Laparoscopic Management of Ovarian Entrapment: A Rare Complication of IVF

Introduction

Oocyte aspiration is practiced hundreds of thousands of times per year throughout the world and is considered to be a relatively low-risk procedure. Complications arising from the retrieval of oocytes are rarely reported and are typically related to adverse events from either bleeding or infection. Similarly, oocyte donors undergoing egg retrieval are considered to be at low risk for developing problems as a result of the procedure, with the majority of complications arising secondary to ovarian hyperstimulation rather than egg aspiration.^1,2 This article reports an unusual case of ovarian entrapment that occurred secondary to a unique set of circumstances present at the time of egg aspiration. The hyperstimulated ovary is at particular risk for inadvertent displacement while the patient is sedated (although this scenario is unlikely), which may render it entrapped or torsed. This case illustrates the need to pay particular attention to the position of the ovaries both prior to and after aspiration to prevent this rare occurrence. Timely use of laparoscopy was essential for making the correct diagnosis and ultimately to replace the displaced ovary back into its proper position in the pelvis.

Case

A 24-year old healthy woman was participating in her third cycle of egg donation. She had an unremarkable past medical history, and her prior cycles of egg donation were performed without any complications. The patient was given a prescription for controlled ovarian hyperstimulation with leuprolide acetate, which was followed by gonadotropin therapy. The stimulation was done in a routine manner for 10 days, at which time, human chorionic gonadotropin (hCG) was administered to cause the eggs to mature for retrieval. During the course of her treatment, both ovaries were always visualized in the posterior cul-de-sac on numerous transvaginal sonograms.

Transvaginal ultrasound (US)–guided needle aspiration was performed for oocyte retrieval with the patient under deep sedation with intravenous propofol and fentanyl. The patient did not report any symptoms of ovarian hyperstimulation syndrome (OHSS), nor did she have any obvious complaints including pelvic pain immediately prior to the procedure. Once she was asleep, the patient was prepared vaginally, using a saline-drenched sponge stick with intermittent swiping of the vaginal fornix in a clockwise manner. During an uncomplicated retrieval lasting approximately 10 minutes, a total of 24 oocytes were obtained with only minimal blood loss. Following the vaginal preparation, and before the needle aspiration began, the right ovary was noted to be high and anterior on the pelvic-side wall and the left ovary was positioned in the cul-de-sac.

Immediately upon awaking postretrieval, the patient experienced severe right-sided lower quadrant abdominal and pelvic pain that did not respond to the administration of narcotics. As a result of ongoing and worsening severe pain, the patient received a total of 150 μg of fentanyl in doses of 25 μg without subjective improvement during the following 2 hours of observation.

Her vital signs remained stable, and follow-up vaginal sonography in the recovery room did not show collections of pelvic fluid or other abnormalities. However, because of the severity of her pain, the patient was transferred to the emergency room for evaluation of possible ovarian torsion.

With no notable improvement of her abdominal pain despite repeated doses of narcotic medications, formal consent was obtained from the patient and she was taken to the operating room for diagnostic laparoscopy. Uncomplicated entry into the abdomen revealed no obvious ovarian torsion bilaterally, with normal ovarian color and appearance. Her appendix was normal in size and appearance. There was no evidence of ovarian bleeding or pelvic hematoma. The hyperstimulated right ovary however was displaced from its normal position in the pelvis and appeared to be entrapped in the anterior compartment on top of the uterus, exerting considerable stretch of the utero–ovarian ligament.

The right ovary was easily repositioned to the cul-de-sac next to the left ovary, and the surgery was completed. Postoperatively the patients pain was reduced, but she still complained of residual discomfort and therefore remained in the hospital for additional observation and analgesics until postoperative day 2. It is possible that some of her residual pain may have been secondary to the laparoscopic procedure itself, but, because of the unusual nature of this case, she was still observed as an inpatient until her symptoms resolved completely.

Results

Follow-up Doppler US sonography showed a normal blood flow to both ovaries on postoperative day 1. Once her pain resolved, the patient was discharged and seen 1 week later. She was doing well, without any further complaints.

Discussion

The complication rate from ovarian torsion in patients undergoing assisted reproduction is low, with ovarian hyperstimulation syndrome being the most prevalent complication.^3,4 This patient did not experience any of the classic symptoms characteristic of OHSS, although her enlarged ovaries probably contributed to her complication. This case exemplifies a condition that mimics ovarian torsion closely, but is distinctly different in that its causation is the result of a procedurally related iatrogenic displacement of the ovary that may incidentally occur during or before the retrieval and result in severe pain that necessitates surgical management. The risk of such a rare event may be increased because patients are under anesthesia and unable to express pain as they normally would if similar circumstances were to occur while they were awake. This is the first such case noted in more than 2000 cycles of egg donation in the current authors' experience. Similarly, the current authors never had encountered an entrapped ovary in the general population of in-vitro fertilization patients, which would be ∼10,000 aspirations in the past decade. In reviewing her previous US reports that showed both ovaries to be located posterior to the uterus, it appears that the anterior displacement and subsequent development of symptoms probably occurred while the patient was under anesthesia. While the possibility that the ovary became displaced at some point during the retrieval cannot be excluded, the current authors speculate that the anterior displacement may have occurred during the vaginal preparation, as the physician performing the aspiration noted the ovary's anterior location upon insertion of the probe.

Conclusions

To avoid such situations in the future, it is recommended that surgeons pay careful attention to the use of vaginally placed instruments, such as the sponge sticks that often used for vaginal cleaning as well as the US probe used to guide the aspirating needle. Ideally, the position of the ovaries should be noted prior to and after the retrieval to ensure that the ovaries are not displaced during the procedure.