{"paper_id":"e5464e68-a1d3-4208-bc92-e80a55dc54ed","body_text":"Clinical Case Reports and Reviews.                                                                                                                                                                           Copyrights@ LU Yu-Feng,  \nAuctores Publishing LLC – Volume 36(4)-1130 www.auctoresonline.org  \nISSN: 2690-4861                                                                                                                              Page 1 of 4 \n \n \nEndometriosis with Ovarian Cysts and Ovulation Induction \nFollowed by Malignant Transformation into Ovarian Clear Cell \nCarcinoma: A Case Report \nLU Yu-Feng 1*, Song Xiao-Tong 1, Tian Li 2 \n1Gynecology and Obstetrics Department of Gansu Provincial People's Hospital, Lanzhou 730000, China. \n2Peking University People's Hospital Department of Obstetrics and Gynecology Reproductive Center Beijing 100053, China.  \n*Corresponding Author: LU Yu-Feng., Gynecology and Obstetrics Department of Gansu Provincial People's Hospital, Lanzhou 730000, China. \nReceived Date: June 11, 2026 | Accepted Date: June 22, 2026 | Published Date: July 10, 2026 \nCitation: LU Yu -Feng, Song Xiao-Tong, Tian Li, (2026), Endometriosis with Ovarian Cysts and Ovulation Induction Followed by Malignant \nTransformation into Ovarian Clear Cell Carcinoma: A Case Report , International Journal of Clinical Case Reports and Reviews , 36(4); \nDOI:10.31579/2690-4861/1130 \nCopyright: © 2026, LU Yu-Feng. This is an open -access article distributed under the terms of the Creative Commons Attribution License, which \npermits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. \nAbstract: \nReport a case of ovarian clear cell carcinoma in a patient with endometriosis (EMs) and ovarian cysts who was treated Peking \nUniversity People's Hospital in May 2018. After the patient was treated, relevant laboratory tests were performed, and assist ed \nreproductive technology (ART) used to help with conception. Ovarian stimulation was performed for 3 cycles, and during the \nprocess of ovarian stimulation, it was found that the ovarian cysts undergone solidification, and blood flow signals appeared  \naround the  cysts. Considering the possibility of a borderline tumor, conservative surgery was performed to preserve the \nreproductive function. The operative pathological diagnosis was clear cell carcinoma stage IC and pelvic endometriosis. After  \nthe operation, the patient was given 3 courses of chemotherapy with 40 of doxorubicin and 450 mg of cisplatin. The correlation \nbetween EMs and ovarian cysts in infertile patients during ovarian stimulation the management of ovarian cysts during ovarian \nstimulation were analyz ed. However, there are few reports of similar cases, and a large number of case data need to be \naccumulated multiple reproductive centers to verify this. \nKey words: endometriosis; ovarian cyst; ovarian clear cell carcinoma; art; infertility \n1.Introduction \nEndometriosis (endometriosis, EMs)is  a common disease caused by the \ntransfer of active endometrial cells to sites other than the endometrium, \nwith an incidence rate of about 10% to 15% [1]. Ovarian cancer (ovarian \ncancer, OC) caused by EMs is called endometriosis -related ovarian \ncancer (endometriosis associated ovarian carcinoma, EAOC). OC is the \nmost lethal gynecological malignancy. Among them, ovarian clear cell \ncarcinoma (ovarian clear cell carcinoma, OCCC) and ovarian \nendometrioid carcinoma (ovarian endometrioid carcinoma, OEC) are the \nmost common [2]. It was found that most of OCCC had EMs precursor \nlesion [2], and about 1 / 3 were directly originated from EMs lesion [3]. \nOCCC accounts for about 5% [4] of all ovarian cancers and is a rare \nmalignant type among the five subtypes of ovarian cancer (high grade \nserous, low grade serous, endometrioid, mucinous cell carcinoma and \nclear cell carcinoma), with specific genetic and molecular features being \na specific histological type in ovarian cancer. This paper presents a case \nof ovarian clear cell carcinoma in an infertile patient with EMs and \novarian cysts, which is reported as follows. \n2.Case Report \nThe patient, a 38-year-old female, presented to Peking University People's \nHospital on June 19,2018 for \"left ovarian cyst found for 2 years and 3 \nyears without contraception\". Two years ago, B ultrasound in the other \nhospital: 2.5x1.7x2.0cm left ovarian