{"paper_id":"dd00fb01-81d5-41aa-b8a7-6b5d74f2aa15","body_text":"Archives of the Balkan Medical Union\nCopyright © 2021 Balkan Medical Union\nvol. 56, no. 1, pp. 110-113\nMarch 2021\nRÉSUMÉ\nRupture de l’abcès ovarien après la récupération d’oo-\ncyte chez un patient avec endométriome: rapport de \ncas\nIntroduction. La rupture d’un abcès pelvien est une \ncomplication rare après des procédés de fécondation \nin vitro.\nPrésentation du cas. Nous décrivons un cas inha-\nbituel de rupture d’abcès ovarien après prélèvement \nd’ovocytes transvaginal chez une femme de 31 ans avec \nun endométriome antérieur. La patiente s’est présen-\ntée dans notre salle d’urgence, 17 jours après le prélè-\nvement d’ovocytes guidé par échographie et 12 jours \naprès le transfert d’embryon, présentant des douleurs \nabdominales basses aiguës, une fièvre septique et un \nmalaise. Une chirurgie laparoscopique a été envisagée \naprès l’échec d’une triple combinaison d’antibiotiques \npar voie intraveineuse.\nConclusions. L’approche des patients présentant cette \ncondition par un traitement contre l’infertilité semble \nêtre difficile en raison de la nécessité d’un traitement \nantibiotique et chirurgical agressif qui augmente le \nABSTRACT\nIntroduction. Pelvic abscess rupture is a rare compli-\ncation following in-vitro fertilization procedures.\nCase presentation. W e describe an unusual case \nof ovarian abscess rupture following transvaginal \noocyte retrieval in a 31-year-old female with a previ-\nous endometrioma. The patient presented 17 days \nafter ultrasound-guided oocyte retrieval and 12 days \nafter embryo transfer in our emergency room, with \nacute lower abdominal pain, septic fever and malaise. \nLaparoscopic surgery was considered after failure of \ntriple intravenous antibiotic combination.\nConclusions. Managing patients undergoing infertili-\nty treatment with this condition appears to be difficult \ndue to the need of aggressive antibiotic and surgical \ntreatment, which increases the risk of spontaneous \nabortion after embryo transfer.\nKeywords: embryo transfer, endometrioma, in-vitro \nfertilization, oocyte retrieval, ovarian abscess.\nCASE REPORT\nOVARIAN ABSCESS RUPTURE AFTER OOCYTE \nRETRIEVAL IN A PATIENT WITH ENDOMETRIOMA: \nCASE REPORT\nNikoleta G. TABAKOVA1,2 , Emil G. KOVACHEV1,2,, Vilislava R. IVANOVA1,2, \nTsvetomir E. KACHOVSKI1,2, Dimitar D. IVANOV1,2\n1 Department of Obstetrics and Gynaecology, Medical University Varna, Varna, Bulgaria\n2 Obstetrics and Gynaecology Hospital SBAGAL Varna, Varna, Bulgaria\nReceived 06 Jan 2021, Accepted 16 Febr 2021\nhttps:/ / doi.org/10.3 1688/ ABMU.202 1.56. 1. 15\n Address for correspondence:   Nikoleta G. TABAKOVA\nDepartment of Obstetrics and Gynaecology , Medical University Varna, \nVarna, Bulgaria\nAddress: Marin Drinov Street No. 55, Varna, P.C. 9002, Bulgaria\nE-mail: nikoletta8708@gmail.com, Phone: +359886591057\n\nArchives of the Balkan Medical Union\nMarch 2021 / 111\nINTRODUCTION\nOvarian abscess rupture certainly is an uncom-\nmon complication following in-vitro fertilization \n(IVF) procedures. The risk factors that may contrib-\nute to the development of the condition following \noocyte retrieval are the presence of endometriomas \nand/or hydrosalpinx\n1. The case who will be presented \nsuggests the importance to recognize these patients \npreconceptionally and to minimize their risk by surgi-\ncal treatment before applying any assisted reproduc-\ntive techniques. On the contrary, because of the lack \nof prospective studies and evidence data based only \non case reports, there is still a debate in the reproduc-\ntive field whether or not to recommend the surgical \ntreatment before undergoing IVF cycles in these pa-\ntients\n2-5.