Late manifestation of pelvic abscess following oocyte retrieval, for in vitro fertilization, in patients with severe endometriosis and ovarian endometriomata

Evidence based management of patients with endometriosis undergoing assisted conception: British fertility society policy and practice recommendations

Endometriosis is a chronic inflammatory condition in women of reproductive age, which can lead to infertility and pelvic pain. Endometriosis associated infertility is multifactorial in nature adversely affecting each step of the natural reproductive physiology and thereby processes and outcomes of Assisted Reproductive Technology (ART) cycles. These outcomes are further complicated by the subtype of endometriosis, being peritoneal, deep infiltrating and ovarian, which bear negative effects on ovarian reserve, response to stimulation, accessibility for oocyte retrieval, intraoperative safety and endometrial receptivity. There is still a lack of clear guidance about the role of surgery for ovarian endometriosis/endometriomas. This guideline evaluates the evidence of the impact of pelvic endometriosis and endometriomas on the outcome of ART and provides recommendations for management options before and during ART including intra-uterine insemination. Recommendations are made based on the current evidence for the management of patients with endometriosis across each step of ART with the primary aim of improving ART outcomes.

Similarities in Pathogenetic Mechanisms Underlying the Bidirectional Relationship between Endometriosis and Pelvic Inflammatory Disease

BACKGROUND

Endometriosis is a common inflammatory disease characterized by the presence of endometrial cells outside of the uterine cavity. Endometriosis affects 10% of women of reproductive age and significantly reduces their quality of life as a result of chronic pelvic pain and infertility. Biologic mechanisms, including persistent inflammation, immune dysfunction, and epigenetic modifications, have been proposed as the pathogenesis of endometriosis. In addition, endometriosis can potentially be associated with an increased risk of pelvic inflammatory disease (PID). Changes in the vaginal microbiota associated with bacterial vaginosis (BV) result in PID or a severe form of abscess formation, tubo-ovarian abscess (TOA). This review aims to summarize the pathophysiology of endometriosis and PID and to discuss whether endometriosis may predispose to PID and vice versa.

METHODS

Papers published between 2000 and 2022 in the PubMed and Google Scholar databases were included.

RESULTS

Available evidence supports that women with endometriosis are at increased risk of comorbid PID and vice versa, supporting that endometriosis and PID are likely to coexist. There is a bidirectional relationship between endometriosis and PID that shares a similar pathophysiology, which includes the distorted anatomy favorable to bacteria proliferation, hemorrhage from endometriotic lesions, alterations to the reproductive tract microbiome, and impaired immune response modulated by aberrant epigenetic processes. However, whether endometriosis predisposes to PID or vice versa has not been identified.

CONCLUSIONS

This review summarizes our current understanding of the pathogenesis of endometriosis and PID and discusses the similarities between them.

Endometrioma increases the risk of antibiotic treatment failure and surgical intervention in patients with pelvic inflammatory disease

OBJECTIVE

To evaluate the outcome of pelvic inflammatory disease (PID) in patients with endometriosis with and without ovarian endometrioma.

DESIGN

A retrospective cohort study.

SETTING

A single university-affiliated tertiary center.

PATIENT(S)

A total of 116 patients with endometriosis hospitalized because of PID between the years 2011-2021. Fifty-nine patients with an ovarian endometrioma component were compared with 57 patients with endometriosis without endometrioma.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcome was severe PID defined as the need for surgical intervention or drainage. Secondary outcomes included tubo-ovarian abscess, number of hospitalization days, a positive cervical bacterial culture or urine sexually trasmitted disease polymerase chain reaction (STD PCR) test, and readmission because of partially treated or relapsing PID.

RESULT(S)

PID in patients with endometrioma was found less likely to respond to antibiotic treatment with increased risk for surgical intervention or drainage compared with endometriosis patients without endometrioma (adjusted odds ratio, 3.5; confidence interval, 1.25-9.87). On admission, patients with endometrioma were older (26.5 vs. 31.0) and less likely to have an intrauterine device (19.3% vs. 5.1%) compared with patients without endometrioma. The rate of the tubo-ovarian abscess (52.5% vs. 19.3%) was significantly higher in patients with endometrioma. Readmission rate, positive bacterial culture, and hospitalization duration were higher in the endometrioma group; however, they did not reach statistical significance. Recent oocyte retrieval and patient's age were not associated with an increased risk of severe PID.

CONCLUSION(S)

Endometrioma patients with PID are less likely to respond to antibiotic treatment and present a higher risk for surgical intervention.

Fertility preservation for women with ovarian endometriosis: results from a retrospective cohort study

RESEARCH QUESTION

What is the outcome of fertility-preservation treatments in women with endometrioma, especially those with endometrioma larger than 4 cm?

DESIGN

Retrospective cohort study. Women with definitive diagnosis of ovarian endometriosis (by histology or ultrasound), who underwent fertility-preservation treatment in two IVF units between 2016 and 2021, were included. As some women cryopreserved oocytes and other embryos, the primary outcome was the number of metaphase II (MII) oocytes retrieved.

RESULTS

Seventy-one women with ovarian endometriosis (OMA) underwent 138 fertility-preservation cycles. The median age of patients was 31 years. Forty out of 71 (56%) women underwent at least one surgery for OMA before fertility-preservation treatment. Multivariate analysis of each patient's first cycle was used. Women who underwent OMA surgery before fertility-preservation treatment had a 51.7% reduction (95% CI 26.1 to 68.5, P = 0.001) in the number of MII oocytes compared with women with OMA who did not undergo surgery. Among a subgroup who did not undergo surgery, those with an endometrioma larger than 4 cm had similar anti-Müllerian hormone concentration (2.6 ng/ml versus 2.1 ng/ml), number of oocytes retrieved (9 versus 9) and number of MII oocytes (7.6 versus seven 7) compared with women with an endometrioma of 4 cm or less.