c yst with clear boundary, poor \ninternal sound transmission and dense punctate echo. Consider ovarian -\ntype endometriosis? The patient had regular menstruation and normal \nsexual life, and had no contraception for 3 years without pregnancy. Visit \nto our hospital for reexamination of B ultrasound: multiple cystic echoes \ncould be seen in the left ovary, large 2.4x1.4cm, clear boundary and fine \ndense dot echo. AMH:1.3ng/ml(2 -7.0ng/ml), the underlying sex \nhormone: FSH:15.33mIU/ml(5-10mIU/mL),LH:3.73mIU/ml(5-\n10mIU/mL),E2:45.17pg/ml (25 -45 pg/mL). Semen routine: semen \ndensity: 4.99 million / ml, forward motile sperm rate (PR): 28.38%. The \n  Open Access  \n Case Report  \n     International Journal of Clinical Case Reports and Reviews \n                                                                                            LU Yu-Feng *                                                                                                                                                        \nAUCTORES \nGlobalize your   Research \n\nClinical Case Reports and Reviews.                                                                                                                                                                           Copyrights@ LU Yu-Feng,  \nAuctores Publishing LLC – Volume 36(4)-1130 www.auctoresonline.org  \nISSN: 2690-4861                                                                                                                              Page 2 of 4 \npatient and the family members requested the IVF. Diagnosis: ① Primary \ninfertility; ② ovarian hypofunction (Diminished Ovarian Reserve, \nDOR); ③ left ovarian chocolate cyst?④ Male oligoasthenospermia. IVF \nassisted pregnancy (see Table 1). The left ovarian cyst persisted during \nproinduction. In September 2018, B ultrasound (during the third drainage \nperiod): left ovarian cyst 4.6x3.6cm, poor internal sound transmission, \nstrong papillary echo in the cyst wall, maximum 1.1x0.9cm, punctate flow \nsignal, and thin 3.0x2.2cm cyst wall, good sound t ransmission, and fine \nsegmentation inside. B ultrasound: left ovarian cyst 5.7x4.1x3.0cm, \nuneven inner wall, multiple papillary processes, maximum diameter of \n1.7cm, blood flow signal RI: 0.43, PI: 0.56. On November 23,2018, we \nperformed laparoscopic surge ry in Peking Union Medical College \nHospital. Microscopically: fine red and purple blue endometriotic lesions \nwere visible in the reverse folding of the bladder, with 2mm purple blue \nnodules, enlarged left ovary, and a 5cm cyst with thin wall, smooth \nsurface, and no exogenous nipple. Operation method: left ovarian cyst \nremoval + fertility preservation function staging (left accessory resection \n+ right ovarian biopsy + peritoneal biopsy + partial resection of omentum \n+ left pelvic abdominal lymph node dissection). Rapid intraoperative \npathology: clear cell carcinoma of the left ovary. Postoperative disease \nexamination: pelvic endometriosis, left ovarian clear cell carcinoma, \nimmunohistochemistry: PAX 8 (+), NapsinA  (minimal +), CK7 (+), \nCK20 ( -), GATA 3 ( -), SATB ( -), CA125 (focal +), ER ( -), Ki -67 \n(index50%), P16 (+), P53 (scattered +), PR (-), WT-1 (-), HNFIB (+). The \npatient underwent chemotherapy in Peking Union Medical College \nHospital for three times. The first chemotherapy was in December 2018. \nThe chemotherapy regimen was doxicin 40mg and bordine  450mg. \nChemotherapy was given in January and February 2019, and the \nchemotherapy regimen was the same as before. From 2019 to 2020, the \npatients were followed up and reviewed at Peking Union Medical College \nHospital on time. Embryo transfer was performed in Peking University \nPeople's Hospital in April 2021.4BB and 4 BC embryos were transplanted \nin HRT-FET protocol and D3 2 (9II 8II) were implanted in January 2022. \nB ultrasound review in September 2023: two mixed echo sizes \n2.1x1.7cm,2.2x1.4cm, regular morp hology and clear boundary in the \nright ovary. CTC and CTEC testing of rare cells of alloploid circulating \ntumors were performed in May 2024:4 CTC, CTEC 4. After consultation, \nprofessor of Obstetrics and Gynecology of Peking University People's \nHospital sug gested a right ovariectomy. The patient and his family \nmembers did not undergo surgery and were still under follow-up. \n Table 1 Patients underwent IVF-ET in the reproductive center   \nPregnancy \ncycle start time \nProtocol for \novulation \ninduction \nThe Gn \ndose and \ntime \nEndometrial \nthickness in \nhCG day \n(mm)） \nE2, hCG \nday (pmol \n/ L） \nDay of \nhCG LH \n(IU / L) \nDay of \nhCG P \n(n \nmol/L) \nNumber of \neggs \n(individual\n) \nEmbryonic \nresults \n1 On June \n16,2018 Letrezole protocol 225IU for 7 \ndays 4 270 6.94 1.49 3 6II 7II \n2 On August \n10,2018 microstimulation 150IU for 4 \ndays 6 234 4.8 0.73 2 No embryo \n3 On September \n17,2018 \nThe luteal stage \npromotes ovulation \n300IU for 9 \ndays 9 2541 2.45 21.63 7 9II 8II \n         4BB 4BC \n4 In August, \n2021 natural period  9 335 14.4 0.58 1 No embryo \n5 In December, \n2021 natural period  12 148 4.4 2.48 0  \n3 Discussion  \n3.1 Clinical features of endometriosis malignancy  \nEndometriosis (endometriosis, EMs)is  a common disease caused by the \ntransfer of active endometrial cells to locations other than the \nendometrium, with an incidence rate of about 10% to 15%. There are now \nabout 176 million women with EMs worldwide. The main clinical \nmanifestations of EMs are dysmenorrhea, menstrual volume, menstrual \ncycle changes and sexual intercourse pain, and most young patients have \nthe confusion of infertility. Ovarian cancer (ovarian cancer, OC) caused \nby EMs is called endometriosis -related ovarian cancer (endometriosis \nassociated ovarian carcinoma, EAOC). OC is the most lethal \ngynecological malignancy. Epidemiological studies have shown that EMs \ncause an increased risk of ovarian cancer in specific tissue types, with \novarian clear cell carcinoma (ovarian clear cell carci noma, OCCC) and \novarian endometrioid carcinoma (ovarian endometrioid carcinoma, OEC) \nbeing the most common. \n3.2 Mechanism of ovarian clear cell carcinoma  \nOvarian epithelial cancer (epithelial ovarian cancer, EOC), is the most \ncommon type of ovarian cancer, accounting for 90% of ovarian cancer \ncases, is a group of heterogeneous disease with different genomic \ncharacteristics, accounting for 3.6% of global fem ale cancer incidence \nand 4.3% of cancer mortality [3], can be divided into five main subtypes: \nhigh grade serous, low grade serous, endometrioid carcinoma, mucous \ncell carcinoma and clear cell carcinoma [5]. Ovarian clear cell carcinoma \n(ovarian clear cell  carcinoma, OCC) accounts for about 5% [4] of all \novarian cancers. It is a rare malignant type among the five subtypes. It has \nspecific genetic and molecular characteristics and is a specific histological \ntype in ovarian cancer, and its cytoplasm is transp arent, so it is named \nclear cell carcinoma [9 -11]. It was found that most of OCCC had \nprecursor lesions of EMs,and about 1 / 3 were directly originating from \nEMs lesion [3]. Studies have reported that 13% – 15% of ovarian cancer \npatients carry the BRCA1 or BRCA2 germline mutation [6]. Treatment \nof PIK3CA and ARID1A mutations, loss of BAF250 protein, promoting \nsustained IL-6 production, also lead to rapid tumor growth. When PI3K -\nAkt is activated, it regulates the expression of downstream genes, thereby \ninhibiting apoptosis and promoting cell proliferation. Furthermore, \n\nClinical Case Reports and Reviews.                                                                                                                                                                           Copyrights@ LU Yu-Feng,  \nAuctores Publishing LLC – Volume 36(4)-1130 www.auctoresonline.org  \nISSN: 2690-4861                                                                                                                              Page 3 of 4 \nPIK3CA mutations enhanced PI3K activity and promoted cell cycle \nprogression, survival and motility [7]. Changes in PI3K / Akt, p53, and \nHER 2 signaling were found in 87% of OCCC, and chromatin remodeling \nevents occurred in 47% of OCCC. \n3.3 ART and ovarian clear cell carcinoma  \nCurrently, there is no clear evidence of a possible correlation between \novulation induction drugs and ovarian cancer due to infertility and \ncombined ovarian endometriosis cysts. In a prospective study of 1.1 \nmillion British women, 8719 women developed ovar ian cancer during \nfollow-up, Gaitskell[8] et al. Nulliparous individuals had a 24% higher \nrisk of ovarian cancer than women with 1 child, with significant increases \nin endometrioid and clear cell tumors. In multiparous women, the risk of \novarian cancer decreased overall by 6% per additional chi ld; with the \ngreatest reduction for