\nCASE PRESENTATION\nA 31-year-old white female, gravida 2, para 1, \npresented on November the 25 th 2020, to the emer-\ngency room for lower abdominal pain, septic fever \nand malaise for 10 days. At the start of the infertility \ntreatment, in November 2020, the patient was known \nwith endometrioma in the right ovary, 5 cm in diam-\neter, diagnosed on its typical ultrasound appearance. \nBy protocol, she received ultrasound-guided transvag-\ninal oocyte retrieval (TVOR) and embryo transfer. \nDuring TVOR, an accidental puncture of the endo-\nmetriotic cyst was suspected. The patient was given \nprophylactic antibiotics. Despite the antibiotic treat-\nment, two days later she experienced lower abdomi-\nnal discomfort and fever. Ten days after the onset of \nsymptoms, the patient presented to our emergency \nroom with severe right lower quadrant abdominal \npain and nausea. The abdominal palpation revealed \nmarked generalized tenderness, rebound tenderness \nand guarding. The pelvic examination showed severe \nbilateral adnexal tenderness to palpation, right great-\ner than left. On admission, she had a temperature \nof 38.4°C. The pelvic ultrasound (Figures 1,2,3,4) \ndepicted a multilocular adnexal mass of 8 cm in di-\nameter, with  heterogeneously echogenicity of the in-\nner portions and irregular thick walls in the right \nadnexal region, with a moderate amount of free fluid \nin the Douglas pouch and an enlarged retroverted \nuterus. The differential diagnosis included torsion \nof the endometriotic cyst or rupture of ovarian ab-\nscess due to an inflammation of the endometrioma \nfollowing TVOR. The patient was started on triple \nantibiotic therapy with Metronidazole, Gentamicin \nand Ceftriaxone.\nThe patient’s condition aggravated after admis-\nsion. Six hours after admission, her abdominal pain \nincreased in severity and the blood pressure dropped \nto 80/40 mmHg, pulse rate accelerated to 130/min, \nand the temperature raised up to 39.5°C. Laboratory \nfindings were consistent with the presumptive di-\nagnosis of intraabdominal ovarian abscess rupture. \nA routine blood test showed that the white blood \ncell count was 16.3×10\n9/L, with 81.1% granulocytes. \nThe C-reactive protein was 266 mg/L. A decision for \nemergent exploratory laparoscopy was made. From \nthe rectouterine space ~300 mL of thick, brownish \nfluid was aspirated. The left adnexa seemed only \nhyperaemic and oedematous. A right adnexal mass \nof approximately 10 cm×8 cm×8 cm in diameter was \nseparated from adherent tissues. The mass arose from \nthe right ovary, and normal ovarian tissue was miss-\ning. Right laparoscopic salpingo-oophorectomy was \nperformed. Pelvic drains were left in situ. A culture \nof vaginal discharge on admission showed no bac-\nterial growth. The histopathological examination \nshowed tubal ovarian abscess. The triple combina-\ntion of intravenous antibiotics was continued till dis-\ncharge. Oral antibiotics were prescribed for another \n7 days. The pelvic drain was removed on the 3\nrd day \npostoperatively. The patient was discharged on the \n4\nth day post- surgery, afebrile and in stable condition.\nDISCUSSION\nEndometriosis occurs in 25% to 50% of women \nwith infertility 6. In vitro fertilization is an effective \ntreatment for these women, and although pelvic \nabscess is a rare complication of oocyte retrieval \n(0.3-0.4%), endometriosis is a risk factor\n7,8. The pro-\nposed pathophysiological mechanism is the bloody \ncontent of the endometrioma, that may serve as a \ngood culture medium for bacteria and facilitate the \nspread of infection\n9. The pseudo-capsule of the endo-\nmetriotic cyst may prevent antibiotics from overcom-\ning bacteria. Endometriosis may increase the risk of \nrisque d’avortement spontané dans les cas ayant subi \nun transfert d’embryon.