CONCLUSIONS

Discussing fertility-preservation treatment options with patients with OMA is recommended, especially if surgery is planned.

Endometriosis is a risk factor for recurrent pelvic inflammatory disease after tubo-ovarian abscess surgery

PURPOSE

To evaluate the clinical outcomes and prognosis of patients undergoing laparoscopic surgery for tubo-ovarian abscess (TOA) and identify risk factors for pelvic inflammatory disease (PID) recurrence.

METHODS

We conducted a retrospective cohort analysis including 98 women who underwent laparoscopic surgery for TOA at the Department of Obstetrics and Gynecology at the Bern University Hospital from January 2011 to May 2021. The primary outcome studied was the recurrence of PID after TOA surgery. Clinical, laboratory, imaging, and surgical outcomes were examined as possible risk factors for PID recurrence.

RESULTS

Out of the 98 patients included in the study, 21 (21.4%) presented at least one PID recurrence after surgery. In the univariate regression analysis, the presence of endometriosis, ovarian endometrioma, and the isolation of E. coli in the microbiology cultures correlated with PID recurrence. However, only endometriosis was identified as an independent risk factor in the multivariate analysis (OR (95% CI): 9.62 (1.931, 47.924), p < 0.01). With regard to the time of recurrence after surgery, two distinct recurrence clusters were observed. All patients with early recurrence (≤ 45 days after TOA surgery) were cured after 1 or 2 additional interventions, whereas 40% of the patients with late recurrence (> 45 days after TOA surgery) required 3 or more additional interventions until cured.

CONCLUSION

Endometriosis is a significant risk factor for PID recurrence after TOA surgery. Optimized therapeutic strategies such as closer postsurgical follow-up as well as longer antibiotic and hormonal therapy should be assessed in further studies in this specific patient population.

Risk factors for abscess development in patients with endometrioma who present with an acute abdomen

Objectives

The objective of this study was to assess the potential risk factors for abscess development in patients with endometrioma who present with an acute abdomen.

Materials and Methods

We retrospectively reviewed the records of 51 patients who underwent emergency surgery for acute abdomen involving an endometrioma at our hospital between April 2011 and August 2021. The patients were divided into an infected group (n = 22) and a control group (n = 29). We analyzed patient characteristics; imaging findings; clinical data, including bacterial cultures; and perioperative outcomes to assess for differences between groups.

Results

Patients in the infected group were significantly older than those in the control group (P = 0.03). They were more likely to have a history of endometriosis surgery (P = 0.04) and more likely to have undergone transvaginal manipulation within 3 months of presentation (P = 0.01). Body temperature on the day of admission was significantly higher in the infected group (P = 0.007), as were C-reactive protein levels on the day of admission and before surgery (P < 0.001; P = 0.018) and the white blood cell count on the day of admission (P = 0.016). Preoperative imaging showed significant thickening of the tumor wall (P < 0.001) and an enhanced contrast effect (P < 0.001) in the infected group.

Conclusion

We identified several factors that suggest abscess in patients with an acute abdomen who have a complication of pathologically confirmed endometriosis. A recent vaginal procedure is a particular risk factor for abscess development in patients with endometriomas.

Which vaginal douching agent is the best choice before oocyte retrieval? A systematic review and network meta-analysis

Objective

The aim of this study was to evaluate six vaginal douching agents (Iodine, Saline, Iodine followed by saline, chlorhexidine acetate followed by saline, Ozone, Potassium permanganate) on oocytes pick-up related pelvic infection (OPU-PI) and IVF outcome in patients underwent assisted reproduction technology (ART).

Design

Through searching PubMed, Embase, Cochrane Library, Web of Science, Ovid, CINAHL CNKI, only human clinical trials were collected to study the effects of the six vaginal douching agents on OPU-PI and IVF outcomes. The included studies were evaluated for methodological quality by the Cochrane bias risk assessment tool, and the data analysis software was used to analyze the data accordingly.

Results

The clinical trials were collected between the earliest available date and June 2022. Eight studies were included, the total sample size used in the study was 12,567. The results of the network meta-analysis showed that Ozone can significantly decrease OPU-PI; Iodine followed by saline can be a antiseptic protocol ranked first without affecting the quality of oocytes and Chlorhexidine acetate followed by saline can improve patients' clinical pregnancy rate.

Conclusion

Based on Ranking Plot of the Network, this review reports the best evidence available regarding different vaginal douching agents used before OPU.

Minimally invasive approach to the management of tubo-ovarian abscesses

PURPOSE OF REVIEW

The purpose of this publication is to review the most up-to-date literature regarding the pathogenesis, diagnosis and management of tubo-ovarian abscesses.

RECENT FINDINGS

Prior to the advent of broad-spectrum antibiotics, tubo-ovarian abscesses necessitated total abdominal hysterectomy and bilateral salpingo-oophorectomy. Although it carries a risk of treatment failure, antibiotic therapy enabled fertility-sparing treatment for many women. Recent studies have identified key predictors for antibiotic treatment failure, including age, BMI and abscess diameter. C-reactive protein was also found to be a strong predictor of antibiotic treatment response. Given the growing evidence of treatment failure with antibiotic therapy alone, along with increased availability and access to interventional radiology, image-guided drainage with or without catheter placement, combined with broad-spectrum antibiotics, is now considered first-line therapy.

