Stage IV endometriosis: to treat or not to treat before in-vitro fertilization? Further considerations besides the pregnancy rate: a case of near-miss for spontaneous hemoperitoneum

Endometriosis represents a well-known cause of infertility. Recently, its association with spontaneous hemoperitoneum in pregnancy (SHIP) was reported. Its occurrence seems to be increased in patients with endometriosis who underwent IVF techniques. We present a case of near miss at 15 weeks of pregnancy associated with SHIP in a nulliparous patient of 39 years old with chronic endometriosis. Previously, she underwent several IVF cycles and controlled ovarian hyperstimulation plus embryo transfer (COH-ET). An explorative laparoscopy was performed, then converted in laparotomy. The bleeding endometriotic tissue was removed and an ureteral stent was placed. The patient lost a total of 4 liters of blood and fully recovered. Unfortunately, miscarriage occurred. The potential link between COH-ET, the number of cycles of ovarian stimulation and SHIP in severe endometriosis must take a part in the balanced decision between preventive surgery of direct hormonal stimulation.