\nMots-clés: transfert d’embryon, endométriome, fé-\ncondation in vitro, prélèvement d’ovocytes, abcès ova-\nrien.\n\nOvarian abscess rupture after oocyte retrieval in a patient with endometrioma: case report – TABAKOVA et al\n112 / vol. 56, no. 1\nabscess formation, because locally impaired immuni-\nty in the pelvic cavity makes the patient susceptible to \ninfection\n10. Both the Royal College of Obstetricians \nand Gynaecologists and the European Society of \nHuman Reproduction and Embryology recommend \nresection for endometriomas measuring 4 cm or \nlarger, in order to reduce the risk of infection\n11,12. \nThis topic is still debated in the field of reproductive \nmedicine. Whether to perform a surgical removal of \nan endometriotic cyst before applying any assisted re-\nproductive techniques or to put the patient at risk of \npossible complications is a question to which there \nare still no guidelines to answer\n13.\nIn our case, the diagnosis was easily made, main-\nly because of the typical clinical manifestation and \nultrasonographic signs of ruptured ovarian abscess, \nin combination with the knowledge of pre-existing \nendometrioma and suspected puncture of the cyst \nduring oocyte retrieval. In some similar cases de-\nscribed in the literature, the symptoms occur late, \nwithin months after TVOR\n14. In this peculiar case, \nthe symptoms started one day after oocyte retrieval, \nbut were probably diminished due to the prescribed \nprophylactic antibiotic treatment.\nTreatment of pelvic abscess in women of repro-\nductive age or during pregnancy is always difficult. \nThe choice to avoid surgical treatment for preserving \nfertility or prolong pregnancy may lead to unwanted \nmaternal and perinatal complication or even death\n15. \nThe embryo transfer in our case was done 12 days be-\nfore her admission in the hospital and since it was too \nearly to diagnose a pregnancy, our decision was not \ninfluenced by assuring maturity and therefore better \nsurvival chances of the foetus, rather than saving the \nFigure 1.  Ultrasonography – a multilocular adnexal mass, \n8 cm in diameter, with heterogeneous \nechogenicity of the inner portions \nand irregular thick walls in the right adnexal region.\nFigure 3. Ultrasonography – sagittal view \nof a retroverted uterus and a free fluid \nin the Douglas pouch with varying echogenicity.\nFigure 2. Ultrasonography – transverse plane \nof the right adnexa demonstrating varying sized cystic \nappearing structures consistent with tubal-ovarian \nabscess. The bladder is also visualized.\nFigure 4. Ultrasonography – transverse plane \nof the uterus showing diffuse enlargement.\n\n\nArchives of the Balkan Medical Union\nMarch 2021 / 113\npatient’s life. After aggravation of patient’s symptoms, \nwe proceeded to surgical treatment of the ruptured \nabscess. Laparoscopy was the preferred route, because \nit has more advantages (shorter operation duration, \nshorter length of hospital stay, less bleeding) compared \nto laparotomy. The prompt decision of surgical man-\nagement of the patient allowed us to be more conserv-\native and keep the uterus and the left adnexa intact. \nWe performed only right salpingo-oophorectomy with \nlavage and pelvic drain placement, which was removed \nwithin three days post-surgery. Unfortunately, the day \nafter surgery moderate uterine bleeding occurred and \npregnancy loss was proven with quantitative human \nchorion gonadotropin blood test.