SUMMARY

Tubo-ovarian abscess is a diagnostic challenge, as presentation can vary. Inadequate treatment is associated with severe morbidity and mortality. Despite adequate conservative treatment, recurrence risk is high and clinical sequelae can have devastating effects on reproductive health. Recent evidence-based developments, including a risk score system to predict antibiotic failure, serve to provide appropriately directed risk-based care. However, large-scale randomized controlled trials are needed to clarify the most appropriate treatment modalities.

Safety of in-vitro fertilization in women with endometriosis

Management of women with endometriosis in general is complex. It requires a multidisciplinary and tailored approach. The time of in-vitro fertilization (IVF) may be particularly complicated because women with the disease face peculiar additional risks. In particular, oocytes retrieval may be more difficult and women with endometriomas are exposed to a low but consistent risk of infection and ovarian abscess development. There are also concerns regarding progression of deep invasive peritoneal lesions and misdiagnosis of an occult early ovarian cancer. However, evidence on these latter points is more controversial. Taken together, this body evidence is generally reassuring and does not justify prophylactic surgery prior to IVF to shrink these risks. However, given the uncertainties, women with endometriosis must be informed in depth of these peculiar additional risks.

Dienogest reduces endometrioma volume and endometriosis-related pain symptoms

This study aimed to evaluate the efficacy and adverse effects of dienogest for the treatment of endometriomas. Dienogest (2 mg/day) was administered to patients with endometrioma continuously through the 6-month study period. The patients were prospectively examined on the efficacy and side effects at baseline, at third months, and sixth months of the treatment. Twenty-four out of 30 patients were able to complete the study. The mean volume of the endometrioma decreased significantly from 112.63 ± 161.31 cm³ at baseline to 65.47 ± 95.69 cm³ at a 6-month follow-up (-41%) (p = .005). The VAS score for pelvic pain decreased significantly from 7.50 to 3.00 (p < .001) at the sixth months of treatment. The most common side effects were menstrual irregularities. Laboratory parameters did not change during the study. Dienogest considered being effective for 6 months of use in decreasing the size of endometrioma, reducing endometriosis-associated pain with a favourable safety and tolerability profile.Impact statementWhat is already known on this subject? Laparoscopic excisional surgery for endometrioma is currently the most valid approach in the treatment of endometriomas. However, there are concerns about ovarian reserve damage during surgery.What do the results of this study add? Dienogest considered being effective in decreasing the size of endometrioma, reducing endometriosis-associated pain with a favourable safety and tolerability profile. Long-term use of dienogest in younger patients with endometriomas who are yet to give birth may reduce the possibility of surgery by reducing the size of the endometriomas and may preserve ovarian reserve.What are the implications of these findings for clinical practice and/or further research? Dienogest may reduce the incidence of infectious complications such as pelvic abscess after oocyte retrieval and the surgical procedures in infertile patients with endometrioma.

Risk factors for the development of tubo-ovarian abscesses in women with ovarian endometriosis: a retrospective matched case-control study

BACKGROUND

The purpose of this study was to assess the risk factors associated with the development of tubo-ovarian abscesses in women with ovarian endometriosis cysts.

METHODS

This retrospective single-center study included 176 women: 44 with tubo-ovarian abscesses associated with ovarian endometriosis and 132 age-matched (1:3) patients with ovarian endometriosis but without tubo-ovarian abscesses. Diagnoses were made via surgical exploration and pathological examination. The potential risk factors of tubo-ovarian abscesses associated with ovarian endometriosis were evaluated using univariate analysis. The results (p ≤ 0.05) of these parameters were analyzed using a multivariate model.

RESULTS

Five factors were included in the multivariate conditional logistic regression model, including in vitro fertilization, presence of an intrauterine device, lower genital tract infection, spontaneous rupture of ovarian endometriosis cysts, and diabetes mellitus. The presence of a lower genital tract infection (odds ratio 5.462, 95% CI 1.772-16.839) and spontaneous rupture of ovarian endometriosis cysts (odds ratio 2.572, 95% CI 1.071-6.174) were found to be statistically significant risk factors for tubo-ovarian abscesses associated with ovarian endometriosis.

CONCLUSIONS

Among the factors investigated, genital tract infections and spontaneous rupture of ovarian endometriosis cysts were found to be involved in the occurrence of tubo-ovarian abscesses associated with ovarian endometriosis. Our findings indicate that tubo-ovarian abscesses associated with ovarian endometriosis may not be linked to in vitro fertilization as previously thought.

Tubo-ovarian abscess: Exploring optimal treatment options based on current evidence

Purpose:

Tubo-ovarian abscess (TOA) and pelvic abscess are characterized by an inflammatory pelvic mass. In the majority of cases, this condition involves the ovaries, the fallopian tubes and/or any other adjacent tissue. TOA is considered a severe complication of PID and can cause severe sepsis. The main risk factors for women’s health are the size of the abscess, the initial amount of white blood cells (WBC), patients’ age as well as, any co-existing comorbidities.

Methods:

This study provides a review of the current literature regarding the management of TOA and the different criteria used in order to establish the optimal therapeutic approach or to predict outcome by individualizing cases. Four major search engines, MEDLINE, Google Scholar, PubMed and EMBASE, up to February 2020 were explored, focusing in epidemiology and risk factors, pathogenesis, diagnosis and treatment.

