexperienced approximately two pain attacks per week, \na significant reduction from the preoperative frequency \nof approximately five attacks per week. No \ncomplications were reported. The pain came from deep \ninfiltrating endometriosis in the ligamentum \nsacrouterina. \nThe patient received Dianogest 1x2 mg for pain \ntreatment. At 8 months after the procedure, the patient \ndecided to plan for pregnancy. Fertility specialists \nassisted the patient and discontinued the patient's \nhormone therapy. \nAt 10 months follow -up, the patient’s menstruation \nwas 1 month late. Sonography confirmed pregnancy \nwith a gestational sac shown on abdominal sonography \n(Figure 3). \n \n\n\nBayu Agung Sangkara Putra, et al. 584 \n      Volume 10, July 2025       Journal of Obstetrics, Gynecology and Cancer Research \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nFigure 2. A) pre-embolization venography showed left ovarian vein dilatation; B) post-amplatzer showed successful \nembolization with no flow to the proximal vein \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nFigure 3.  Abdominal ultrasound with gestational sac \nconfirming pregnancy \n \n3. Discussion \nThe current case was 33 years old. Some studies say \nthat PCS cases generally affect women of reproductive \nage who have at least one child. There are no reported \ncases of PCS in postmenopausal patients (6). \nMeanwhile, cases of DIE usually occur in women \nbetween 25 and 39 years of age (7). Studies show that \nDIE is more common in women who have never given \nbirth (nulliparous), with approximately 65.8% of DIE \npatients falling into this category. In addition, DIE is \noften associated with symptoms of pelvic pain, severe \nchronic infertility, dyspareunia, and subfertility, which \nare also more common in women of childbearing age \n(8). \nClinical symptoms of PCS usually include chronic \npelvic pain of varying intensity and duration. This pain \ncan be described as a dull or severe pain in the pelvic \narea that lasts at least 3-6 months and may worsen over \ntime, especially before or during menstruation and after \nprolonged standing or physical activity (9). Factors that \nincrease abdominal pressure, such as prolonged \nstanding, lifting weights, or changing positions can \nworsen pain symptoms. In addition, patients may \nexperience additional symptoms such as pain during \nintercourse (dyspareunia), urgency, consti pation, and \nfatigue (9). \nThe current patient has a double diagnosis of PCS \nand DIE, which have similar symptoms but differ in \nterms of management. The clinical manifestation of \nDIE is mainly characterized by pain, with \ndysmenorrhea as the main symptom that can appear as \na primary or secondary disorder (10). \nVenography is the gold standard for diagnosing PCS, \nwhich involves catheterization of the ovarian and iliac \nveins to identify venous reflux, venous dilatation, and \npelvic venous congestion. Venography confirms the \ndiagnosis and assists in embolization planning and coil \nselection (11). CT angiography can be used to visualize \nthe pelvic venous anatomy and identify signs of \ncongestion. An imaging test called triple -phase to \ndelayed-phase CT angiography can demonstrate \novarian vein dilatation, venous reflux, and pelvic vein \ncongestion. Th is method can also be used to identify \nother pelvic pathologies (11,12). MRI can be used as \nan effective non -invasive alternative to detect PCS. \n\n\n585 Pregnancy in Advance Epithelial Ovarian Cancer \n      Volume 10, July 2025       Journal of Obstetrics, Gynecology and Cancer Research \nMRI can show pelvic venous detail and identify \nvaricose veins, venous reflux, and venous congestion. \nThe advantage of MRI is that it does not expose the \npatient to radiation, making it safer for the patient. \nHowever, the sensitivity and specificity of MRI for \nPCS are still controversial and require more \nstandardized diagnostic criteria (11,12). In the current \ncase, MRI was performed as the second diagnostic \napproach after sonography. After MRI, dilatation of the \nleft ovarian vein and multiple DIE was found. The \ndiagnosis of PCS must be confirmed, so CT \nangiography was our third diagnostic study , which \nconfirmed the diagnosis of PCS. \nThe management of DIE involves an integrated \nmedical and surgical approach. For medical treatment, \nprogestins, subcutaneous etonogestrel, and \nLevonorgestrel Intrauterine System (LNG-IUS) are \nrecommended as first -line therapy, while Combined \nOral Contraceptive s (COCs) may be used as second -\nline therapy. If the patient does