Emergent Complications of Assisted Reproduction: Expecting the Unexpected

Abstract

With the increasing popularity of assisted reproductive technology (ART), radiologists are more likely to encounter associated complications, especially in an emergency setting. These complications include ovarian hyperstimulation syndrome (OHSS), ovarian torsion, and ectopic and heterotopic pregnancy. OHSS occurs following ovulation induction or ovarian stimulation and manifests with bilateral ovarian enlargement by multiple cysts, third-spacing of fluids, and clinical findings ranging from gastrointestinal discomfort to life-threatening renal failure and coagulopathy. Enlarged hyperstimulated ovaries are at risk for torsion. Clinical symptoms are often nonspecific, and ovarian torsion should be suspected and excluded in any female patient undergoing infertility treatment who presents with severe abdominal pain. The most consistent imaging finding is asymmetric enlargement of the twisted ovary. There is also an increased risk for ectopic pregnancy following ART, with a relative increased risk for rarer and more lethal forms, including interstitial and cervical ectopic pregnancies. Heterotopic pregnancy refers to simultaneous intrauterine and ectopic pregnancies and has an incidence of 1%-3% in ART patients. Careful evaluation of the adnexa is critical in this patient population, even when an intrauterine pregnancy has been confirmed. Ultrasonography is the first-line imaging modality for the evaluation of complications of ART, although nonspecific symptoms may sometimes lead to cross-sectional imaging being performed. Familiarity with the multimodality imaging appearance of these entities will allow accurate and timely diagnosis and help avert potentially fatal consequences.

Fertility-sparing for young patients with gynecologic cancer: How MRI can guide patient selection prior to conservative management

“…Embryo and oocyte cryopreservation may be associated with ovarian hyperstimulation syndrome (OHSS), an exaggerated response to ovarian stimulation resulting in increased capillary permeability (11). Clinical signs/symptoms, imaging findings (ovarian size, presence of ascites, and pleural effusions), and biochemical parameters are combined to grade OHSS as mild, moderate, or severe (12).…”

“…Ovaries acquire a characteristic ‘spoke wheel’ appearance due to multiple peripheral ovarian cysts surrounding the central ovarian stroma (11, 13, 14) (Figure 1). Enlarged cystic ovaries should not be mistaken for cystic ovarian neoplasm (14).…”

“…Presence of ascites indicates that OHSS is at least moderate in severity. Possible OHSS complications include thromboembolism and ovarian torsion (11, 15, 16). …”

Ectopic Pregnancy Among American Indian and Alaska Native Women, 2002–2009

“…Several behavioral risks have been linked to EP, including smoking and STDs [1, 3–6]. Disruption of ciliary function related to smoking is a reported risk factor for EP [6].…”

“…Although studies have found that only 1–2 % of pregnancies in the United States are ectopic and deaths due to EP are decreasing, EP remains an important cause of morbidity and mortality and there are opportunities for prevention [2]. Risk factors for EP include: a history of assisted reproductive technology use; endometriosis; previous obstetrical or gynecological surgery, including tubal sterilization and cesarean section; tubal inflammation and scarring due to infections such as chlamydia and gonorrhea; and disruption of ciliary function attributable to smoking [1, 3–6]. Women affected are not only exposed to complications from the ectopic pregnancy itself and the related treatment procedures, but are also at greater risk of another ectopic pregnancy and infertility [2].…”