Results:

Our review suggests that there are no clear guidelines for best practice, in case of TOA, but it appears that intravenous antibiotics combined with interventional radiology have good results for TOA <5 cm. When TOA is >5 cm, laparoscopic approach is indicated. Further studies are needed in order to evaluate the best treatment for women with TOA.

Conclusions:

More prospective studies on large-series of patients are in need, in order to determine a clear pathway and to suggest specific criteria, which can guide clinicians to choose optimal approach in a timely manner.

Acute abdominal pain in non-pregnant endometriotic patients: not just dysmenorrhoea. A systematic review

Endometriosis, defined as the presence of functional endometrial tissue outside the uterine cavity, presents mainly with pelvic pain and infertility. Acute abdominal pain in non-pregnant patients with endometriosis might be minimised as a typical feature of the disease, while endometriosis is rarely considered in the differential diagnosis of acute abdominal pain. Our objective was to conduct a systematic review of the current literature of cases of acute abdomen/acute abdominal pain in non-pregnant endometriotic patients. We performed a PubMed/MEDLINE search of studies published from January 1990 to December 2018, selecting English language reports and series of non-pregnant patients with acute abdomen and histological confirmation of endometriosis. The studies were revised by two independent authors. Data were abstracted and compiled for analysis. Fifty articles reporting 62 patients were identified. The complications were classified according to anatomical sites in bowel, urinary tract, and genital organs emergencies. Rarely was the first diagnostic hypothesis endometriosis, misdiagnosis was frequent. The time frame from symptoms onset to management was often long. This is the first systematic review evaluating acute abdomen/acute abdominal pain in non-pregnant endometriotic patients. These conditions are rare but possibly life-threating and require prompt diagnosis and emergent medical or surgical treatment.

Assisted Reproductive Technology as a Transcutaneous Route for Bacterial Contamination of Ovarian Endometrioma with Coagulase-Negative Staphylococcus: Case Report and Review of the Literature

Tubo-ovarian abscess may develop in women with endometrioma following assisted reproductive technology (ART). The infection, though rare, is typically late in onset and may present several months after the procedure, and in pregnancy—with the risks of abortion and premature labor. It is thought that transcutaneous oocyte retrieval during ART is the route for bacterial contamination resulting in infection of the endometrioma. Pathogens reported in the literature include Escherichia coli (E. coli) and Group B streptococcus (GBS) but Staphylococcus lugdunensis (S. lugdunensis), a coagulase-negative staphylococcus (CoNS), and groin and perineal skin commensal was isolated from the endometrioma in this case. We discuss the challenges in diagnosis and treatment of this rare condition and the implications of the discovery that an organism previously dismissed as a contaminant has emerged as a causative organism in severe, deep-seated infections of soft tissues in recent literature.

Does the presence of endometriosis cause a challenge for transvaginal oocyte retrieval? A comparison between patients with and without endometriosis

Objective

The aim of the study was to compare patients with and without endometriosis regarding performance rates, difficulties, and complications associated with transvaginal oocyte retrieval (TVOR) procedures.

Material and Methods

A prospective cohort study was conducted at the In Vitro Fertilization Unit of the Division of Reproductive Endocrinology and Infertility Department of a university hospital. Fifty-eight patients with endometriosis and 61 patients without endometriosis underwent TVOR procedures consecutively. Primary outcome measures were; number of needle entries per patient and performance rating defined as the total number of oocytes retrieved per vaginal needle entry. The requirement for manual compression of the abdominal wall (assistance) to reach the ovaries, procedure-related pain, and procedural complications were also evaluated.

Results

The median number of needle entries through the vaginal wall per patient was comparable between the two groups (p=0.45). Performance rates were higher in the control group (p=0.001). Performance rates and total number of the needle entries through the vaginal wall were not significantly correlated with ovarian endometrioma (OMA) diameter (r=0.28; p=0.68; r=0.275, p=0.068, respectively) in the endometriosis group. Body mass index (BMI) scores were found to be correlated with the number of the needle entries and higher BMI scores were associated with higher numbers of vaginal wall punctures (p<0.001). The requirement for manual compression of the abdominal wall was significantly higher in the control group (57.4% vs 27.6%, p=0.001). A similar proportion of women needed analgesic medications after the TVOR procedure in both groups (10.3% vs 16.4%, p=0.33). Hospital readmissions for any symptoms were also comparable between the two groups (p=0.22). Three women were treated for pelvic infection, all of whom were in the endometriosis group.

Conclusion

Endometriosis seems to cause a challenge for TVOR that may have reflection on individual surgeon’s performance rates for the procedure, independently from the diameter of a pre-existing OMA or ovarian adhesions. Obesity is another factor that may present a challenge for the procedure.

[Conservative management of endometrioma in women undergoing in vitro fertilization]

Endometriosis is a chronic disease. The pathogenesis is actually still unclear. Endometriosis is responsible for infertility and/or pelvic pain. One of the most important features of the disease is the heterogeneity (clinical and anatomical). Among the different phenotypes of endometriosis, the ovarian endometrioma seems to most important lesion in the management of endometriosis-related infertility. Surgical treatment is associated to a decrease of the ovarian reserve and a potential detrimental effect on in vitro fecondation (IVF) outcomes. Thus, the choice between conservative or surgical management of endometrioma before IVF is actually debated. The advantages and drawback of surgical and conservative management should be discussed before to plan the treatment. In the present review, we aimed at assessing the risks of a conservative management of endometrioma as compared to surgery before IVF.