not respond to this \ntherapy, GnRH agonists may be considered as an \nadditional therapy. On the surgical side, diagnostic \nlaparoscopy should be avoided, and surgical \nintervention is usually performed when medical \ntreatment fails. In addition, given the high risk of \nrecurrence, cryopreservation of ovarian tissue may be \nan option to preserve the patient's fertility (13). In the \npresent case, the patient's infertility was the main \nreason we did not pursue surgical therapy. The patient \nwas still trying for her second pregnancy, so hormonal \ntherapy was our first choice. \nThe management of PCS begins with the \nidentification of signs and symptoms. Next, \ntransvaginal duplex ultrasound is performed to assess \npelvic vein dilatation and determine the type of blood \nflow (reflux or derivative). If necessary, transparent \nduplex ultrasound can be used to observe compression \nof the veins. If the results indicate a problem, pelvic \nphlebography is then performed to confirm the \npresence of reflux or compression. Based on this \nfinding, endovascular treatment can be performed, \nincluding em bolization procedures to treat venous \nreflux or stenting to treat compression, thereby \nreducing symptoms and improving the patient's quality \nof life (14). \nEmbolization is one of the mainstay treatments for \nPCS. In the study by Senechal et al. , on 327 subjects \nwho underwent embolization for pelvic congestion \nsyndrome, the technical success rate for this procedure \nwas 80.9%. study found significant results in pain \nreduction and quality of life. There were only 16 minor \nand four major adverse even ts (15). A systematic \nreview of embolectomy as a treatment for PCS found \nsimilar results. A total of 25 trials with 2038 patients \nwere included. Transcatheter embolization had a \ntechnical success rate of 94%. The overall \ncomplication rate was 9.0%. However, this study's low \nquality of evidence warrants further investigation, \nalthough it is sufficient to conclude that PCS may be an \nalternative treatment with a low complication and \nrecurrence rate (17). This evidence suggests that \nembolization is a good alternative therapy for PCS. \nThis is like our case, where the patient showed \nsignificant improvement in pain and no complications \nrelated to embolization. \nMedical treatments for PCS include Gonadotropin-\nReleasing Hormon e (GnRH) agonists, hormone \ntherapy, phlebotomy, and nonsteroidal anti -\ninflammatory drugs (16). We did not consider any of \nthe medical treatments because previous medical \ntreatments had failed to control pain and symptoms. In \naddition, the failure of medical treatments warranted \ninvasive treatment, including embolization.  \nThe prognosis for DIE can vary depending on the \nseverity of the disease and the effectiveness of \ntreatment. Although medical treatments such as \nprogestins (e.g., dienogest) can provide temporary \nrelief of painful symptoms and reduce the size of \nlesions, DI E is often a recurrent and progressive \ndisease (17). \nThe impact of embolization on fertility in women \nundergoing PCS treatment has been documented in the \nliterature. A study by Liu et al. On 12 subjects found \nthat embolization was successful in reducing pain. \nMoreover, 66.7% of the subjects could still becom e \npregnant even after embolization (18). Their finding \nwas like our case, which suggests that embolization \nmight not affect fertility.  \nThe differential diagnosis between Deep Infiltrating \nEndometriosis (DIE) and Pelvic Congestion Syndrome \n(PCS) is clinically challenging due to the overlap in \nsymptoms exhibited by these conditions. The two \nconditions can present similar symptoms, including \nchronic pelvic pain, dysmenorrhea, and dyspareunia, \nwhich can complicate accurate diagnosis. A multitude \nof case reports have documented this diagnostic \nchallenge. Mpourazanis et al. , reported a case of a 35 -\nyear-old woman initially suspected of having PCS. In \ntheir case, Magnetic Resonance Imaging (MRI) and \nComputed Tomography (CT) scans were \ncontraindicated due to allergies to contrast media. A \ndiagnostic laparoscopy was performed, which revealed \nthe presence of both multiple DIE lesions and \nsignificant dilatation of several veins in the pouch of \nDouglas. This finding confirmed the coexistence of \nboth cond itions. In contrast to the embolization \nprocedure performed in our case, the patient in the \nstudy was treated with GnRH agonist therapy (19).  \nThe present case report has several strengths. The \nstrength of this case report is the multidisciplinary \napproach involving several specialists. The \ngynecologist prescribed hormonal treatment, while \ninterventional radiology assisted in the diagnosis of \nPCS. Vascular surgery was also involved in the \ndiagnosis and embolization that treated the patient's \nPCS. A fertility specialist was also involved in the \npatient's pregnancy. \n\nBayu Agung Sangkara Putra, et al. 586 \n      Volume 10, July 2025       Journal of Obstetrics, Gynecology and Cancer Research \n \n4. Conclusion \nThis case report highlights some important points for \nearly diagnosis and proper treatment of PCS, especially \nin women with CPP and infertility. Embolization \nremains the mainstay of treatment for PCS -related \ninfertility. A multidisciplinary approach involv ing \nspecialists in obstetrics and gynecology, interventional \nradiology, and thoracic cardiovascular surgery is \nrequired to plan optimal treatment.  \n \n5. Declarations \nAcknowledgments \nThe authors would like to thank the staff of \nAirlangga University for their help in preparing this \nmanuscript. \nEthical Considerations \nThe patient had consent for participation in the \npublication of this manuscript. Written consent had \nalready been obtained from the authors. \n \nAuthors' Contributions \nBayu Agung Sangkara Putra contributed to the \nconceptualization, conceiving and designing the \nanalysis, collecting data, and writing the paper. \nAshon Sa'adi, Sri Ratna Dwiningsih, and Danang \nHimawan Limanto performed conceptualization, \nwriting and reviewing the paper. \n \nConflict of Interest \nThe authors declare no conflict of interest. \n \nFund or Financial Support \nThe authors declare no funding or financial support \nfor this study. \n \n \n \n \n1. Chronic Pelvic Pain: ACOG Practice Bulletin, \nNumber 218. Obstet Gynecol. 2020;135(3):e98–\n109. [DOI:10.1097/aog.0000000000003716]  \n2. Parasar P, Ozcan P, Terry K. Endometriosis: \nEpidemiology,Diagnosis, and Clinical \nTreatment. Curr Obstet Gynecol Reprod. \n2017;6(1):34–41. [ DOI:10.1007/s13669-017-\n0187-1] \n3. Pham KC, Dao VQ, Nguyen LTP, Tran VD. 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Alson S, Jokubkiene L, Henic E, Sladkevicius P. \nPrevalence of endometrioma and deep \ninfiltrating endometriosis at transvaginal \nultrasound examination of subfertile women \nundergoing assisted reproductive treatment. \nFertil Steril. 2022;118(5):915 –23. \n[DOI:10.1016/j.fertnstert.2022.07.024] \n8. Yuan X, Wong BWX, Randhawa NK, Win TPP, \nChan YH, Ma L, et al. Factors associated with \ndeep infiltrating endometriosis, adenomyosis \nand ovarian endometrioma. Ann Acad Med \nSingap. 2023;52(2):71 –9. \n[DOI:10.47102/annals-acadmedsg.2022334] \n9. Kuo CH, Martingano DJ, Saadat Cheema O, \nSingh P. Pelvic Congestion Syndrome. In: \nStatPearls. StatPearls Publishing, Treasure \nIsland (FL); 2025. [PMID] \n10. Imperiale L, Nisolle M, Noël JC, Fastrez M. \nThree Types of Endometriosis: Pathogenesis, \nDiagnosis and Treatment. State of the Art. J Clin \nMed. 2023 Jan 28;12(3):994. \n[DOI:10.3390/jcm12030994] \n11. O’Brien MT, Gillespie DL. 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Senechal Q, Echegut P, Bravetti M, Florin M, \nJarboui L, Bouaboua  M, et al. Endovascular \nTreatment of Pelvic Congestion Syndrome: \nVisual Analog Scale Follow -Up. Front \nCardiovasc Med. 2021;8:751178. \n[DOI:10.3389/fcvm.2021.751178] \n16. Kuo CH, Martingano DJ, Saadat Cheema O, \nSingh P. Pelvic Congestion Syndrome. Treasure \nIsland: Statpearls Publishing; 2025. [PMID] \n17. Wu C, Wei MYK, Yeung JMC, Battye S, Cho J. \nDeep infiltrating endometriosis mimicking \ncolorectal cancer. ANZ J Surg. \n2023;93(11):2751–3. [DOI:10.1111/ans.18525] \n18. Liu J, Han L, Han X. The Effect of a Subsequent \nPregnancy After Ovarian Vein Embolization in \nPatients with Infertility Caused by Pelvic \nCongestion Syndrome. Acad Radiol. \n2019;26(10):1373–7. \n[DOI:10.1016/j.acra.2018.12.024] \n19. Mpourazanis G, Laganà AS, Tepelenis K, \nTsirkas P, Gkrozou F, Paschopoulos M, et al. An \nUnusual Case of Pelvic Congestion Syndrome: \nA Case Report. Cureus. 2024;  16(12):e75502. \n[DOI:10.7759/cureus.75502]  \n \n \n \n \n \nHow to Cite This Article:  \nAgung Sangkara Putra , B., Sa'adi, A., Dwiningsih, S.R., Himawan Limanto, D. Successful Pregnancy Following \nOvarian Vein Embolization in a Patient with Pelvic Congestion Syndrome and Deep Infiltrating Endometriosis : A \nCase Report. J Obstet Gynecol Cancer Res. 2025;10(7):582-7. \nDownload citation:                             RIS | EndNote | Mendeley |BibTeX |","source_license":"CC0","license_restricted":false}