clear cell tumors, where the overall risk of ovarian \ncancer in this large prospective study was much higher than the expected \nimpact of singleton births, particularly clear cell and endometrioid \ntumors, potentially sugge sting that infertility is associated to these \nhistotypes. Williams[ 9] et al, in a British follow -up of 255786 women \nfrom 1991 to 2010 showed an increased risk of ovarian cancer after ART. \nBut women receiving ART only for male factors, fallopian factors and \nunexplained infertility did not have an increased risk of ovarian cancer. \nTherefore, it also does not explain whether ovarian cancer development \nin patients receiving ART is due to ART treatment or due to endometriosis \nitself. In contrast, Frida et al [10] in a 1982 – 2012 study of 13840097 \nwomen in Sweden 2,38025 women delivered after receiving ART, 49208 \nwomen did not receive ART after diagnosis of infertility and 1252864 \nwomen naturally conceived and gave birth. During the follow-up period, \n991 women were diagnosed with ovarian cancer. The incidence of ovarian \ncancer is higher in women who delivered after ART compared to women \nwho did not develop infertility. The incidence of ovarian cancer was also \nhigher in women receiving ART compared with women diagnosed with \ninfertility and who did not undergo ART. Kessous et al. [11], a \npopulation-based study comparing the incidence of malignancies in \nwomen with and without a history of pregnancy -assisted therapy \n(including in vitro fertilization (IVF) and induced ovulation (OI)). During \nthe follow -up period, patients with  a history of IVF treatment were \ndiagnosed at a significantly increased risk of ovarian cancer compared \nwith patients after OI and those without a history of assisted treatment. \nThe IVF treatment history was independently associated with ovarian \ncancer. Dariush et al [12] reviews involving more than 70 papers found \nthat high doses of ovulation induction drugs, multiple IVF cycles can \nincrease the risk of ovarian cysts, which leads to ovarian cancer. It was \nalso found that there should be an association betw een the occurrence of \novarian cancer and drug type, dosage, and continuous ovulation induction \nfor more than 1 year. This case with older, low ovarian function, infertility \ntime is longer, and before ovulation drugs treatment endometriotic cyst, \nthe third ovulation found ovarian cyst consolidation, because this kind of \ncases belong to rare cases, less sample size, it is difficult to say ovarian \ncyst evil in the relationship between ovulation and infertility itself. In \naddition, it is also possible that the ovarian cyst itself may have potential \nmalignant changes, resulting in a reduction of basal follicles, which \nrequires multiple ovulation induction. Therefore, it is not necessarily \novulation induction leading to ovarian cyst malignant change. \n3.4 Management of the ovarian cysts included in the ART  \nAbout 40%~50% of EMS patients in childbearing age are complicated \nwith infertility, and ART technology is needed to help pregnancy. Studies \nhave shown that [13]. For patients receiving ART, such as ovarian cyst, \nvaginal ultrasound examination should be performed repeatedly during \nART treatment to dynamically monitor the changes of ovarian cyst, such \nas cyst size, morphology, echo and CDFI. Acc ording to the condition, it \nis feasible to puncture the ovarian cyst, and the puncture fluid can be sent \nfor pathological examination, so as to avoid the patient directly entering \nthe IVF cycle when the ovarian cyst is malignant. However, there are also \ndifferent opinions. The puncture may cause pelvic infection, tumor \ndissemination, bleeding and other risks, which will affect the progress of \nthe IVF cycle. At this time, it can enter the IVF cycle normally, and the \ntumor markers and vaginal ultrasound can b e closely monitored. In the \nprocess of egg retrieval, ovarian cyst puncture and disease examination \ncan be performed at the same time, so as to achieve early detection and \nearly treatment. Infertility caused by endometriosis is a common cause of \ninfertility. Most patients often help pregnancy through assisted \nreproduction. In the process of assisted pregnancy, the age, ovarian \nfunction, cyst ultrasound performance, tumor markers should be \ncomprehensively evaluated, and whether to conduct assisted reproduction \nafter surgery. Therefore, whether the