In vitro fertilization complicated by rupture of tubo-ovarian abscess during pregnancy

OBJECTIVE

Pelvic abscess during pregnancy is an uncommon complication, but can lead to adverse perinatal outcomes during pregnancy.

CASE REPORT

We present a patient who developed rupture of a tubo-ovarian abscess during pregnancy following in vitro fertilization and embryo transfer. Thirty-eight reported cases are reviewed, and transvaginal oocyte retrieval, genital tract infections, endometrioma, and previous pelvic surgery are considered as risk factors for pelvic abscess during pregnancy.

CONCLUSION

Prolonging gestational duration when an infection situation is allowed is the principle of treatment.

Risks of tubo-ovarian abscess in cases of endometrioma and assisted reproductive technologies are both under- and overreported

OBJECTIVE

To study possible associations among endometriosis, pelvic infectious disease, and ART.

DESIGN

Retrospective cohort analysis over 4 consecutive years, based on medical records and insurance coding in a tertiary endometriosis reference center.

SETTING

Tertiary university-based reference center for endometriosis.

PATIENT(S)

We retrieved all charts carrying the diagnoses infectious process and endometriosis in 2009-2012. Each chart was individually analyzed for categorization of the infectious episode and determining whether ART had been performed.

MAIN OUTCOME MEASURE(S)

Hospitalization for acute infection in women with known endometriosis and possible past ART.

INTERVENTION

Retrospective insurance codes-triggered chart analysis.

RESULT(S)

Ten patients were admitted for an acute infection with fever, acute abdomen syndrome, elevated white blood cell count, and adnexal mass. Three women had oocyte retrieval, and an endometrioma was present 16, 57, and 102 days earlier. In one patient, the complication occurred 37 days after a cesarean section without prior ART. In the remaining six cases tubo-ovarian abscesses (TOAs) occurred spontaneously in endometriosis women who never had ART. Medical treatment succeeded in only two patients, and the remaining eight needed laparoscopic drainage. In 6 out of those 8 cases, laparoscopic drainage was a second-stage measure justified by failure to respond to antibiotic therapy.

CONCLUSION(S)

Our data indicate that some putative complications of ART and endometrioma may actually not be linked to ART, but rather constitute sporadic occurrences in endometriosis. Furthermore, TOAs occurring in women with endometriosis are best treated by early surgical drainage together with intravenous antibiotics.

Reduction in Endometrioma Size with Three Months of Aromatase Inhibition and Progestin Add-Back

The purpose of this study was to assess the impact of 3 months of aromatase inhibition together with progestin add-back on ovarian endometrioma size. This prospective cohort study was performed at University Medical Center (UC San Diego). Women trying to conceive were excluded. After informed consent, all women were treated with the aromatase inhibitor letrozole (5 mg/d) with norethindrone acetate (5 mg/d) add-back for 3 months. Pre- and posttreatment assessments of endometrioma sizes were performed by ultrasound. The impact of treatment on pain was determined using the patient assessed endpoints of the Biberoglu and Behrman scale. These included assessing dysmenorrhea, dyspareunia, and nonmenstrual pelvic pain each on a scale from 0 to 3. The primary endpoint of this study was the change in ultrasound documented endometrioma size. Fourteen endometriomas in 8 consecutive women were treated for 3 m. Mean endometrioma diameter decreased 50% from 4.6 ± 1.6 cm to 2.3 ± 1.6 cm (mean ± SD). This represents a 75% decrease in endometrioma volume. Endometriosis symptoms of dysmenorrhea, dyspareunia, and nonmenstrual pelvic pain also improved with treatment. In conclusion, a 3-month course of high dose aromatase inhibition with progestin add-back significantly reduces ovarian endometrioma size and warrants further investigation.

Primary Ovarian Abscess Arising Spontaneously within an Endometrioma: A Rare Case

We report a very rare case of de novo abscess formation inside an endometrioma without any prior intervention in a 32-year-old woman. She presented with acute abdominal pain and persistent high-grade fever. A lump was palpable and tender and showed features of endometrioma on ultrasound. Laparotomy was conducted, as her clinical condition deteriorated despite broad spectrum antibiotics, and her fever did not subside. Thick foul-smelling pus was drained from the endometrioma, and the abscess wall was removed, followed by cystectomy. The patient improved markedly and did well in the postoperative period.

Comparison of complication rates and pain scores after transvaginal ultrasound-guided oocyte pickup procedures for in vitro maturation and in vitro fertilization cycles

OBJECTIVE

To compare complication rates and pain scores after oocyte pickup (OPU) in in vitro maturation (IVM) and IVF cycles.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated ART center.

PATIENT(S)

One hundred eighty-eight IVM and 188 IVF OPUs.

INTERVENTION(S)

IVM OPUs were done using a 19-gauge single-lumen needle, and IVF OPUs were done using a 17-gauge single- or 16-gauge double-lumen needles.

MAIN OUTCOME MEASURE(S)

Duration of OPU, complication rates, and pain scores during the OPU procedure.

RESULT(S)

IVM OPU took significantly more time than IVF OPU (22 vs. 15 minutes). Two women in the IVM and four in the IVF group experienced bleeding from the vaginal wall or ovary. None of them required hospitalization, transfusion, or an operative intervention. One patient in each group had pelvic infection. Severe post-OPU abdominal pain occurred in one patient in the IVM group and five patients in the IVF group. No differences were found between pain scores in the IVF and IVM groups (3.4 vs. 3.8).