\nCONCLUSIONS\nOvarian abscess may develop in women with \nendometrioma following assisted reproductive tech-\nniques. The condition, although rare, may complicate \ncoexisting pregnancy, with the risks of spontaneous \nabortion or preterm labour and may also lead to se-\nvere complications for the woman. Thus, the prompt \nrecognition of the condition is of great importance \nand, based on our experience, the immediate surgi-\ncal treatment after symptoms aggravation despite the \naggressive antibiotic therapy allows to be as conserva-\ntive as possible in terms of fertility preservation.\nAuthor Contributions:\nN.T., E.K., V.I. were responsible for the diagnostic \nprocedures, clinical diagnosis, and treatment decisions. T.K. \nperformed the surgery. D.I. and N.T. wrote the manuscript. \nV.I. translated the abstract in French. All authors have \nread and agreed to the published version of the manuscript.\nCompliance with Ethics Requirements:\n“The authors have no conflict of interest relevant to \nthis article”\n“The authors declare that all the procedures and ex-\nperiments of this study respect the ethical standards in the \nHelsinki Declaration of 1975, as revised in 2008, as well \nas the national law. Informed consent was obtained from \nthe patient included in the study”\n“No funding for this study”\nAcknowledgments\nNone\nREFERENCES\n1. Brosens I. Endometriosis and the outcome of in vitro ferti-\nlization. Fertil Steril . 2004;81:1198–200.\n2. Garcia-Velasco JA, Arici A. Surgery for the removal of endo-\nmetriomas before in vitro fertilization does not increase im-\nplantation and pregnancy rates. Fertil Steril . 2004;81:1206.\n3. Gibbons WE. Management of endometriosis in fertility pa-\ntients. Fertil Steril . 2004;81:1204–5.\n4. Somigliana E, Vercellini P, Vigano P, Ragni G, Crosignani \nPG. Should endometriomas be treated before IVF-ICSI cy-\ncles? Hum Reprod Update.  2006;12:57–64.\n5. Garcia-Velasco JA, Mahutte NG, Corona J, et al. Removal \nof endometriomas before in vitro fertilization does not im-\nprove fertility outcomes: a matched, case-control study. Fertil \nSteril.  2004;81:1194–7\n6. Verkauf BS. The incidence, symptoms, and signs of en-\ndometriosis in fertile and infertile women. J Fla Med \nAssoc. 1987;74:671–675. \n7. Padilla SL. Ovarian abscess following puncture of an endo-\nmetrioma during ultrasound-guided oocyte retrieval. Hum \nReprod.  1993;8:1282–3\n8. Moini A, Riazi K, Amid V, et al. Endometriosis may contrib-\nute to oocyte retrieval-induced pelvic inflammatory disease: \nreport of eight cases. J Assist Reprod Genet . 2005;22:307–309.\n9. Chen MJ, Yang JH, Yang YS, Ho HN. Increased occurrence \nof tubo-ovarian abscesses in women with stage III and IV \nendometriosis . Fertil Steril.  2004;82:498–9.\n10. Matsunaga Y, Fukushima K, Nozaki M, et al. A case of preg-\nnancy complicated by the development of a tubo-ovarian \nabscess following in vitro fertilization and embryo transfer. \nAmerican Journal of Perinatology.  2003;20(06):277-282.\n11. Leyland N, Casper R, Laberge P, Singh SS; SOGC. \nEndometriosis: diagnosis and management. J Obstet \nG y n a e c o l  C a n .  2 0 1 0  J u l ; 3 2 ( 7  S u p p l  2 ) : S 1 - 3 2 .  P M I D :  \n21545757.\n12. Kennedy S, Bergqvist A, Chapron C, et al. ESHRE guide-\nlines for the diagnosis and treatment of endometriosis. Hum \nReprod.  2005;20:2698–2704.\n13. Demirol A, Guven S, Baykal C, Gurgan T. Effect of endo-\nmetrioma cystectomy on IVF outcome: a prospective rand-\nomized study. Reprod Biomed Online.  2006;12:639–43.\n14. Han C, Wang C, Liu XJ, et al. In vitro fertilization compli-\ncated by rupture of tubo-ovarian abscess during pregnancy. \nTaiwan J Obstet Gynecol . 2015;54(5):612-6.\n15. Khawaja N, Walsh T, Gleeson R, Geary MPP. Tubal ab-\nscess in pregnancy: A case report. Journal of Obstetrics and \nGynaecology . 2005; 25(2):210.","source_license":"CC0","license_restricted":false}