JBRA Assist. Reprod. 2024;28(1):209-210
CASE REPORT
doi: 10.5935/1518-0557.20230056
Transient ovarian torsion in a pregnant woman after vitrified-warmed embryo transfer: a case report
1Assistant professor of Obstetrics and Gynecology, Zagazig University, Zagazig, Egypt
2Lecturer of Obstetrics and Gynecology, Zagazig University, Zagazig, Egypt
CONFLICT OF INTERESTS
None.
ABSTRACT
Assisted reproduction is a risk factor for adnexal torsion due to ovarian
hyperstimulation and increased incidence of twin pregnancy. Both risk factors
can be eliminated in frozen embryo transfers, but in our case ovarian torsion
occurred after the use of an aromatase inhibitor (Femara) in endometrium
preparation due to the presence of corpus luteum. Case presentation: G2P1+0
presented at 7 weeks gestation after vitrified-warmed embryo transfer with right
loin pain and mild right iliac pain and tenderness. Ultrasound examination
revealed transient or incomplete ovarian torsion. The presentation of the case
was somewhat misleading and the transient nature of the torsion provided an
opportunity for the conservative management of the case. In conclusion, ovarian
torsion is still an undesired event, even after single embryo transfers and in
vitrified-warmed cycles. Clinical and ultrasound follow-up precluded the need
for surgery in our case.
Keywords: ovarian torsion, pregnancy, vitrified-warmed cycles
INTRODUCTION
Adnexal torsion is the fifth most common cause of acute abdominal pain in women
during the reproductive period (Amirbekian &
Hooley, 2014). Although incidence during pregnancy is uncertain, it is
estimated to range from 0.2 to 3% (Huchon &
Fauconnier, 2010). It is defined as complete or partial rotation of the
adnexa around the ligamentous supports, which contain the vascular pedicle. This
results in the interruption of venous reflux and arterial flow, consequently leading
to ischemia and necrosis of the affected adnexa.
Pregnancy and assisted reproductive techniques have been implicated as risk factors
for adnexal torsion (Houry & Abbott,
2001). Adnexal torsion occurs at any time during pregnancy; however, it often
occurs during the first and second trimesters. The symptoms of adnexal torsion are
non-specific, and patients with the condition may be misdiagnosed with other causes
of acute abdominal pain such as appendicitis and urinary tract infection (Sasaki & Miller, 2014). Clear guidelines for
the management of adnexal torsion during pregnancy are lacking, as there is a
paucity of studies on this important topic (Wang
& Deng, 2020).
CASE PRESENTATION
G2P1+0, aged 32 years, with a history of primary infertility due to male factor,
presented with right renal flank pain and right iliac pain in the 7th week of pregnancy after undergoing a vitrified-warmed embryo transfer. Her first
pregnancy was after vitrified-warmed ET. Preparation performed at the time was by
hormone replacement therapy (HRT) and two day-5 embryos were transferred. She became
pregnant with twins and at 19 weeks of gestation she felt lower abdominal heaviness;
ultrasound examination revealed cervical dilatation with bulging of membranes.
Emergency cervical cerclage was performed and tocolytic drugs administered, with
continuation of pregnancy until 26 weeks, at which time preterm labor started. Two
preterm female babies were delivered by Cesarean section and placed on the
incubator; unfortunately, the two died, one within 24 hours and the other within six
days of birth.
She came in for another FET and was advised to undergo a single embryo transfer. HRT
was prescribed for endometrial preparation and a single day-5 embryo was
transferred, but she did not get pregnant. Two months later, she underwent another
FET after HRT for endometrial preparation, the BhCG test was positive, but it was a
case of chemical pregnancy. Two months later, she came in for a third FET, in which
preparation of the endometrium was performed with an aromatase inhibitor (Femara) 5
mg daily from day 3 of the cycle for five days. A follow-up visit on day 9 of the
cycle found a follicle measuring 16.5 mm on the right ovary and the endometrium
measuring 7mm; two days later, the follicle measured 20.5 mm and the endometrium
12.2mm. She was given 10000IU HCG and progesterone was administered for 5 days when
a single embryo (4AA) was transferred. Fifteen days later, her BhCG level was 572IU.