CONCLUSION(S)

Although IVM OPU requires more punctures per ovary, it is well tolerated and does not seem to be associated with a higher complication rate than IVF OPU.

Early pregnancy loss following laparoscopic management of ovarian abscess secondary to oocyte retrieval

Severe pelvic infections following ultrasound-guided transvaginal oocyte retrieval (TVOR) are rare but challenging. Ovarian abscess formation is one of the consequences and management of such cases as highly debated in pregnant patients. In this case report, an early fetal loss following laparoscopic management of ovarian abscess is described and possible etiologies are discussed.

Actinomyces urogenitalis bacteremia and tubo-ovarian abscess after an in vitro fertilization (IVF) procedure

We describe the first case of bacteremia due to Actinomyces urogenitalis. Bacteremia was secondary to a tubo-ovarian abscess following transvaginal oocyte retrieval. Identification was established by matrix-assisted desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and confirmed by 16S rRNA gene sequencing. A. urogenitalis should be considered as a potential causative agent of infection after gynecological procedures.

Pelvic abscess after oocyte retrieval in women with endometriosis: A case series

BACKGROUND

Pelvic inflammatory disease with progression to pelvic abscess is a rare complication after oocyte retrieval during in vitro fertilization cycles. However, in patients with endometriosis the risk appears to be increased. Many authors agree on the need for antibiotic prophylaxis during the oocyte retrieval in these patients, but there is no consensus regarding the best antibiotic.

CASE

We discuss 3 clinical cases of tubo-ovarian abscess in women with endometriosis after oocyte retrieval despite antibiotic prophylaxis between 2004 and 2011 at our center, and discuss our experience in the context of earlier reports.

CONCLUSION

It is unclear whether antibiotic prophylaxis is necessary in these women, and which antibiotic is best. Only douching with povidone-iodine appears to decrease the rate of pelvic infection.

Actinomycosis pelvic abscess after in vitro fertilization

OBJECTIVE

To report a case of pelvic actinomycosis presenting as large, multiloculated abscesses after an in vitro fertilization (IVF) cycle for male factor infertility.

DESIGN

A case report and literature review.

SETTING

University hospital.

PATIENT(S)

A 31-year-old nulligravid woman presenting with urinary retention, pelvic pain, and fever 6 days after transvaginal oocyte retrieval and an embryo transfer for male factor infertility.

INTERVENTION(S)

Intravenous and oral antimicrobial therapy, and computed tomography (CT)-guided drainage of pelvic abscesses.

MAIN OUTCOME MEASURE(S)

Clinical and radiologic resolution of symptoms and infection.

RESULT(S)

The CT scan revealed several large, multiloculated pelvic and tuboovarian abscesses. The patient defervesced after 6 days of intravenous antibiotics, but the pelvic pain did not improve. After CT-guided drainage of the pelvic abscesses, the patient's symptoms improved. The drained material was cultured, and the patient was diagnosed with pelvic actinomycosis tuboovarian abscesses, an infrequent cause of tuboovarian abscess and a rare complication of assisted reproductive technology (ART). The patient was switched from intravenous to oral antibiotics and discharged home.

CONCLUSION(S)

Pelvic Actinomyces israelii presenting as pelvic abscesses may occur as a rare complication of ART. Physicians should consider a diagnosis of tuboovarian abscess in a patient reporting fever and pelvic pain after IVF and embryo transfer.

Term delivery following tuboovarian abscess after in vitro fertilization and embryo transfer

A tuboovarian abscess (TOA) during pregnancy following oocyte retrieval is extremely rare. We report a rare case of pregnancy complicated by the development of a TOA following in vitro fertilization-embryo transfer that was treated successfully with laparoscopy. We also review all similar cases reported in the English-language literature.

Comparison of success rates of 'transvaginal aspiration and tetracycline sclerotherapy' versus 'only aspiration' in the management of non-neoplastic ovarian cysts

AIM

To investigate the value of tetracycline sclerotherapy for management of recurrent or persisting non-neoplastic ovarian cysts in comparison to the aspiration without sclerotherapy.

MATERIAL AND METHODS

Ninety-six patients with proven non-neoplastic ovarian cysts were randomized into two groups. Group 1 patients underwent cyst aspiration together with tetracycline sclerotherapy (n=48). Group 2 patients underwent only cyst aspiration without tetracycline sclerotherapy (n=48). Then, all patients were followed up monthly with ultrasonography for 12months. The procedure was considered to have failed if the recurring cyst, detected by ultrasound, was 4cm in size or greater.

RESULTS

There were no differences between the two groups regarding demographic data, initial cyst volume and tumor markers. Recurrence rates within 12months were 14.6% in group 1 and 50% in group 2 (P<0.001).

CONCLUSION

Based on the recurrence rates, we suggest transvaginal aspiration together with tetracycline sclerotherapy rather than only simple transvaginal aspiration in the management of non-neoplastic ovarian cysts.

