Sonographic features of tubo-ovarian abscess mimicking an endometrioma and review of cystic adnexal masses

A 36-year-old female presented with constant, worsening left lower quadrant pain without associated fever or vaginal discharge. Pelvic and transvaginal ultrasound examinations were performed which demonstrated a large complex cystic structure in the left adnexa with peripheral flow on color Doppler imaging. Given the sonographic appearance and patient symptoms, possibilities included endometrioma or hemorrhagic cyst. Tubo-ovarian abscess (TOA) and other cystic ovarian masses were considered less likely. Two days later, the patient returned with severe pelvic pain as well as fever and leukocytosis. Follow-up ultrasound showed enlargement of the mass and a tubo-ovarian abscess (TOA) was suspected. Ultrasound-guided transvaginal abscess drainage was performed with removal of purulent fluid. The case demonstrates that the radiological features of TOA may mimic those of adnexal cystic masses such as an endometrioma or hemorrhagic cyst. A complementary case is also included which demonstrates similar sonographic findings in a patient with endometrioma. In addition to sonographic imaging, a thorough clinical and laboratory evaluation is important in differentiating these entities. Furthermore, we provide a comprehensive discussion about imaging features of cystic ovarian mass on different imaging modalities.

Unusual laparoscopy finding with previous laparotomy for endometrioma: a rare case report

An unmarried girl with severe dysmenorrhea had laparotomy for bilateral endometriomas, later treated with danazol and GnRHa Depo injection for more than three years. On laparoscopy she had a large, noncommunicating, functioning rudimentary horn with ipsilateral renal agenesis. Laparoscopic excision of the rudimentary horn gave major relief from the suspected endometrioma, which was not the cause of her severe pain.

Imaging in gynaecology: How good are we in identifying endometriomas?

AIM

To evaluate the performance of subjective evaluation of ultrasound findings (pattern recognition) to discriminate endometriomas from other types of adnexal masses and to compare the demographic and ultrasound characteristics of the true positive cases with those cases that were presumed to be an endometrioma but proved to have a different -histology (false positive cases) and the endometriomas missed by pattern recognition (false negative cases).

METHODS

All patients in the International Ovarian Tumor Analysis (IOTA ) studies were included for analysis. In the IOTA studies, patients with an adnexal mass that were preoperatively examined by expert sonologists following the same standardized ultrasound protocol were prospectively included in 21 international centres. Sensitivity and specificity to discriminate endometriomas from other types of adnexal masses using pattern recognition were calculated. Ultrasound and some demographic variables of the masses presumed to be an endometrioma were analysed (true -positives and false positives) and compared with the variables of the endometriomas missed by pattern recognition (false negatives) as well as the true negatives.

RESULTS

IOTA phase 1, 1b and 2 included 3511 patients of which 2560 were benign (73%) and 951 malignant (27%). The dataset included 713 endometriomas. Sensitivity and specificity for pattern recognition were 81% (577/713) and 97% (2723/2798). The true positives were more often unilocular with ground glass echogenicity than the masses in any other category. Among the 75 false positive cases, 66 were benign but 9 were malignant (5 borderline tumours, 1 rare primary invasive tumour and 3 endometrioid adenocarcinomas). The presumed diagnosis suggested by the sonologist in case of a missed endometrioma was mostly functional cyst or cystadenoma.

CONCLUSION

Expert sonologists can quite accurately discriminate endometriomas from other types of adnexal masses, but in this dataset 1% of the masses that were classified as endometrioma by pattern recognition proved to be malignancies.

Vaginal disinfection with povidone iodine immediately before oocyte retrieval is effective in preventing pelvic abscess formation without compromising the outcome of IVF-ET

PURPOSE

In this study, the method of employing preretrieval vaginal douching with aqueous povidone iodine is examined to see if it can decrease the incidence of pelvic abscess without compromising the clinical outcome of IVF-ET.

METHODS

Patients with ovarian endometrioma and received IVF-ET treatment were retrospectively classified into two groups according to the difference of vaginal douching solution immediately before oocyte retrieval.

RESULTS

There was no difference in the fertilization rate (81.2% versus 79.8%, P > 0.05), implantation rate (19.2% versus 23.3%, P > 0.05), clinical pregnancy rate (39.3% versus 46.2%, P > 0.05) between the two groups. There was no infection in patients of group two but two cases in group one developed pelvic abscess and needed surgical intervention.

CONCLUSIONS

Vaginal douching with aqueous povidone iodine followed by normal saline irrigation immediately before oocyte retrieval is effective in preventing the pelvic infection without compromising the outcome of IVF treatment.

In vitro fertilization in patients with ovarian endometrioma

PURPOSE

To assess the influence of ovarian endometrioma during IVF.