application of ovulation induction \ndrugs will increase the ovarian endometriosis cyst malignant change, the \nrisk of malignant change, is a clinical research topic. It is necessary to \naccumulate a large number of cas e data in multiple reproductive centers \nto demonstrate, and to extend the follow -up time after the end of the \nassisted reproductive treatment cycle, so as to monitor the occurrence of \novarian cancer in the process of ovulation induction and after ovulation  \ninduction, and guide the egg retrieval interval, and be alert to the \noccurrence of ovarian cancer. \nReferences \n1. Laganà AS ，Garzon S ，Götte M et al, (2019). The \npathogenesis of endometriosis: molecular and cell biology \ninsights ［J］． Int J Mol Sci 20: 5615． \n2. Barnard ME, Farland LV, Yan B, Wang J, Trabert B,. (2024). \nEndometriosis Typology and Ovarian Cancer Risk. JAMA.; \n332:482-489. \n3. Webb PM, Jordan SJ. (2024). Global epidemiology of epithelial \novarian cancer. Nat Rev Clin Oncol.; 21:389-400. \n4. (2023). Department of Obstetrics and Gynecology, Osaka \nMedical and Pharmaceutical University, Osaka, Japan ：\nClinical perspectives of rare ovarian tumors: clear cell ovarian \ncancer，Japanese Journal of Clinical Oncology, 53, 664–672 \n5. Zhang Guonan. (2021). Treatment strategies and perspectives \nfor ovarian clear cell carcinoma [J]. Chinese Journal of \nPractical Gynecology and Obstetrics, ,37:193-197. \n6. Jasiak A,Koczkowska M、Stukan M、Wydra D、et al (2023). \nAnalysis of BRCA1 and BRCA2 alternative splicing in \npredisposition to ovarian cancer[J] 。Exp Mol Pathol .; \n130:104856 \n7. Farah AM, Gu S, Jia Y. (2022). Clinical analysis and literature \nreview of a case of ovarian clear cell carcinoma with PIK3CA \ngene mutation: A case report. Medicine; 101:37 \n8. Gaitskell K, Green J, Pirie K, Barnes, et al. (2018). Histological \nsubtypes of ovarian cancer associated with parity and \nbreastfeeding in the prospective Million Women Study. Int J \nCancer;142(2):281-289. \n9. Williams CL, Jones ME, Swerdlow AJ, Botting BJ, Davies MC, \net al. (2018). Risks of ovarian, breast, and corpus uteri cancer \n\nClinical Case Reports and Reviews.                                                                                                                                                                           Copyrights@ LU Yu-Feng,  \nAuctores Publishing LLC – Volume 36(4)-1130 www.auctoresonline.org  \nISSN: 2690-4861                                                                                                                              Page 4 of 4 \nin women treated with assisted reproductive technology in \nGreat Britain, 1991 –2010: data linkage study including 2.2 \nmillion person years of observation. BMJ.; 362:2644. \n10. Frida E, Anna L. V, Kenny Rodriguez Wallberg, et al. (2019). \nAssisted reproductive technology and risk of ovarian cancer \nand borderline tumors in parous women: a population -based \ncohort study. European Journal of Epidemiology 34:1093–1101 \n11. Kessous R, Davidson E, Meirovitz  M, Sergienko R, et al., \n(2016). The risk of female malignancies after fertility \ntreatments: a cohort study with 25-year follow-up. J Cancer Res \nClin Oncol.; 142:287–293 \n12. Dariush D. FARHUD, Shaghayegh ZOKAEI, Mohammad \nKEYKHAE, et al. (2019). Strong Evidences of the Ovarian \nCarcinoma Risk in Women after IVF Treatment: A Review \nArticle. Iran J Public Health,2124-2132 \n13. Wei Likun, Zhang Xuhong, Luo Ying, et al. (2023). A case of \novarian endometriosis cyst complicated by pelvic abscess and \nliterature review [J]. Chinese Journal of Clinical Medicine for \nWomen and Children (electronic edition), ,19 (06): 696-702. \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n This work is licensed under Creative    \n   Commons Attribution 4.0 License \n \n \nTo Submit Your Article Click Here: Submit Manuscript \n \nDOI:10.31579/2690-4861/1130\n  \n  \n  \n \n  \nReady to submit your research? Choose Auctores and benefit from:  \n \n➢ fast, convenient online submission \n➢ rigorous peer review by experienced research in your field  \n➢ rapid publication on acceptance  \n➢ authors retain copyrights \n➢ unique DOI for all articles \n➢ immediate, unrestricted online access \n \nAt Auctores, research is always in progress. \n \nLearn more  https://auctoresonline.org/journals/international-journal-of-\nclinical-case-reports-and-reviews","source_license":"CC0","license_restricted":false}