Ovarian endometriomas and IVF: a retrospective case-control study

We performed this retrospective case-control study analyzing 428 first-attempt in vitro fertilization (IVF) cycles, among which 254 involved women with a previous or present diagnosis of ovarian endometriosis. First, the results of these 254 cycles were compared with 174 cycles involving patients with proven non-endometriotic tubal infertility having similar age and body mass index. Women with ovarian endometriosis had a significantly higher cancellation rate, but similar pregnancy, implantation and delivery rates as patients with tubal infertility. Second, among the women with ovarian endometriosis, the women with a history of laparoscopic surgery for ovarian endometriomas prior to IVF and no visual endometriosis at ovum pick-up (n = 112) were compared with the non-operated women and visual endometriomas at ovum pick-up (n = 142). Patients who underwent ovarian surgery before IVF had significantly shorter period, lower antral follicle count and required higher gonadotropin doses than patients with non-operated endometriomas. The two groups of women with a previous or present ovarian endometriosis did, however, have similar pregnancy, implantation and live birth rates. In conclusion, ovarian endometriosis does not reduce IVF outcome compared with tubal factor. Furthermore, laparoscopic removal of endometriomas does not improve IVF results, but may cause a decrease of ovarian responsiveness to gonadotropins.

Endometriosis and in vitro fertilisation: a review

This review aims to evaluate whether severe endometriosis has an impact on the outcome of in vitro fertilisation (IVF), whether IVF is associated with specific complications in this context, whether a specific ovarian stimulation protocol is most appropriate, whether the endometrial condition progresses following ovarian stimulation, and whether endometrial cysts pose a specific problem for IVF. In patients with severe endometriosis, IVF represents an effective treatment option for infertility, as a complement to surgery. The prognostic parameters of IVF are identical to those of other patients. However, the risks related to the severity of endometriosis, particularly the risk of ovarian deficiency, need to be considered. Because of this issue, to which endometriosis-related pain often adds, IVF treatment should be initiated as early as possible, using appropriate protocols and after having fully informed the patient about the specific oocytes retrieval-related risks.

Ethanol sclerotherapy: a treatment option for ovarian endometriomas before ovarian stimulation

Several surgical treatment modalities have been described in cases of isolated or multiple ovarian endometriotic cysts. The aim of this preliminary study was to investigate and test the efficacy of ethanol sclerotherapy (EST) for recurrent endometriotic cysts, before ovarian stimulation in infertile patients with an adequate ovarian status. In the setting of a prospective comparative study, EST was proposed to 31 infertile patients with recurrence of ovarian endometriomas before inclusion in assisted reproduction cycles. Reproductive outcome was compared with that of patients who had previous laparoscopic cystectomy for recurrent endometriomas. The mean size of endometriomas treated with sclerotherapy was 38.6 +/- 11.2 mm in diameter. Ovarian cysts recurred in 12.9% of cases; at a mean time of 10 months after EST. Ovarian reserve and ovarian response to stimulation were better in the EST group than in the control group. Consequently, clinical and cumulative pregnancy rates of the study group were higher than those of the control group (48.3% versus 19.2%, P = 0.04; and 55.2% versus 26.9%, P = 0.03, respectively). Ethanol sclerotherapy may be a good alternative to surgical management of recurrent endometriotic cysts before assisted reproductive treatment. It could be advised for selected infertile patients.

A review of complications following transvaginal oocyte retrieval for in-vitro fertilization

Transvaginal ultrasound guided oocyte retrieval (TVOR) during in vitro fertilization (IVF) treatment was first described in 1985. By virtue of its simplicity and effectiveness, it has gained widespread popularity and has now become the gold standard for IVF therapy. Nevertheless, despite the advantages, the aspiration needle may injure the adjacent pelvic organs and structures leading to serious complications. The most common complications are haemorrhage, trauma and injury of pelvic structures, and pelvic infection. Other complications described include adnexal torsion, rupture of endometriotic cysts, anaesthetic, and even vertebral osteomyelitis. In the last two decades, several reports have described the complications associated with this technique, and tried to address the risk factors and safety issues. However there is wide variation in the way this common procedure is performed, with room for improvement through published guidelines. This article reviews the most common complications reported in literature, summarizes the recommendations made to minimize their occurrence, and raises some of the controversial issues related to the procedure especially that of pelvic infection.

Distributive justice and infertility treatment in Canada

An exploration of distributive justice in Canadian infertility treatment requires the integration of ethical, clinical, and economic principles. In 1971, American philosopher John Rawls proposed a theoretical model for fair decision-making in which "rational" and "self-interested" citizens are behind a "veil of ignorance" with respect to both their own position and the position of other decision-makers. Rawls proposed that these self-interested decision-makers, fearing that they are among the least advantaged persons who could be affected by the decision, will agree only upon rules that encode equality of opportunity and that bestow the greatest benefit on the least advantaged citizens. Regarding health policy decision-making, Rawls' model is best illustrated by Canadian philosopher Warren Bourgeois in his panel of "volunteers." These rational and self-interested volunteers receive an amnestic drug that renders them unaware of their health, social, and financial position, but they know that they are representative of diverse spheres of citizens whose well-being will be affected by their decision. After describing fair decision-making, Bourgeois considers the lack of a distributive justice imperative in Canada's Assisted Human Reproduction Act, in contrast to legislation in European nations and Australia, summarizes the economic and clinical considerations that must be provided to the decision-makers behind the "veil of ignorance" for fair decisions to occur, and considers altruism in relation to equality of access. He concludes by noting that among countries with legislation governing assisted reproduction Canada is alone in having legislation that is void of distributive justice in providing access to clinically appropriate infertility care.

Pelvic abscess complicating an in vitro fertilization pregnancy and review of the literature

INTRODUCTION

In vitro fertilisation has become a very common procedure in the infertility practice due to both accessibility and good success rates.