METHODS

Patients were submitted to cystectomy by the laparoscopic route for exeresis of ovarian endometrioma. Group I (n = 28) consisted of patients without ovarian endometrioma and group II (n = 14) consisted of patients with recurrence of ovarian endometrioma during IVF.

RESULTS

Fertilization and cleavage rates were higher in group I and the pregnancy rate per transfer was similar in the two groups.

CONCLUSIONS

The presence of endometrioma during IVF causes a worsening of oocyte fertilization and embryo cleavage but does not affect the pregnancy rate per transfer.

Poor response of ovaries with endometrioma previously treated with cystectomy to controlled ovarian hyperstimulation

PURPOSE

To compare ovarian response to controlled ovarian hyperstimulation (COH) between normal ovaries and ovaries previously treated surgically for unilateral ovarian endometrioma.

METHODS

From January 1996 to December 2001, 32 patients with unilateral ovarian endometrioma previously treated surgically underwent 38 cycles of COH. Their records were reviewed retrospectively. The number of dominant follicles observed on the day of hCG injection and the number of eggs retrieved from the diseased and the normal ovaries in each patient were compared.

RESULTS

The numbers of dominant follicles from diseased and normal ovaries were 1.9 +/- 1.5 and 3.3 +/- 2.1, respectively (P < 0.001). During ovum pick up, the numbers of eggs retrieved from diseased and normal ovaries were 2.9 +/- 2.6 and 6.1 +/- 4.1, respectively (P < 0.0001). For diseased ovaries, 21.1% (8/38) had no dominant follicles, while only 7.9% (3/38) of normal ovaries lacked dominant follicles. The clinical pregnancy rate and the implantation rate per embryo transfer were 33.3 and 17.6%.

CONCLUSIONS

Surgery for ovarian endometrioma may damage ovarian reserve. It potentially results in poor ovarian response to COH, compared to the response of the contralateral normal ovary in the same individual.

Exposure of human oocytes to endometrioma fluid does not alter fertilization or early embryo development

BACKGROUND

Extensive endometriosis causes a mechanical disturbance in the pelvis leading to obstructive-type infertility. However, minimal or mild endometriosis is suspected to cause infertility, possibly through a humoral agent. Previous studies reported the presence of a factor in the serum of patients with endometriosis which reduced fertilization and early embryo formation in a rat IVF model.

METHODS

In the present article, we report a comparison of oocytes exposed to endometrioma fluid and oocytes not exposed (controls) in the context of a human IVF setting. We have been in the practice of aspirating oocytes into prewarmed 60-ml syringes containing culture medium. We have shown previously that this technique reduces the length of oocyte retrieval without compromising success. In 14 women undergoing oocyte retrieval, we inadvertently entered an endometrioma. This resulted in retrieved oocytes that were either exposed or not exposed to endometrioma fluid.

RESULTS

In contrast to previous reports, we found no difference in fertilization or early embryo development between the two groups. The fertilization rate for oocytes exposed to an endometrioma was 60%, versus 56% for controls. The good-quality embryo formation rate for oocytes exposed to an endometrioma was 45%, versus 46% for controls.

The influence of endometriosis on the success of gamete intrafallopian transfer (GIFT)

PURPOSE

Our purpose was to evaluate the outcomes of gamete intrafallopian transfer (GIFT) therapy in patients with endometriosis.

METHODS

One hundred eight GIFT cycles performed under the indication of endometriosis were compared to 156 GIFT cycles with indications of other disease entities. A maximum of seven oocytes was transferred into one or both fimbriate ends with prepared spermatozoa. Clinical pregnancy rates and outcomes were evaluated according to Mantel-Haenszel's chi-square test. Multiple logistic regression analysis was performed to determine factors influencing the success on pregnancy in the total treatment cycles.

RESULTS

The anthropological variables, such as age of patients, duration of infertility, and semen grading, were comparable in both groups. The responses to controlled ovarian hyperstimulation (COH) were progressively decreased while increasing the severity of endometriosis conditions such as nonendometriosis, mild-form endometriosis, and advanced-form endometriosis patients. However, there were no significant differences in the clinical pregnancy rates (40.4, 36.7, and 41.7%, respectively), multiple pregnancy rates (34.9, 27.3, and 45.0%, respectively), and early pregnancy loss rates (27.0, 18.2, and 30.0%, respectively). Multivariate statistics of pregnancy rates that adjusted the effects of patients' age, tubal health, presence of active endometriosis and/or endometriomas, number of oocytes transferred, and quality of sperm exhibited no statistical significance between endometriosis and nonendometriosis groups.

CONCLUSIONS

Our data show that patients with records of endometriosis have both a decreased ovarian response to gonadotropin stimulation and a decreased number of retrieved oocytes. Since the number of oocytes needed for the GIFT procedure is limited, pregnancy results for patients in the study group were comparable with those for patients in the control group.