At 7 weeks of gestation, she developed right loin pain and right iliac pain with
altered urinary frequency. On examination, she had a lax abdomen, minimal right
iliac tenderness, and maximum pain on the right loin region. Ultrasound revealed a
7-week embryo and a right ovarian cyst measuring 59 x 30mm with clear fluids.
Analgesics and antibiotics were given to alleviate the pain, since she had history
of urinary stones; right renal flank pain mainly placed UTI as the most probable
diagnosis, so urinalysis and urine culture and sensitivity were performed with
negative results. Ultrasound scans showed normal findings with no ureteric
dilatation or backpressure. Pain decreased 24 hours later, but she still had mild
pain in the flank, so another ultrasound was performed which revealed right ovarian
edema and minimal vasculature with an ovarian cyst measuring 48 x 44mm, indicative
of intermittent or incomplete ovarian torsion (Figures
1). Pain decreased to minimal levels. We decided to follow the patient
and perform another ultrasound examination six days later of she did not have pain
(Figures 2). Follow-up ultrasound scans
showed improved signs and a decrease on the size of the ovarian cyst. Another
ultrasound scan was performed at 12 weeks, in which a normal fetus with no suspicion
of torsion and an ovarian cyst measuring to 27x16mm were seen. The patient has since
been doing well.
Figure 1. Ultrasound scan showing edema and cyst in the RT ovary.
Figure 2. Ultrasound scan of the same ovary six days later showing resolution
of edema.
DISCUSSION
Ovarian torsion is an undesired event that may complicate pregnancy. Our patient
became pregnant after FET and was administered an aromatase inhibitor (Femara) for
endometrial preparation, which resulted in the development of a corpus luteum cyst
and ovarian torsion, subsequently. She had atypical signs that, combined with her
medical history, were suggestive of urinary tract infection. However, tests excluded
this possibility and she was suspected with ovarian torsion, which was later
confirmed in ultrasound examination and further described as a transient form of
ovarian torsion.
Since she improved from pain, conservative management was chosen and the torsion
resolved. Ovarian torsion may at times be challenging to diagnose, particularly in
cases in which patients have primarily loin pain, as in our patient. However,
ovarian torsion must be considered in the differential diagnosis of patients offered
ovarian stimulation for endometrial preparation. Lastly, conservative management of
transient or incomplete ovarian torsion can be performed successfully.
CONCLUSION
The use of an aromatase inhibitor (Femara) in the preparation of the endometrium for vitrified-warmed embryo transfer which results in corpus luteum development might be a risk factor for ovarian torsion. Conservative non-surgical management is an option in cases of transient ovarian torsion.
Consent of publication
Written informed consent was obtained from the patient prior to the publication of
this case report and accompanying images.
Acknowledgement
The authors would like to thank the patient for allowing us to share her medical
information in this case report.
REFERENCES
Amirbekian S, Hooley RJ. Ultrasound evaluation of pelvic pain. Radiol Clin North Am. 2014;52:1215-35. PMID: 25444102 DOI: 10.1016/j.rcl.2014.07.008 Medline
Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001;38:156-9. PMID: 11468611 DOI: 10.1067/mem.2001.114303 Medline
Huchon C, Fauconnier A. Adnexal torsion: a literature review. Eur J Obstet Gynecol Reprod Biol. 2010;150:8-12. PMID: 20189289 DOI: 10.1016/j.ejogrb.2010.02.006 Medline
Sasaki KJ, Miller CE. Adnexal torsion: review of the literature. J Minim Invasive Gynecol. 2014;21:196-202. PMID: 24126258 DOI: 10.1016/j.jmig.2013.09.010 Medline