DISCUSSION

Complications, however, are constant reminders that no procedure is totally safe. In this paper, we present a case of IVF pregnancy that presented with pelvic abscess, and despite two laparotomies the triplet pregnancy was lost at 22 weeks gestation.

CONCLUSION

This case highlights the fact that the progression of pelvic infection in pregnancy can be slow.

Choice in fertility preservation in girls and adolescent women with cancer

With the cure rate for many pediatric malignancies now between 70% and 90%, infertility becomes an increasingly important issue. Strategies for preserving fertility in girls and adolescent women occur in two distinct phases. The first phase includes oophorectomy (usually unilateral) and cryopreservation of ovarian cortex slices or individual oocytes; ultrasound-guided needle aspiration of oocytes, with or without in vitro maturation (IVM), followed by cryopreservation; and ovarian autografting to a distant site. The second phase occurs if the woman chooses to pursue pregnancy, and includes IVM of the oocytes, followed by in vitro fertilization (IVF) and transfer of any created embryos to the woman's uterus (or to a surrogate's uterus if the cancer patient's uterus has been surgically removed or the endometrium destroyed by radiotherapy). For ovarian autografting, the woman would undergo menotropin ovarian stimulation and retrieval of matured oocytes (likely by laparotomy, but possibly by ultrasound-guided needle aspiration if the ovary is positioned in an inaccessible location). The ethical challenges with each of these phases are many of fertility preservation and include issues of informed choice (consent or refusal). The lack of proven benefit with these strategies and the associated potential physical and psychological harms require careful attention to the key elements of informed choice, which include decisional capacity, disclosure, understanding and voluntariness, and to the benefits of in-depth counseling to promote free and informed choice at a time that is emotionally difficult for the decision makers.

Peri-implantation pelvic inflammatory disease with normal pregnancy outcome

OBJECTIVE

To report on the presentation, diagnostic assessment, treatment, and outcome of a case of peri-implantation pelvic inflammatory disease.

DESIGN

Case report.

SETTING

Emergency department and gynecology ward of a tertiary university hospital.

PATIENT(S)

A 25-year-old multiparous woman in her 1st month of pregnancy.

INTERVENTION(S)

Diagnostic laparoscopy, antibiotic therapy, and pregnancy surveillance.

MAIN OUTCOME MEASURE(S)

Surveillance and outcome of pregnancy.

RESULT(S)

The patient presented with abdominal pain and fever 26 days after her last menstrual period. Examination revealed peritoneal irritation and cervical tenderness, with free fluid in the pelvis. Diagnostic laparoscopy was performed, with no evidence of ectopic pregnancy. A significant quantity of yellow purulent fluid was drained from the pelvis, which cultured for Escherichia coli. Antibiotic therapy yielded excellent response. The pregnancy continued, with no complications, to healthy term delivery.

CONCLUSION(S)

This rare diagnosis of peri-implantation pelvic inflammatory disease should be considered in the differential diagnosis of abdominal pain in early pregnancy. Timely, rational treatment, including early pelvic drainage and appropriate antibiotic therapy, may save the pregnancy.

Transvaginal oocyte retrieval for in vitro fertilization complicated by ovarian abscess during pregnancy

OBJECTIVE

To describe an ovarian abscess presenting very late after oocyte retrieval for IVF with several unusual clinical features.

DESIGN

Case report.

SETTING

Academic medical center.

PATIENT(S)

A 35-year-old nulliparous woman underwent IVF with uncomplicated transvaginal oocyte retrieval (TVOR), resulting in a dizygotic twin pregnancy. At 13 weeks of pregnancy she presented with vaginal discharge, but was otherwise constitutionally well. At 30 weeks she developed a low-grade fever, and the diagnosis of ovarian abscess was made. She received broad-spectrum antibiotics, and the abscess was drained percutaneously after cesarean delivery of twins.

INTERVENTION(S)

Antimicrobial therapy; cesarean section; postpartum percutaneous drainage.

MAIN OUTCOME MEASURE(S)

Clinical and radiologic resolution of infection.

RESULT(S)

Complete resolution of the abscess; delivery of healthy twins.

CONCLUSION(S)

Infectious complications of TVOR and other surgical procedures usually occur within days of the intervention. Our case illustrates the possibility of infectious complications of TVOR presenting months after the procedure. Our patient did not become acutely ill due to the formation of a spontaneous vaginal fistula, which allowed the abscess to drain. The optimal management of this complication is unclear, but final resolution of any pelvic abscess generally requires drainage.

The presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotropins

OBJECTIVE

To clarify whether the presence of ovarian endometriomas is associated with a reduced responsiveness to ovarian hyperstimulation.

DESIGN

Observational study.

SETTING

University teaching hospital.

PATIENT(S)

Women selected for in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) cycles who were found to have unilateral ovarian endometriomas and who did not undergo previous ovarian surgery.

INTERVENTION(S)

Ovarian hyperstimulation using gonadotropins.

MAIN OUTCOME MEASURE(S)

Number of codominant follicles (mean diameter >15 mm) in the affected and in the contralateral intact gonads.

RESULT(S)

Thirty-six patients were enrolled. They underwent 56 IVF-ICSI cycles. The number of codominant follicles in the intact and affected ovaries were 4.0 +/- 2.2 and 3.0 +/- 1.7, respectively (P=.01). This difference corresponded to a mean reduction (95% confidence interval [CI]) of 25% (6%-44%). This deleterious effect was more evident in women with larger cysts, in those with more than one cyst, and in those who were more responsive to ovarian hyperstimulation.

CONCLUSION(S)

The presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotropins.