Spontaneous recurrent pneumothorax after in vitro fertilization

Suparna Bhattacharya
In: International Journal of Reproduction, Contraception, Obstetrics and Gynecology · 2026 · vol. 15(5) , pp. 1863–1866 · doi:10.18203/2320-1770.ijrcog20261304 · W7159593145
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A 39-year-old woman experienced recurrent spontaneous pneumothorax associated with exogenous estrogen therapy during in vitro fertilization, which resolved with a modified hormonal protocol.

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The paper reports a case of a 39-year-old woman with secondary infertility and multiple failed IVF attempts who developed recurrent spontaneous pneumothorax temporally linked to exogenous estrogen used for endometrial preparation. During a donor oocyte cycle with oral estradiol, she presented with acute chest pain and dyspnoea and was diagnosed with a left-sided pneumothorax managed conservatively; recurrence occurred after re-exposure to estrogen, with imaging showing left upper lobe involvement. A modified protocol using GnRH agonist downregulation followed by transdermal estrogen allowed embryo transfer and resulted in an ongoing twin pregnancy with an uneventful antenatal course and delivery at 35 weeks. The authors note limitations inherent to a single case report and propose that the hormonal therapy may have been associated with pleural pathology or occult thoracic endometriosis, which relates to endometriosis because the discussion frames the event as possibly estrogen-mediated and consistent with endometriosis-related pneumothorax patterns seen in catamenial pneumothorax. This paper is centrally about endometriosis—specifically suspected thoracic endometriosis presenting as recurrent, hormone-associated pneumothorax around IVF estrogen therapy.

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Abstract

Catamenial pneumothorax (CP) is a rare form of spontaneous pneumothorax occurring within 72–96 hours before or after the onset of menstruation, accounting for approximately 3–6% of cases, and is commonly associated with thoracic endometriosis. It typically affects women over 31 years of age and predominantly involves the right hemithorax, although atypical presentations may occur. We report the case of a 39-year-old woman with secondary infertility and multiple failed in vitro fertilization (IVF) attempts who developed recurrent spontaneous pneumothorax temporally associated with exogenous estrogen therapy during endometrial preparation. Initial IVF treatment resulted in a biochemical pregnancy; however, during preparation for a donor oocyte cycle with oral estradiol, she presented with acute chest pain and dyspnoea and was diagnosed with left-sided pneumothorax, managed conservatively. Recurrence was noted upon re-exposure to estrogen, with imaging confirming left upper lobe involvement. In view of this, a modified protocol using gonadotropin-releasing hormone agonist downregulation followed by transdermal estrogen was employed, after which embryo transfer was successfully performed, resulting in a twin pregnancy with an uneventful antenatal course and delivery at 35 weeks. This case highlights an atypical presentation of recurrent pneumothorax likely influenced by hormonal therapy, raising the possibility of occult thoracic endometriosis or estrogen-mediated pleural pathology. Recognition of this association is essential for optimizing management, and individualized, multidisciplinary approaches are recommended in the absence of standardized guidelines.
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Spontaneous recurrent pneumothorax after in vitro fertilization DOI: https://doi.org/10.18203/2320-1770.ijrcog20261304Keywords: Infertility, Recurrent spontaneous pneumothorax, ART, Non cataminal pneumothorax, Successful pregnancyAbstract Catamenial pneumothorax (CP) is a rare form of spontaneous pneumothorax occurring within 72–96 hours before or after the onset of menstruation, accounting for approximately 3–6% of cases, and is commonly associated with thoracic endometriosis. It typically affects women over 31 years of age and predominantly involves the right hemithorax, although atypical presentations may occur. We report the case of a 39-year-old woman with secondary infertility and multiple failed in vitro fertilization (IVF) attempts who developed recurrent spontaneous pneumothorax temporally associated with exogenous estrogen therapy during endometrial preparation. Initial IVF treatment resulted in a biochemical pregnancy; however, during preparation for a donor oocyte cycle with oral estradiol, she presented with acute chest pain and dyspnoea and was diagnosed with left-sided pneumothorax, managed conservatively. Recurrence was noted upon re-exposure to estrogen, with imaging confirming left upper lobe involvement. In view of this, a modified protocol using gonadotropin-releasing hormone agonist downregulation followed by transdermal estrogen was employed, after which embryo transfer was successfully performed, resulting in a twin pregnancy with an uneventful antenatal course and delivery at 35 weeks. This case highlights an atypical presentation of recurrent pneumothorax likely influenced by hormonal therapy, raising the possibility of occult thoracic endometriosis or estrogen-mediated pleural pathology. Recognition of this association is essential for optimizing management, and individualized, multidisciplinary approaches are recommended in the absence of standardized guidelines. Metrics References Iqbal B, Hallifax R, Rahman NM. Pneumothorax: an update on clinical spectrum, diagnosis and management. Eur Respir Rev. 2020;29(156):190100. Visouli AN, Darwiche K, Mpakas A, Zarogoulidis P, Kougioumtzi I, Machairiotis N. Catamenial pneumothorax: a rare entity? Report of 5 cases and review of the literature. J Thorac Dis. 2012;4(1):17-24. Haga T, Kurihara M, Kataoka H, Ebana H. Clinical characteristics of catamenial pneumothorax. J Thorac Dis. 2018;10(22):S2655-61. Alifano M, Jablonski C, Kadiri H, Falcoz PE, Bobbio A, Régnard JF. Catamenial and noncatamenial, endometriosis-related or nonendometriosis-related pneumothorax referred for surgery. Am J Respir Crit Care Med. 2007;176(10):1048-53. DOI: https://doi.org/10.1164/rccm.200704-587OC Baisi A, Raveglia F, De Simone M, Santambrogio L, Melloni G, Nosotti M. Endometriosis-related pneumothorax after in vitro fertilization embryo transfer procedure: a case report. J Thorac Cardiovasc Surg. 2010;139(4):e73-4. DOI: https://doi.org/10.1016/j.jtcvs.2008.12.056 Halvorson SA, Ricker MA, Barker AF, Kocheril AG. Thoracic endometriosis unmasked by ovarian hyperstimulation for in vitro fertilization. J Gen Intern Med. 2012;27(9):1224-7. DOI: https://doi.org/10.1007/s11606-011-1959-3 Light RW. Pleural Diseases. 6th ed. Philadelphia: Lippincott Williams and Wilkins. 2013. Giudice LC. Clinical practice. Endometriosis. N Engl J Med. 2010;362(25):2389-98. DOI: https://doi.org/10.1056/NEJMcp1000274 Harknett EC, Chang WY, Byrnes S, Johns RA, Kiser P, Mahler DA. Use of variability in national and regional data to estimate the prevalence of lymphangioleiomyomatosis. QJM. 2011;104(11):971-9. DOI: https://doi.org/10.1093/qjmed/hcr116 Judge DP, Dietz HC. Marfan's syndrome. Lancet. 2005;366(9501):1965-76. DOI: https://doi.org/10.1016/S0140-6736(05)67789-6 Marshall MB, Ahmed Z, Kucharczuk JC, Bhat GS, Smith B, Deschamps C. Catamenial pneumothorax: optimal hormonal and surgical management. Eur J Cardiothorac Surg. 2005;27(4):662-6. DOI: https://doi.org/10.1016/j.ejcts.2004.12.047

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