Laparoscopic Management Of A Torted Hyperstimulated OvaryMr Fevzi Shakir MBBS BSc MRCOG, Obstetrics and Gynaecology Registrar1, Mr Taner Shakir BSc, Medical Student2

1Department of Obstetrics and Gynaecology, Royal Surrey County Hospital, Guildford, UK, 2University of Bristol, UK

Introduction:

Torsion of a hyperstimulated ovary occurring post in vitro fertilisation (IVF) is rare. We present a case where the management of a patient with a torted hyperstimulated ovary was dealt with laparoscopically.

Case report:

A 37 year old patient in her eighth week of pregnancy presented to the Emergency Department with acute onset right iliac fossa pain. This was an IVF pregnancy with no complications prior to this episode. She presented with an acute abdomen and tachycardia. A pelvic ultrasound scan was performed promptly and demonstrated a normal ongoing intrauterine pregnancy together with a cystic area around the right ovary and minimal intra-peritoneal free fluid. The ultrasound diagnosis was a heterotopic pregnancy and the patient was placed on the emergency operating theatre list for laparoscopic management. At laparoscopy no instrumentation of the uterus was made and bilateral enlarged hyperstimulated ovaries were noted. The right ovary appeared grossly enlarged with a dusky colour and areas of haemorrhage. Further exploration demonstrated that the ovary was torted at its pedicle. Carefully untwisting the ovary restored normal anatomy. The patient made a prompt recovery with a normal viability scan 24 hours later and ovaries with good blood flow bilaterally.

Discussion:

Ovarian torsion is a rare but recognised complication that can occur in pregnant individuals with hyperstimulated ovaries following IVF [1]. Assisted fertility is increasing and Obstetricians and Gynaecologists together with Emergency Department doctors need to be aware of this possible diagnosis. Prompt diagnosis and management can lead to preservation of the ovary with no deterioration clinically. Laparoscopy together with untwisting of the ovary is a simple and effective technique that should be utilised as first line if appropriate [2].

References:[1] Gorkemli H, Camus M, Clasen K (2002). Adnexal torsion after gonadotrophin ovulation induction for IVF or ICSI and its conservative treatment. Arch Gynecol Obstet. Nov;267(1):4-6.[2] Bottomley C, Bourne T (2009). Best Practice & Research Clinical Obstetrics & Gynaecology Volume 23, Issue 5, October, Pages 711-724. Acute Gynaecology Volume 2: Infection, uterine and ovarian pathology.

Right hyperstimulated torted ovary, dusky in appearance with haemorrhage

Normal hyperstimulated left ovary

Restoration of normal anatomy with fallopian tube visible following untwisting of the ovary.