Adnexal torsion after gonadotrophin ovulation induction for IVF or ICSI and its conservative treatment

Abstract

This study was designed to find out the incidence of ovarian torsion in the patients who were in ovulation induction treatment for either In vitro fertilization (IVF) or Intracytoplasmic sperm injection (ICSI). Also operative laparoscopic conservative treatment (detorsion or unwinding the twisted adnex) was tried to perform to all the patients. Among 10,583 cycles 9 ovarian torsion cases had been diagnosed laparoscopically between January 1994 and October 1998. 104 ovarian hyperstimulation syndrome (OHSS) patients were evaluated during that time. From 104 hyperstimulated cases three had torsion of the adnex and two of them were pregnant. Five of the patients were clinically and one was chemically pregnant. First, laparoscopy was done to all the patients and 8 of them could be detorsioned, in one case unwinding performed by laparotomy because of the large size of the ovary. No complications were observed after conservative surgery. These results demonstrate that, in the IVF or ICSI clinics ovarian torsion has to be regarded as one of the major complications especially if the patients are hyperstimulated or pregnant or both. Immediate manipulation is needed conservatively, preserving the ovaries which were very important for those infertile patients.

Conservative laparoscopic management of adnexal torsion

“…Blood tests and imaging techniques contribute little to a preoperative diagnosis. The majority of patients present with a sudden onset of lower abdominal pain often associated with nausea and vomiting, adnexal mass, fever, and leukocytosis (8)(9)(10)14). Pain relief observed during observation may be the result of perceptive nerve death and tissue degeneration in the affected ovary (17,18).…”

“…However, a significant association between thromboembolism and detorsion of an ischemic pedicle has never been established (7). In the last 15 years, many reports describe minimally invasive surgery with laparoscopy, detorsion, and preservation of the ovary, which has currently shifted the standard approach from oophorectomy to laparoscopy (2,(8)(9)(10)(11)(12)(13). As these patients tend to be young, and future fertility is desired, conservative management seems a feasible choice and preferable approach.…”

Ovarian torsion in a 20-year-old patient

“…11 Patients undergoing ovulation induction are also at higher risk of adnexal torsion -theoretically because of ovarian enlargement from multiple maturing follicles and theca lutein cysts. 12 Another predisposing factor for torsion is a hypermobile adnexa due to hydrosalpinx or an elongated mesosalpinx. Finally, previous gynecological surgery (including tubal ligation) is a risk factor for torsion because adhesions may act as pivot points upon which the adnexa can rotate.…”

Diagnosis of pregnancy after conservative management for adnexal torsion due to ovarian hyperstimulation in the same cycle

“…Torsion of the right adnex is more common, and few reports of bilateral torsion, either simultaneously or subsequently, exist (Peña et al, 2000;Mathevet et al, 2003;Born et al, 2004). Adnexal torsion frequently occur in the first trimester after ovarian stimulation for IVF (Hibbard, 1985;Roest et al, 1996;Govaerts et al, 1998;Gorkemli et al, 2002). The diagnosis of ovarian torsion is difficult and occasionally remains a diagnostic dilemma.…”

“…Recent studies show that in vitro maturation (IVM) can be a potentially useful method for women with PCOS-related infertiliy. However, there are no adequately controlled studies available (Hibbard, 1985;Roest et al, 1996;Govaerts et al, 1998;Gorkemli et al, 2002; The Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, 2004;Cha et al, 2005;Siristatidis et al, 2009). Adnexal torsion is an emergency condition where the adnex rotate on their pedicle.…”